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'•''"•i'JS^^r-"'-
 
 
IE¥ ELEMENTS  TJJP
           OF                 A j
OPERATIVE  SURGERY:
            ALF. A. L. M. VELPEAU,
 Professor of Surgical Clinique of the Faculty of Medicine of Paris, Surgeon of the Hospital of La Charit6,
          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 OF
 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 OF, AND WITH NOTES AND OBSERVATIONS BY
              VALENTINE MOTT, M.D.
   Professor of the Operations of Surgery with Surgical and Pathological Anatomy, in the University of
        New York; Foreign Associate of the Academie Royale de Medecine of Paris,
                of that of Berlin, Brussels, Athens. &c.   o.
                                  .or. v»grn'., ,,,

               IN THREE VOLUMES. 0 J *7P*%

                     VOL. III. ^


                  NEW YORK:
        SAMUEL  S. & WILLIAM  WOOD,
                No. 261 PEARL STREET.
                       1847. 
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  v.3
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       Entered according to Act of Congress, in the year 1847, by
               SAMUEL S. & WILLIAM WOOD,
In the Clerk's Office of the District Court of the Southern District of New York.
BTEREOTYPKD BY THOMAS B. SMITH,
 216 WILLIAM STREET, NEW YORK. 
                          PREFACE

TO  THE  THIRD  AND  LAST  VOLUME  OP THIS WORK.
BY  P.  S.  TOWNSEND,  M.D.
   If it were possible that any portion of these volumes could  be considered more
valuable to students and to practitioners than the rest, we should say, apart from the
great capital  operations on aneurisms, amputations, exsections, &c, in the  2d
volume, and the rudimental subjects of minor surgery and the  new operations em-
braced  in the  1st volume,—that the special operations on all the varied regions of
the human body, contained in this 3d and last volume, especially in relation to the
important subjects of Hernia and Tumors, and  those most difficult  manipulations
exacted in the minute and delicate surgery of  the face, neck,  and all the different
vital organs and passages considered separately, together with  the accompanying
beautiful quarto atlas of nearly 200 figures  of  surgical instruments and processes,
would unquestionably bear the  palm of precedence for direct practical utility.
   The  whole, as will be perceived, have been treated of with the habitual felicitous
manner of M. Velpeau, both in regard to the perspicuity of the style of the author,
and his intimate  practical  familiarity with the operations  themselves.  But for
having been already somewhat accustomed, however, to his  manner  of describing
surgical processes, we should have despaired of rendering some of the more intri-
cate of these operations intelligible in our own language.
   We trust we have succeeded, at least we count with some degree of security on
not having committed in any place, any sensible deviation from the path traced out
for us, while endeavoring to adhere as  closely as possible to the meaning  of the
original, and at the same time to convey the ideas of the  author into  our own
idiom, in a manner, we hope, not entirely wanting either in  spirit or  perspicuity.
   We are gratified in being enabled to  state from a recent letter of  M. Velpeau,
that the work, so far as it had progressed, had met with his entire approbation ; so
much so, that he hesitates  to  our enquiry  of  his intention to publish a second
French edition, by saying that he should meditate upon this present work, in order
to satisfy himself first, that the necessity of such a task had  not been fully antici-
pated by our labors.
   The  text of this present volume, we may furthermore remark, is so ample and
searching in its details, and so perfectly au courant to the present condition of sur-
gery, in respect to the subject-matters therein embraced, that  any attempt almost
on our part, to superadd any thing new to what M. Velpeau himself  has said, has
been  almost entirely superseded.   Nevertheless, it will be perceived that we have
deemed it advisable to incorporate some 100 pages of new matter in various places,
among which  the animated discussion still in progress, on the diagnosis of Fibrous
and Cancerous Tumors, and the important, though brief remarks of Dr.  Mott  on
his eminently  successful  mode  of treating the  distressing affection of Immobility
of the Lower Jaw, will, we are sure, be found of some interest to the profession.
  While touching on this matter, we may remark, that in a  case of this kind, and
as an auxiliary to  the  screw-lever of Dr. Mott, the right masseter  muscle was
totally divided, and  the left  partially so, as early as the year 1840, by  James
R. Wood,  M. D.  of this city.  Complete success, however, did not reward  the
bold expedient of  this skilful  young  surgeon,  which, however, might possibly
have been obtained if it had occurred to him  to have  adopted the  ingenious re-
source of his preceptor, Dr. Mott, by severing also the pterygoid muscles. 
IV
PREFACE.
   We are somewhat strengthened in this opinion by what happened in the case of
 M. Dieulafoy, of Toulouse, who also  after all the discussion  which has occu-
 pied our pages, (see Vols. I. and II., Drs. Schmidt and Carnochan,) on the claims
 of priority for the total division of the masseter, appears to have been  the first
 surgeon, who first actually achieved this triumph, as well as  a complete cure in the
 case in question, but not until after the subsequent partial division of the pterygoid
 muscles.
   M.  Dieulafoy,  according  to the Journal de Med. et de  Chirurg. Prat., of
 August,  1839, divided the year before (1838) by puncture in the cheek externally,
 and then by the subcutaneous method the entire right masseter in a soldier  aged 29,
 at the Hotel Dieu, Saint Jacques (Toulouse,) in  whom the muscle on  this  side
 had become permanently contracted, and to such degree in consequence of scurvy,
 while with the French army in Africa,  as to effect a rigid closure of the jaw.  The
 cure was, however, not completed until the surgeon, after the  cicatrization of the
 wound, had divided also the anterior fibres of the pterygoid muscles, which formed a
 bridle behind the last molar teeth.   (See also  American  Journal of the Med.
 Sciences, Vol. XXVI., Philadelphia, 1839, p. 218.)
   While on the subject of the adjustment of disputed claims,—the preceding one
 having now we presume been put forever at rest,—we will  remark, that we have
 in our notes to Vol I.,  taken occasion to bestow some laudation upon Dr. Mott, as
 the first  person, who upon his last return from Europe, took  an  early opportunity
 to establish at the University of this city, and upon a  secure basis, the valuable
 course of public instruction and gratuitous surgical services  to the poor, known for
 the first time in our country, but for several years since  in Europe as  a Medical
 and Surgical Clinique.
   Dr.  March, an  esteemed Professor  in the Medical College  of Albany, claims
 priority on this subject—by a year or two in advance of Dr.  Mott. We are ready
 to concede to him all the praise he is thereby entitled to.  But we will  observe,
 that so far as public attendance and surgical operations,  and  medical prescriptions
 for the out-door  poor soliciting  advice  at  hospitals, dispensaries, &c, goes, the
 matter of Cliniques (applied in an inverse sense to the truth  so far as the  etiology
 of the word or bed-side practice is considered,) is quite an old  affair all over the
 world, having been in  common vogue  for a century, or  for half a century  at least.
   It is a source of infinite satisfaction both to Dr. Mott and myself, to have an op-
 portunity at this late hour, of rescuing  another and more important surgical claim
 from oblivion, by  the  accidental acquaintance  we  made during the past  summer
 with the venerable Walter Brashear, M. D., for many years an eminent planter of
 Attakapas, Louisiana,  and a senator of that state.
   To our countryman, Dr.  Brashear, who was a pupil of the  eminent Dr. Ridgeley,
 of the continental army of the revolutionary war, and  also a student at the Uni-
 versity of Philadelphia, under Dr. Rush and other famous men of that day, are we
 indebted  as is now ascertained,  for the first operation, or amputation of the thigh
 at the hip joint or coxo-femoral articulation ever performed in America, and which
 was  followed with complete success.   This occurred as early as the  year 1806,
 only three years after the illustrious Larrey had revived and perfected this operation
 in the campaigns of Napoleon. (See text of M. Velpeau  on this subject, p. 637. etc.
 in Vol. II. of this work.)
   With that self-neglect of one's own rights, that is ever a prominent characteristic
 of the  diffidence of men of genius, and from his having  early in life withdrawn
from active practice, Dr. Brashear had never published this case.   Dr. Mott there-
 fore, as is seen in  his case of coxo-femoral disarticulation  in Vol. II. of this work,
had hitherto  supposed that he was the surgeon who in  this  country had first per-
formed this important operation.   With a magnanimity which ever belongs to him,
 and which we trust will serve as an emphatic lesson to those  who in their malig-
nity would rob and calumniate both the dead and  the living, Dr. Mott cheerfully
abstracts the plume from his own honored brows, that can spare many and much
more like this, and affixes it upon the  name of the gentleman to whom it rightly
belongs.
  As it may doubtless become the theme  of future discussion, we take the opportu-
nity of placing here upon the record, a too-brief account of the achievement of Dr.
Brashear as communicated in his own words, in a letter we have had the honor to
receive from that  venerable surgeon. 
PREFACE.
V
                                            Philadelphia, August 13th, 1846.
  Mr Dear Sir,
      In conformity to promise, I now give you a brief statement of the operation
which I performed in Bardstown, Kentucky, in August, 1806, on the hip joint.
  The subject was a boy seventeen years of age.  Without assigning the causes
which led to the necessity of the  operation, the same was, after consultation with
Drs. Harrison  and Goodlet,  conducted in  manner  following:—first premising,
that in  absence of any knowledge  of an established  mode  for this operation,  a
common-sense reasoning as to its safety and facility alone  dictated  the  manner of
performing it.  Therefore an operation of the thigh in the ordinary manner was
determined on, as remote from the hip joint as circumstances might justify, (in this
case about mid-thigh.)  The amputation was performed, and the arteries secured.
  The next step was  to make an  incision to and from the lower end of the bone
externally over the great trochanter to the head  of the bone and upper part of the
socket.  The dissection of the bone from the surrounding muscles, was simple and
safe by keeping  the edge  of the  knife resting against the bone.  The bone being
disengaged from its integuments at  its lower  extremity, was then turned  out at a
right angle from the body, so as to give every facility in the operation, to separate
the capsular ligament and remove the  head from its socket.   After the  operation,
nothing more than ordinary dressings were  used, and in the course of a  short time
the patient removed to St. Louis, where he was  living within a few years past.
                                              I am, very respectfully,
                                                       Walter Brashear.
  Dr. P. S. Townsend.

  It may be proper to state from the verbal communications we have had with Dr.
Brashear, that the injury which led to the operation in question was a fracture of
the thigh, complicated with much contusion of the parts, and which from bad man-
agement or neglect, or both, resulted in the establishment of an  extensive and
dangerous suppuration in the neighboring tissues and inter-muscular spaces.
  To another of our countrymen and  a citizen of New York,  Prof.  John W.
Francis, M. D., we would with pleasure have  also devoted a larger portion of
space in the body of the text than we shall in this preface have an opportunity to
do,  had not the volume already become augmented to such size as to preclude the
possibility of giving  the  details of all the interesting and important cases of ova-
rian and  other tumors which have occurred in his obstetrical practice, and the
principal part of which must be reserved for  a second edition.
  Professor Velpeau, in his various valuable publications on obstetrical science, has
with his usual discrimination adverted to the several affections with which the uterine
system is at times invaded, and hence we may account for the omission of his elabo-
rate disquisitions in the present work, on the subject of the several forms of uterine
tumors, and the disorders of the ovaria.  A chapter of some extent might unquestion-
ably be embraced in this work, on this great topic, so closely associated with medical
and chirurgical practice, inasmuch as the services of several of our American prac-
titioners and operators have shed light on the pathology of these disorganizations,
and enforced by surgical  measures  additional means for the alleviation of these
morbid conditions.  The cases of extirpated diseased ovaria by Dr. M'Dowell, of
Kentucky, as recorded in the Eclectic Repertory, evince not less the skill than
the intrepidity of this bold operator  of tumors  connected with the  uterus.  We
may search in vain I believe, for any  instances of so  formidable a bulk as that
recorded by Professor Francis in his  improved edition of Denman's Midwifery.
The case fell  under the observation  of Professor Mott, and the circumstances
characterizing the case are given in the work just alluded to with great minute-
ness.  The patient was aged about 32 years : the tumor grew from the fundus of
the womb, externally.  According to evidence taken at the time of the post-mortem
examination, the entire mass of abnormal growth, including several excrescences
attached to the tumor itself, weighed  one  hundred and one  pounds.  Its fibrous
nature was evident.   Upon cutting into its substance  in different directions, a sac
was found in its right portion, out of which issued three quarts of a purulent  and
most offensive matter.  The extent  of the abdomen of the patient, before the re-
moval of the tumor measured four feet eight inches and  a half.  Professor Francis
has in the same work given other cases of fleshy tumors of the uterus ;  and in the 
vi
PREFACE.
New York Medical and Physical Journal other instances of uterine affections with
extensive ovarian dropsy.
   In conclusion on the subject of reclamations, and without deeming it at all neces-
sary to pay the  slightest  attention  to some  puerile and insignificant pretensions
which have been set forth and vehemently insisted upon in sundry professed notices
and maudlin criticisms on  the two first volumes, we will here barely state, that in
a respectful communication transmitted to us from Dr. Samuel S. Whitney, un-
der date of Dedham, (Mass.,) March 5th, 1846, he claims the honor of having been
the first person,—and before Dr. Ruschenberger of the U. S. Navy, to whose com-
munication (see  Vol. II. of this work,)  he alludes,—in this country at least—who
clearly diagnosed a case of unequivocal aneurism of the basilar artery.  Dr. Whitney
says (see his case in the Oct. number of the Philadelphia American Journal of  the
Medical Sciences,  for  1843,) that this  occurred  as  early as the  year 1841, and
during  the  time he was making investigations and  collecting  facts in regard to
cerebral auscultation.
   Not only  has the complete exsection of one half the lower jaw, and various por-
tions of the upper maxillary bone, been long since performed by Dr. Mott and many
other surgeons, (see text of Vol. II.,) but also recently the  exsection of the entire
upper jaw on both sides.  This was  accomplished July 23, 1844, by a surgeon  of
Germany, Dr. Heifelder, of Erlangen, on a male patient aged 23, for an indurated
tumor, occupying the vault of the palate, and which had displaced  and elevated
the nose, &c.  The operator  made two incisions, each commencing at the great
angle of the eye, and terminating at  the  commissure of the lips, circumscribing
thus  together a quadrangular flap, which was reversed upwards on the forehead.
Passing Jeffrey's chain-saw through the left  spheno-maxillary  fissure, (fente,)  he
detached the maxillary bone from the  zygoma;  proceeded  in  the  same  manner
on the right side, and then  separated  both bones  from the  frontal, os unguis and
ethmoid by the  same saw; separated  the  vomer and other  adhesions with the
scissors, and brought clown and united the  flaps by 27 points  of suture.   There
was no hemorrhage or fever, and the cicatrization was complete in four days, and
the patient was enabled to swallow with ease.  Very little deformity remained, a
cleft  of 15  lines only being left on the median line  of the vault of the palate,
(Walther  ^* Ammon's Journal fur  Chirurgie, t.  III., f. 4,  p. 633, Arch.  Gen.  de
Paris, 4e ser., t. IX., November, 1845, pp. 355, 356.)
   A  new method also of curing false joints has been proposed by the  illustrious
Dieffenbach.  In a girl aged 14, (Dr. Hering, Ueber das Wiedernaturaliche, Ge-
lenk ; Berlin.1843,  also Arch. Gen., Sept., 1845, p. 100,) with a false articulation in
the leg, he at first divided the flexor  muscles, which drew the limb into an  angular
projection, viz., the tendo  achillis, flexor longus pollicis pedis, and tibialis  anticus,
and then by means of two or three very narrow incisions leading down to  the bones,
applied a small perforating trephine, which he worked  drill-fashion, as in lithotrity,
till he had made 5  to 8 holes through the morbid  osseous parts and  their connec-
tions.   Rapid cicatrization  and  perfect restoration of the  limb followed  a short
confinement of the limb on a wooden gutter.
   The diagnosis of substernal aneurisms (see Vol.  II.,) is not the  only  one which
has baffled the acumen of  the  most eminent surgeons now living in the practice of
the stethoscope and auscultation.  Even the fingers, and most refined sense  of touch
that can be acquired by long habitude with morbid growths, are frequently found
to lead to the most humiliating results as interpreters of the real difficulties that exist.
We have  in this volume  alluded, under the head of Hematocele, to the deductions
made in one recent case, by the singular tremulous or oscillating, or gelh/-Hke sensa-
tion of fluctuation imparted to the touch, and which after the operation was discov-
ered  to have proceeded from the  coagulated or clotted condition of the contained
sanguineous fluid.
   In a recent successful extirpation  by Dr. Mott, of a remarkable tumor involving
the entire mamma, and of the  rapid  growth of only 8 months, in a married woman
aged about 50, and the uniform ovate or oblong spheroidal shape of which, of the size
of a foetal head at full term, was one remarkable feature, we  saw a similar scene of
embarrassment.  Almost every person present was satisfied of a clear fluctuating
limpid fluid in large quantity within the malignant production.  Dr. Mott, as usual,
was slow to express an opinion, and waited for the demonstrations of his unerring
scalpel.  The story was soon told, and we think to the astonishment of all. 
PREFACE.
VH
  There was first a regularly formed outer tough fibro-membranous covering of
considerable thickness:  next came another stratum  an inch thick, of hard semi-
transparent, homogeneous gelatino-albuminous tissue, (similar to what is sometimes
seen in the hypertrophy of the bronchial glands at the bifurcation of the trachea,)
and finally, within,  and  close and next to this last, and forming the central nucleus
of the tumor, and about three inches in diameter, a red, semi-transparent globose
mass of softest friable coagula apparently, and no doubt in fact the residuum of an
ancient hematocele,—but no  water any where between  these strata  or none to
speak of, sufficient  to convey the  slightest degree of hydropical fluctuation pro-
perly  so called.   It was the  coagula, or as I conceive the debris of coagulated fibri-
nous blood that imparted the deceptive sensation of fluctuation, and which fluctua-
tion was  in truth, as far as my own examinations went, precisely of the tremulous
or oscillatory character already mentioned.
  It was our intention, but for the size of this volume to  have inserted under the
article of laryngo-thyroidean bronchotomy, a highly important case, in which a large
shawl or hair-pin near two and a half inches long, and with a head the third of an
inch in diameter, and lying  with its  head  upwards, and  playing up and down in
the larynx, was successfully  extracted by Dr. Mott, from a child aged about three
years, the daughter  of Lieut. Governor H----, of Connecticut.   We  have how-
ever, in a note (p. 656, 657,  vol. I.) alluded to the important and neglected practi-
cal point to be attended  to in such operations, especially in children, viz. the dan-
ger of cutting carelessly down into the air  passage through  the engorged tissues,
and the necessity of guarding with the utmost precaution  against the slightest ad-
mission of blood into the respiratory tube.
  We could also have expatiated upon the recent, still more remarkable operation,
in which a gold  piece of coin, viz., a  half sovereign, was by an ingenious contriv-
ance of Sir Benj. Brodie in  inverting  the body,  successfully removed from the la-
rynx of a son of Mr. Brunei the celebrated English engineer,  after all hope  of re-
covery almost had been  extinguished.   This case however, has been so frequently
detailed in the principal publications both in Europe and America, that the mere
allusion to it at present may suffice, until the oppbrtunity shall present of another
edition of this work.  We  will  now, until  such event may arise, bring this work
to a final close, with the single expression, that my respected associate and myself,
can both conscientiously declare, that without fear or favor, we have endeavored,
to the utmost of our ability, to fulfil in a proper manner all that we promised, and
to present to the profession, to the practitioner as well  as to the student, a complete
and systematized elementary treatise on Operative Surgery, embodying all its most
valuable history and processes down to the present moment, in such purity of dic-
tion, and upon principles so orthodox, that it might be deemed worthy for along time
to come,  to occupy  a permanent  rank  in the  hands of every person devoted to this
now-absorbing and most clearly-defined department of the healing art.
                                                                   P. S. T.
  New York, February 2d, 1847. 
 
TABLE    OF    CONTENTS
            OF  THE

THIRD   VOLUME.
Preface by P. S. Townsend, M.D., to this
    Third Volume,.........................   hi
Table of Contents,.......................   ix

Section Twelfth.—TUMORS,.........   1

CHAPTER THIRD—Lymphatic Tumors,,   ib.
Art. I.—Crushing (Ecrasement),............   2
     II.—Setons............................  ib.
     III.—Extirpation,.....................   3
[Noteon InguinalJagged, Phagedenic Ulcers,
    by P. S. Townsend, M.D................   9

CHAPTER IV.—Neuromatic Tumors (Neu-
    romas), ................................  24
Art. I.—Extirpation of Neuromas in general,  28
     H.     "            "     in particu-
        lar.................................  30

CHAPTER V. — Lipomas, or Fatty Tumors
    or Wens (Loupes,).....................  36
Art. I.—Sub-cutaneous Lipomas,............  39
     II.—Sub-aponeurotic   "    ...........  42
[Note on Fatty Tumors, by P. S. T...........  48
CHAPTER VI.—Elephantine Tumors, ....   ib.
[Note on Do................................  49

CHAPTER VII.—Hematic Tumors,........  5<r
Art. I.—Hematic Tumors in General,........51

CHAPTER VIII.—Cysts, (properly so called,)  56
Art. I.—Sebaceous Cysts,................... ib.
[Remarkable Sebaceous Tumors of the Nose,
    successfully extirpated by P. S. Town-
    send, M.D., with plates,.................  60
Art. II.—Hematic Cysts,...................  64
[Note on the Treatment of Cysts, by P. S. T.,  74
Art. III.—Serous Cysts,....................  76
Art. IV.—Synovial Cysts (Nodus-Ganglions),  79
[Note on Crushing as the True  Treatment
    when at all practicable, by P. S. T.,......  83
[Note on Cartilaginous and Osseous  Tumors,
    by P. S.T...............................  88
[Note on Mediastinal Tumors, by P. S. T.,...  ib.
[Note on Cartilaginous Tumors of the Face
    and Scalp, by P. S. T.,..................  89
[Note on Ganglionic, Serous and Synovial Tu-
    mors and Cysts, Bursas Mucosas et Serosa;,
    and Iodine Injections, by P. S. T.,........  90
TNote on Close Cavities in General.  M. Vel-
    peau's recent opinions thereon, by P. S. T., 101
[Note on Treatment of Tumors in General, by
    P. S. T.,................................ 105

CHAPTER  IX.—Fibrous Tumors,......... 108

CHAPTER X.—Cancerous Tumors,....... Ill
                                       Page
[Note on Cancerous Tumors, by P. S. T.,.....  115
[Note on Cruveilhier's opinions  thereon, by
    P. S.T..................................  116
[Note on Discussions of the Paris  Academy
    thereon.  Opinions of M. Velpeau  and
    others thereon,  by P. S. T.,..........121—124
[Note on Opinions of MM. Lebert, Mandl, Lis-
    ton, &c, by P. S. T.,................124—126
[Note on Psuedo-Cancers, by P. S. T.,....... 127
[Note on Fungus Hematodes occupying the
    entire bladder, by P. S. T.,..............  129
[Note on Congenital Encephaloidal Tumors,
    by P. S.T.,.............................  130
[Note on Scirrhous Tumor of the Brain,  by
    P. S. T.,................................  131

CHAPTER XL—Tumors of the Bones (Ex-
    ostoses),..............................  ib.
Art. I.—Exostoses of the Trunk,............  133
Art. II.—Exostoses of the Hand,  Fore-arm,
    Humerus, Scapula,  Foot,  Tibia,  Fibula,
    Patella, Femur,.....................136—143
CHAPTER XII.—The Ligature in Mass, .  143
Art. I.—Ligature without Dissection,.......  145
Art. II.—Ligature in Mass with Dissection,...  147
Art. III.—Manner of Effecting Strangulation
    by the Mass,............................  ib.
Art. IV.—Appreciation of Methods,..........  150

CHAPTER XIII.—Foreign Bodies,........  151
Art.  I.—In the Trunk, Head, Thorax, Abdo-
    men, (Notes), Urinary Passages,.....152—160
Art. II.—In the Limbs......................  160
Art. III.—Operative Process,...............  165
Art. IV.—Foreign Bodies in the Articulations,  168

TITLE  FOURTH. — SPECIAL  OPERA-
        TIONS,............................  172
PART I.—Operations which are Perform-
        ed on the Head,...................  ib.
CHAPTER I.—The Cranium,..............  ib
Art.  I.—Fungous Tumors, Fibrous  and He-
    matic Tumors, Vegetations, fire...........  ib.
Art. II.—Encephalocele,....................  178
Art. WL.—Meliceroma,  (Melicerous  Tumors,)  179
Art. IV.—Hydrocephalus,...................  182
Art. V.—Spina Bifida......................  184
[See Note at p. xcix. of Supplemental Appen-
    dix, Vol. II., by Dr. Mott. and  at p. 1138
    of this Vol., (111.), by Do.
Art.  VI.—Cephalematoma, (Sanguineous Tu-
    mors of the Cranium,)..................186
Art. Vn.—Operations required by the Diseas-
    es of the Frontal Sinus :  as Caries and
    Necrosis, Abscesses, Foreign Bodies, &c,  188 
TABLE  OF CONTENTS.
                                        Page
CHAPTER II.—Face.......................  194
Art. I. — Operations on the Nose:  as Tu-
    mors,  Occlusion and Contraction  of  the
    Nares, &.c...............................  194
Art. II.—Operations on the Lachrymal Pas-
    sages : as on the Puncta and their Ducts,
    for Lachrymal Tumors  and Fistula Lach-
    rymals, ...........................200—232
Art. III. — Operations on  the Eyelids:  as
    for Ectropion,  Blepharoptosis, Trichiasis,
    Entropion, Tumors of the Eyelids, Ankylo-
    blepharon, Symblepharon, Tumors at  the
    Great Angle, &c.....................232—251
Art. IV.— Operations  on  the  Orbitar  Cavi-
    ity: as for Loupes, Aneurisms, Exostoses,
    Hypertrophy of the Lachrymal  Gland,
    Solid Tumors, &c,..................251—254
Art. V.—On the  Globe of the Eye:  as For-
    eign  Bodies,  Vegetations,  Cataract,  in-
    cluding the  subjects of  Immobility of  the
    Pupil,  Black Cataract, Tremulus  Iridis,
    False Cataracts, Instruments for Cataract,
    the process by Scleroticonyxis, Milky and
    Purulent Cataract, Process by Reclination
    or  Reversion,   Process   by  Keratonyxis,
    Cataract in  Children, Process by Extrac-
    tion, Scleroticotomy, Keratotomy, Depres-
    sion, Artificial Cataracts, &c,.......254—303
[Note on Cataract by P S. T.,............... 301
Artificial Pupil, by Coretomy; by Coredialysis,
    or Decollement; by Corectomy, &c. 303—315
Puncture and Incision of the Eye: as in Onyx,
    Hydrophthalmia, Hypopyon,  Empyesis,
    Buphthalmia, &c, •■................315—319
Excision of the Eye: as for Staphyloma, Em-
    pyema, Hypopyon....................... 319
Extirpation of the Eye : as for Proptosis, Exor-
    bitism,  Fall of  the Eye, Cancers of  the
    Eye and Orbit,.....................320—327
Artificial Eyes............................. 327
[Note on do., ..............................328

CHAPTER III.—Diseases of the Mouth, .. 329
Art. I.—Lips : as Harelip, Cancer, Eversion,
    and Mucous Bourrelet.  Hypertrophy, and
    Tumors of the  Lips, Atresia  or Contrac-
    tion of the  Mouth, False Anchylosis and
    Stiffness of the Lower  Jaw, Unnatural
    Adhesion of the Cheeks, &c.  [See  Dr.
    Mott's article on Immobility of the Lower
    Jaw, at the end of volume.]........ 329—354
Art. II.—Salivary Fistulas, as Fistulas of the
    Parotid Gland,  of Stenon's  Duct, Sub-
    maxillary Gland, &c,...............354—361
Art. III.—Ranula (or Grenouillette,) ....361—367
Art. IV.— Tumors of the Mouth,.............367
Art. V.—The Tongue: as for Filet, or in cases
    of Tongue-tie, Anchyloglossis, Tumors and
    Abrasion of the Tongue, Palate, &.C...363—377
Art. VI.—Posterior Fauces: as Hypertrophied
    Tonsils, Abscesses  and Incision of  the
    Tonsils, Cancer of the Tonsils, Excision of
    the Uvula,  Staphyloraphy,.........377—400
[Note on Staphyloraphy................... 395

CHAPTER IV.—Olfactory Apparatus..... 400
Art. I.—Nasal  Fossa : as for Foreign Bodies,
    Hemorrhage, orEpistaxis and Tamponing
    for the same, Polypi of the Nose, Polypi of
    the Velum Palati....................400—421
[Note on Calculi in the  Nasal Fossse, or Rhi-
    nolites, Osseous Plate in the  Diaphragm,
    Polypi of the  Frontal Sinuses, &c., ..... 416
Art. II.—Sinus Maxillare:  as Perforation of
    the Aveoli,  Foreign  Bodies,  Osseous
    Cysts,  &c,........................421—428

CHAPTER V.—Auditory Apparatus,......  428
Art. I.—External Ear: as Otoraphy, Tumors
    of  the  Lobe, Deformities of  the Meatus
    Auditorius, Foreign Bodies, Polypi, &c. 428-436
                                        Page
Art. II.—Internal Ear :  as perforation of the
    Membrana Tympani, and of the Mastoid
    Cells,  Catheterisin of  the  Eustachian
    Tube, &c...........................436—443
PART SECOND.—OPERATIONS WHICH
    ARE PERFORMED ON THE NECK,.. 443


CHAPTER I.—Tumors of the Salivary Re-
    gions, ................................. ,D-
Art. I.—The Parotid and Parotid Tumors, 443-445
[Note, Extirpation of the Parotid, by V. Mott,
    with plates,............................ 451
Art. II.—Sub-maxillary Gland,............. 455

CHAPTER II.—Tumors  of the Subhyoid
    Region,................................ 456
Art. 1.— The Thyroid Body or Gland,....... ib.
Art.  II.— Tumors  Foreign  to  the  Thyroid
    Body,.................................. 463

CHAPTER III.—Air Passages.............. 464
Art. I.—Bronchotomy: as for GEdematous An-
    gina, Croup, Tumors, and Engorgements,
    Foreign  Bodies  in  the Air Passages or
    (Esophagus,   Tracheotomy,  Cricoidean
    Laryngotomy, Laryngo-Tracheotomy.Thy-
    roidean  Laryngotomy,  Thyro-Hyoidean
    Laryngotomy, &c,.................464—478
[Note on Laryngotomy  and Tracheotomy for
    Foreign Bodies, Croup,  &c...........473—I'M
Art. II.— Catheterism of the Larynx,........ 484

CHAPTER  IV.—Alimentary Passages,-- 485
Art. I.—Catheterism of the (Esophagus :  as
    through the Nose, and by the Mouth, 485—487
Art. II.—Contraction of the Oesophagus,..... 487
[Note on Organic Stricture and Contraction
    of the CEsophagus,.................487—190
Art. III.—Foreign Bodies in the (Esophagus, 490
Art. IV.—QZsophagotomy,..................493
[Note on do.,..........................493—498



PART THIRD.—THE CHEST,........... 498


CHAPTER I.—Tumors..................... ib.
Art. I.—Tumors and Extirpation of the Breast, ib.
Art. II.— Tumors of the Thorax disconnected
    with the Mamma,....................... 506

CHAPTER II.—Effusions into  the Tho-
    rax, ................................... 507
Art. I.—Empyema: as for Effusions of Pus,
    Gas, the place for the Operation, &c. 507—518
[Note on Paracentesis of the Thorax......... 517
Art. II.— Wounding of the  Intercostal Artery, 518
Art. III.—Paracentesis of the Pericardium, .. 520
PART FOURTH— ABDOMEN,..
523
CHAPTER I.—Effusions, Cysts, and Fistu-
    las.................................... ib.
Art. I.—Paracentesis,...................... lb.
Art. II.—Humoral Tumors of the Liver,.....534
Art. III.—Cysts and Tumors  of the Ovarium
    and Lower Belly, and Ovariotomy,.... 535—540
Art. IV.— Tumors of  the Abdominal  Parie-
    tes,................................540—541
[Note  on Ovariotomy....................... 540
Art. V.—Fistulas in the Stomach,........... 541 
TABLE  OF  CONTENTS.
XI
                                         Page
PART FIFTH.—HERNIA,................  542


CHAPTER I.—Herniain General,........  ib.
Art. I.—Anatomical Remarks on the Anatomy
    of Hernia,.............................  ib.
Art. H.—Radical cure of Hernia: as by Com-
    pression, Position, Cauterization. Ligature,
    Suture, Incision, Excision, Scarifications,
    Organic Plugs, as of the epiploon or intes-
    tines, or invaginated integuments, or by a
    pouch of gold-beater's skin, &c. By In-
    jections of  Iodine,  &c. Radical cure of
    Inguinal Hernia by Castration,...... .547—560
Art. III.—Strangulated Hernia: as Obstruct-
    ed Hernia, Strangulated Hernia, Incarcer-
    ation of the Hernia, Peritonitis, Inflamed
    Sac,  Hydatid Tumors, Epiplocele, Taxis,
    Prolonged Taxis, Compulsory Taxis, Posi-
    tion, Baths, Bleeding, Purgatives, Opiates,
    Enemata, Refrigerants, Belladonna,  Hyos-
    cyamus, Acupuncture. Electro-Puncture,
    &c..................................560—580
Art. IV.—Herniotomy or Kelotomy, or the Ope-
    ration for Strangulated Hernia : as Instru-
    ments, Position, Incision   of the Integu-
    ments  and Subjacent Tissues,  Hydropsy
    of the Sac,  Adhesion of the Viscera,  Co-
    arctation  of the Ring,  Dilatation and Inci-
    sion, or Debridement to remove the Stran-
    gulation,   Repeated Debridements,  Epip-
    locele,  Immediate  Reunion.  Secondary
    Reunion after the Operation, Subsequent
    Treatment, Inflammation,  Peritonitis, In-
    ternal Strangulations, Hernia  with Gan-
    grene, or with Perforation of the Intestine,
    and  the Processes for the  same after the
    operation,  viz., Suture,  Canula of Fish
    (illie. Suture with  Invagination, Suture
    with contact of serous surfaces, &c. Acci-
    dental or  Artificial Anus,  and its Treat-
    ment, its Eperon ; Artificial Anus, with or
    without Eperon....................580—645
[Note on Enterotomy, to  establish an  artifi-
    cial anus ; Gastrotomy for do. in constipa
    tion  from intussusception ;  Enterotomy for
    Cancer of the Colon ; Voluntary Enterot-
    omy and Excision of 18 inches of intestine,
    followed  by  a  perfect restoration of the
    functions and of  health;  Colon opening
    into  the stomach ; Perforation  of the Il-
    eum, &c,..........................645—651)

CHAPTER II.—Hernia in Particular,.... 650
Art. I.—Inguinal Hernia : its Various Forms,
    External  Inguinal, either  Supra-Inguinal
    eventration, or  Incomplete Inguinal Her-
    nia, or through abnormal openings ;  Inter-
    nal Inguinal, either of the Tunica Vagi-
    nalis, as in the Fwtus or Adult; the parts
    composing an Inguinal Hernia, Complica-
    tions, Secondary Degenerations, Irreduci-
    ble Hernias, Rupture of the Sac, Hernial
    Bandages, Trusses, Pelotes, Strangulation
    of Inguinal Hernia, Operation,  Reduction,
    Dressing, &c........................650—681
[Note on cure of artificial anus ;  also on Radi-
    cal cure  of  Inguinal Hernia by Seton,
    &c,...............................680—681
Art. II.—Crural Hernia:  Anatomy of,  its
    Formation, Strangulation,  Operation  for,
    &c,...............................681-691
[Note on Femoral Hernia, with complication
    of Foreign Bodies and Worms, in the prac-
    tice  of Laurence Proudfoot, M.D.,  and
    V. Mott, M.D.,....................691—692
Art. III.— Umbilical Hernia : Anatomy, Ope-
    ration, &c..........................692—6S8
Art. IV.—Ventral and other Hernias :  in the
    Linea Alba; Obturatic, Ischiatic, Perineal,
    Vulvar, and Vaginal Hernias.........698—700
[Note on Internal Hernial Sacs, Diaphragmatic
    Hernia,  Statistics and Cases  of Hernia,
    &c. [See Atlas.]  ..................700—702
                                         Page
PART SIXTH.—ORGANS OF  GENERA-
    TION,.................................702
CHAPTER I.—Genital Organs of Man, ...  ib.
Art.  I.— Hydrocele.  Hydrocele in  man,  as
    Acute and Chronic Hydrocele ; Anatomy
    of;  Position of Testicle; Signs of Hydro-
    cele; Prognosis of;  Accidental Lacera-
    tion of the Cyst;  Palliative Cure of Hy-
    drocele ;  Radical   Cure,  by  Operation;
    Cauterization;  Tents,  Canulas,  Setons,
    Incision,  Excision; Partial Excision and
    Immediate  Reunion ;  by Injections  of
    Red  Wine, Sulphate of Zinc, Acupunc-
    ture, Iodine,  &.c.  Congenital Hydrocele;
    Hydrocele of the Hernial Sac, of the Sper-
    matic Cord ;  Infiltration ;  Encysted Hy-
    drocele,  &c.   Hydrocele  in  Women,
    &c,...............................702—738
[Note on Iodine Injections in Hydrocele, late
    Discussions at Paris, &c,............738—741
Art. II.—Hematocele,....................... 741
[Note o n Scrotal Hematocele, ...........744, 745
Art.  III.—Elephantiasis  of the Genital Or-
    gans, .................................. 745
Art.  IV.—Castration, and as a Radical Cure
    for Hernia,.............................748
[Note on New Practice of Incision into the Tu-
    nica Albuginea for Parenchymatous Or-
    chitis ; also  new  Cure for Pseudo-Fun-
    gus of the Testicle; also on M. Velpeau's
    celebrated Diagnosis of Debris of a Fmtus
    in the Scrotum, &c,.................759—764
Art.  V.—Diseases of the  Penis,............. 764
Phymosis;  Paraphymosis ;  Strangulation  or
    Incarceration of the Penis; Division of the
    Frenum ; Adhesion of the Prepuce to the
    Glans  Penis  :  Destruction  of Prepuce;
    Amputation of the Penis.................  ib


CHAPTER  II.—The   Sexual Organs  in
      Women,............................. 777
Art.  I.— Tumors of the Vulva: of the Labia
    Majora, Mons Veneris,  Clitoris,  Nymphs
    or Labia Minora, Vaginal Septa, &c, 777—785
Art.  II.—Imperforation of the Vulva,........ 785
[Note on Vaginal Occlusion from  Traumatic
    Lesion, &c,  Dr. Mott's Practice, &c,  785—789
Art.  III.—Puncture of the Uterus : Occlusion
    of the Neck  of the Uterus,  Retroversion,
    &c.................................789—792
Art.  IV.—Reversion of the Vagina,.......... 792
Art.  V.—Prolapsus of the Uterus: Excision of
    the Uterus,  Suture,  Contraction of the
    Vulva,.................................  ib.
[Note on Prolapsus,........................ 796
Art.  VI.—Reduction of the Womb and Vagina, 797
Art.  VII.—Pessaries for the Vagina and Ute-
    rus.  [See Atlas of Plates,].........798—803
Art.  VIII.—Foreign Bodies in the Genital Or-
    gans : in the Vagina and Uterus.....803—805
Art.  IX.—Polypi of the Uterus: Varieties and
    Processes for Extraction of, &c,.....803—820
[Note on  Polypi  of the Uterus, Dr. Bullen's
    Views, &c,........................820—825
Art.  X.—Cancers of the Neck of the Uterus:
    Processes, as Cauterization, Excision, &c,
    use of the Speculum Vaginae, &c, ...825—835
Art.  XI.—Extirpation of the Uterus : as  for
    Prolapsed Uterus, Inversion of Uterus, Re-
    duction of the same, Complete Inversion
    and Protrusion of the Womb, &c.....835—848
Art.  XII.—Vesico-Vaginal Fistulas : Cure of
    by Suture,  Erisrnes.  Cauterization, Ana-
    plasty, Obturation of the Vulva, &c.  848—861
Art.  XIII—Recto-Vaginal  Fistulas : Sponta-
  neous Cure, Suture, &c,..............861—864 
Xll
TABLE  OF  CONTENTS.
                                         Page
Art. XIV.—Entero- Vaginal Fistulas,.......  864
Art. XV.—Fissvres, Ruptures, and Suttireof
    the Perineum : Spontaneous Cure, Suture,
    Cauterization, &c...................805—872
Art. XVl.—Dystochia. (Difficult Parturition,)
    Symphysiotomy,  Cesarean Operation, 872—881
Art.  X V11.— Vaginal Uterotomy...........  881
[Note on the Cesarean Operation ;  Removal
    of the  Cterus by Ligature ; Tearing out
    of the Uterus; Tiemann's Speculum Va-
    gina et Ani, with plates,............881—887


PART SEVENTH.—URINARY APPARA-
    TUS,.................................  887


CHAPTER I.—Calculi of the Bladder,   ib.
Art. I.—Diagnosis of Vesical Calculi.......  ib.
Art. II.—Indications,....................  893
Art.  III.— Lithotomy : Perineal and  Infra-
   pubic Lithotomy, or  Lower Operation ; as
    the Lateral Method, or  Cystotomy, Little
    Operation, or the Process of Antylus or
    Paul of Egina, Process  of F. Jacques, F.
    Come,  Raw, Cheselden,  Foubert, &c. ;
    Median Lithotomy, or the Great Opera-
    tion ; Processes of Mariano, Vacca, &c.;
    the Oblique or Lateralized Operation, and
    Processes of Franco. Garengeot, Le Dran,
    F.  Come, the Author, &c.  The Trans-
    verse, ISi-lateral or Bi-oblique Operation ;
    Processes of Chaussier, Beclard, Dupuy-
    tren,  &c.  The Quadrilateral Operation.
    Lithotomy Instruments,  [See Atlas of
    Plates,] as the Lithotome, &c, Forceps,
    State of the Calculus.  Foreign Bodies
    that are introduced, or escape  into the
    Bladder; Operation for Spasm of the
    Bladder, Wounds of the Intestine, Fistu-
    las,  &c.  Perineal Lithotomy.   Recto-
    vesical Lithotomy;  Wounds from. Sta-
    tistics of, &c. The Hypogastric, or Su-
   pra-pubic Operation ; Wounds  from. &c.
    Lithotomy  in Wom'm;  Vesico-Vaginal
    Lithotomy; Urethral Methods,......895—978
Art. IV.—Lithotrity ;  Rectilinear  Mithod;
    Civiale and Method. Instruments ; as the
    Litholabe, Percussor, Lithotritors, Stone-
    breakers, Perforator, Drills, Mandril, &c.
    [See Atlas.] Processes, Crushing. Cur-
    vilinear Method.  Instruments  of M. Ja-
    cobson, M.Heurteloup, M. Leroy, M. Ci-
    viale, &.C.'   Parallel of  Lithotomy and
    Lithotrity;   Statistics  of each method,
    &x................................978—1019

CHAPTER II.—Urinary  Calculi  Exter-
    nal to the Bladder,................ 1019
AhT. I.—In the  Kidney and Urethra: Ne-
    phrotomy, and Ureterotomy,......-.1019—1021
Art. II.— Urethral Calculi:  in the tissue of
    the Vaginal Septum,  Prostate, Urethra,
    &c................................1021—1025
[Note on  Lithotomy and Lithotrity.....1025—1031
PART  EIGHTH— DISEASES OF  THE
    URETHRA,........................... 1032


CHAPTER I.—Catheterism,.............   ib.
Art.  I.—Methods and Instruments : Cathe-
    ters, Bougies, Sounds, &c.  Catheterism
    in Women,.......................1032—1042

CHAPTER II.—Contraction of the  Ure-
    thra.................................. 1042
AttT.  I.—Forced Catheterism : Forced Evac-
    uative Catheterism ;  Forced Dilating Ca-
    theterism, &c,....................1042—1046
Art.  II.—Forced Injections,................ 1046
                                         Pago
Art. III.—Incisions and Scarifications on the
    Contracted Part,....................... 1047
Art. IV.—External Incisions ;  Button-hole
    Incision,.............................. 1050
Art. V.—Dilatation;  Contraction  of the
    Meatus, &c.......................1052—1059
Art. VI.— Cauterization,.................. 1059
Art. Xll.—Treatment by  Topical Applica-
    tions.................................. 1067
Art. VIII.— Contraction resulting from a loss
    of Substance in the Urethra............. 1067
Art. IX.—Polypi of the Urethra: in woman,
    man, &c,............................. 1069
[Note on Polypi of the Urethra............. 1070
Art. X.—Abnormal Dilatation of the  Ure-
    thra................................... 1071

CHAPTER III.— PlNCTIRE OF  THE BLAD-
    DER................................... 1071
Art. I.—Perineal Puncture,................  ib.
Art. II.—Puncture through the Rectum,.... 1073
Art. III.—Hypogastric Puncture,.......... 1074
Art. IV.—Parallel of the various Punctures :
    Recto-Vesical  Puncture ;   Supra-pubic,
    through the symphysis pubis, &.c, 1076—1078

CHAPTER IV.—Urinary Fistulas.......1078
Art. I.—Recto-Vesical Fistulas,............  ib.
Art.  II.—Internal Fistulas,...............  1079
Art. III.—Fistulas of the Urethra,.........   ib.
Art. IV.—Hypospadias,................... 1082
[Note on Hypospadias................1082  1085
See also Atlas.


PART  NINTH.—DISEASES  OF  THE
    RECTUM.............................^ 1085


CHAPTER I.—Defects of Conformation,   ib.
Art.  I.—Imperforation:  to re-establish the
    Natural Anus,  Anus at the Fourchette,
    Seeking for the Intestine,  to establish an
    Artificial Anus, ..................1085—1093
Art. II.—Contractions  of the Rectum : Dila-
    tation, Incision, Cauterization, &c, 1093—1095
[Note on Polypi of the  Rectum.........1095, 1096

CHAPTER II.—Bodies  to be Extracted
    from the Rectum,.................... 1096
Art. I.—Foreign Bodies in  the Anus,  ..1096—1098
Art. II.—Polypi of the Rectum.............. 1098
Art. III.—Hemorrhoids and Hemorrhoidal
    Tumors : Processes by  the Ligature, Ex-
    cision, &c,............................ 1099

CHAPTER III.-The  Fall,  or Prolapsus
    of the Anus,......................... H03
Art. I.—Reduction,........................   ib.
Art. II.—Debridement,.................... 1104
Art. III.—Extirpation,....................   ib.
Art. IV.—Process of  Hey and Dupuytren, .. 1105
Art. V.— Cauterization,.................... 1107
Art. VI.— The  Intestine Protruded  through
    the  Anus,............................. 1108
Art. VII.—Fissures at the  Anus : Signs, Cu-
    rative Treatment; as Cauterization, In-
    cision, &c........................1108—1116
Art. VIII.—Fistulas, or Fistula in  Ano : as
     External Blind, Internal Blind, and Com-
    plete ; Diagnosis, Treatment, &c.,. .1116— ~" f*
Art. IX.— Cnnccrs of the Anus : Method by
     Exti rpation or Excision, &c,.......113?
[Note, Concluding Remarks on some of '
     Subjects treated of in  this volume,
     especially on Immobility of the Jav
     V.  Mott,.......................
 Index to the Three Volumes........ 
          NEW  ELEMENTS

                     OF


OPERATIVE   SURGERY.
SECTION  TWELFTH.

          TUMORS.
                         CHAPTER  III.

                       LYMPHATIC TUMORS.

   I mean here by lymphatic tumors, the tumors which are  formed
by degenerate lymphatic glands, (ganglions.)  It is a class of tumors of
which,  up to the present, scarcely anything has been said in works
upon operative surgery.  Generally the treatment of them has been
confined to topical applications and general remedies, (medications ;)
but I have long since satisfied myself that surgical processes are fre-
quently their best,  and sometimes, in fact, their only remedy.  This
is also, I believe, the opinion of M. Warren (on Tumors, etc., p. 162.)
Those tumors which are sometimes the result of a simple hypertrophy
of the natural elements  of the organ, at other times formed by the
establishment of a  variable number of clots (grumeaux) of concrete
pus, or of tuberculous matter, or of cysts or purulent abscesses (foyers)
which are disseminated as it were in the parenchyma of the hyper-
trophied ganglionic tissue, represent masses which are very tardy
in contracting adhesions to the organic layers which surround them.
When they have once  acquired a certain degree of hardness, and
have continued beyond  six months or for a year, it is rare that they
disappear by resolution, (i. e. resolvents.)  They then rest on  the
tissue like  so many foreign  bodies, whose internal  morbid action,
(travail central,) usually very slow, approaches by degrees the neigh-
boring ganglions, (i. e. lymphatic glands or ganglions,)  produces an
indefinite enlargement, or a fungous degeneration, or suppuration, or
ulceration of the primitive masses.  We may conceive, then, the ad-
vantage which would result to patients  if it were possible to destroy
such tumors surgically.  We have in practice three modes which we
may resort to in such  cases with some chances of success:   These
are crushing, setons and extirpation.
                                 1 
a
NEW ELEMENTS OF OPERATIVE SURGERY.
                     Article I.—Crushing.

  The crushing of engorged lymphatic ganglions, which was proposed
and put into practice in a certain number of cases by M. Malgaigne,
is not so irrational as might at first view  be  supposed.   The tumor
broken up (broyee), comminuted (morcelee), and reduced into a pulp
(bouillie) underneath the  integuments which remain intact, is  then
placed in conditions similar to those of a tumor formed by clots of ef-
fused blood.  Permanent compression succeeding to crushing, proper-
ly so called, sometimes induces the matters thus broken  up to be ab-
sorbed, and then  resolution is thereby evidently rendered more easy ;
only that it is unfortunate that the inflammation  from being chronic,
often passes in this manner into an acute  state, and to such degree as to
sometimes transform the  lymphatic tumor into  a true abscess, the
healing  (mondification) of which is then always tedious  and difficult.
There are also a great number of cases in which the crushing cannot be
performed but with great difficulty.   It cannot in fact., be undertaken
but for tumors which are absolutely external, and  for  those which
rest on some solid point of support.
  M. Malgaigne, who has employed  crushing only for ganglions of
the groin, used for this purpose the thumb or thumbs  applied  with
force and directly from before backwards on each  tumor.  In pro-
ceeding in this manner there is sometimes need of a great degree of
force, and most of the tumors  cannot  be broken up by this mode.
There might also, perhaps, be danger in  this region of doing some
mischief to  the  femoral artery.  In that region, as well  as in the
axilla, and under the jaw, and  in the neck, I have  found it answer
better, when the  condition of the parts allow of it, to seize the tumor
between the fingers  or between two smooth pieces  of  pliant wood,
and thus to  compress it with a sufficient degree of force upon the
sides, and  successively  upon  all the  points of its circumference.
Many lymphatic ganglions, treated by this process, have, as it has
appeared to me, restored themselves afterwards with a promptitude
which the long duration of the disease had scarcely permitted me to
hope for.  But I hasten to declare that crushing nevertheless,  is a
method which is exceedingly uncertain,  and one that  cannot be at-
tempted but in a very small number of cases.

                     Article II.—Setons.

  M. Levanier, a surgeon of Toulon, asserts that he has succeeded in
effecting the rapid dispersion of inguinal tumors of very long standing
by traversing them with small setons.  These consist of simple threads,
which are passed by means of a needle through the entire thickness
of the ganglion,  in which they are left to  remain for four, five or six
days, and then withdrawn to be replaced by new  ones in different
directions.  One, two, or a greater number of threads are introduced
in this manner at the same operation  or after  an  interval of some
days, in the same way nearly as I have said in speaking of  erectile
tumors.   The suppuration which is established in the  track  of each
of these threads soon reduces the engorgement of the ganglionic tissue, 
LYMPHATIC  TUMORS.
3
and the molecular or interstitial absorption of the tumor afterwards
continues to go on without interruption to the termination of the cure.
  Without conceding as much confidence to this method as  M. Le-
vanier, which moreover I have as yet employed but on two occasions,
I nevertheless believe  it worthy to be made trial of, especially for
ganglions that are of little volume,  situated in regions where extirpa-
tion would be  dangerous, and existing in patients who prefer submit-
ting to all the  uncertainties of doubtful processes, rather than  recui
to the resources of a cutting instrument.

                   Article III.—Extirpation.
   Up to the present time, lymphatic ganglions have not been sub-
jected to extirpation but by a very small number of surgeons.   The
reason of this peculiarity is owing to two circumstances:  1, lym-
phatic ganglions scarcely ever become engorged or degenerate except
from the influence of remote causes; so that there are almost always
a certain number of them diseased at the same time, and that it is
rarely possible to remove them all; 2, considered as the  result of the
disease  denominated scrofulous, they  have been deemed to form only
a symptom, or indication (ombre) of  a general affection,  so that their
removal would remedy nothing, or the least important element only
of the  malady.  In this  matter we must understand ourselves cor-
rectly.  If the lymphatic tumors are  in reality imputable to a  gene-
ral constitutional  affection, their extirpation should not be attempted.
It is the cause which we must first attack and not this feeble symp-
tom.  Nor should we moreover extirpate them, when, notwithstand-
ing they have been produced  by an  external cause, they are nume-
rous and diffused, [disseminees—i. e. existing in various regions. T.]
But if there be one only, or if notwithstanding their number, they
are well isolated and easy of dissection, we are not  to  hesitate.  If
there is reason to suppose that the  constitution  is good, and that the
interior of the  sphlanchnic cavities  is  not compromised, their removal
offers incontestable advantages.  Different also from cancerous tu-
mors, degenerate lymphatic tumors possess also this remarkable fea-
ture, that  the extirpation of those that are most  diseased or most
voluminous, rather favors than prevents the  diminution (degorge-
ment), resolution  or dispersion of the  others.  Thus have  I frequently
confined myself to the extirpation of a single one, or  of a certain
number of these tumors, though  I knew perfectly well beforehand
that I should be obliged to leave  many others.  Having thus  extir-
pated those which were ulcerated, or very salient externally, or those
which  occasioned most inconvenience  and  deformity,  I have  fre-
quently noticed that the others continued in the same condition they
were before, or that they afterwards imperceptibly disappeared. More-
over,  those that  have advanced farthest being destroyed,  nothing
prevents our healing the  others by the same topical applications,  and
of submitting the patient to the different courses of general treatment
which are deemed to possess the greatest efficacy.  When we reflect
upon the  manner in which these  tumors terminate  by  suppuration,
and upon the character of the ulcers, burrowings (decoUements)  and
cicatrices  which they establish in the skin, even when they get well
without an  operation,  we may well be permitted to  consider the 
i
new elements of operative surgery.
advantages which their extirpation might  procure.  The extirpation
having been once decided upon, there is no serious preparation required
for the patient:  if the skin is not changed and the tumor be not of a
large size, we may confine  ourselves to a simple  incision  of the  in-
teguments.  In  the contrary case,  we  comprise  the  degenerated
tissues in an elliptical incision more or  less elongated,  as  in  the ex-
tirpation of any other kind of tumors.  In the place of the T or cru-
cial incision which are generally preferred when the tumor is of a
large size, I am in the habit  of substituting the  semilunar incision, so
as to construct a flap which  is reversed from the  free border to the
base, and which allows of every possible  facility for the rest of the
operation.  The incision of the integuments having  been effected,
the surgeon  proceeds to the dissection of the  tumor.  In the event
of this being occupied by cysts or purulent or tuberculous layers, we
should be cautious not  to excise their tissue.  In whatever way we
proceed, it is better to hook fast of the tumor with a  simple or double
erigne, which should be then immediately consigned to the care of
an assistant.  Then holding  the parts asunder  by means of the  fin-
gers or forceps, the surgeon  divides and detaches them with caution
by means  of  a straight bistoury.  As  these tissues are only super-
posed upon (appliques) or cling loosely around  [colles—means here
to invest, or to be loosely attached to, T.] the ganglion, it is generally
easy to isolate them from it.   Also the enucleation [of the tumor]  by
means of the  finger or the handle of the scalpel ought in these cases
to be substituted for the  cutting instrument, whenever we perceive
that there would be any actual danger of wounding the large sized
vessels or nerves.   On the other hand,  masses to be extirpated that
have no character  of malignity, do not exact that we should extirpate
the last portions of them with the same care that we do in cases of
cancerous tumors.   So that  in all cases during the course of the dis-
section, the bistoury ought to be directed upon the exact limits or
circumference of the tumor rather than in an opposite direction.  We
may for the same reason make use of the fingers for the purpose of
detaching or  even tearing out the remaining  roots of the diseased
ganglion, when it is deeply situated, or is found to be implicated with
organs which it would be dangerous to approach  with the bistoury.
In delicate  regions, and where the lymphatic tumors  are  composed
of many lobes united by simple pedicles, there  is no  improprietv in
detaching that which presents itself the first, in order afterwards to
seize successively upon the others.  We thus cause less destruction
of parts, and more easily preserve the other tissues.   Of all other  tu-
mors moreover, the lymphatic or ganglionic are those which the most
frequently require  a ligature to be applied  to their root when we un
dertake their extirpation.  In fact, if,  after  having isolated their cuta-
neous surface or circumference, we should have any apprehension in
separating the root, that we  might open into large veins or arteries
which it might afterwards be difficult to reach or tie, we strangulate
these tumors as deep as possible by means of a ligature composed of
two to five braids of thread,  so as to  interrupt their entire circulation
in such manner as to cause their separation, or to enable us to excise
them as we have  said under the chapters on  Cutaneous and Erec-
tile Tumors. 
LYMPHATIC  TUMORS.
5
   Dressing.—After the  extirpation  of lymphatic ganglions, the he-
mostatic means and the dressing of the wound exact the same  pre-
cautions as after all capital operations.  I ought to remark however,
that except in a small  number  of cases,  immediate union does  not
here succeed, and that in attempting it there are more inconveniences
than advantages.   The  wound being almost, inevitably anfractuous
and constituted of irregular cavities, necessarily presents walls which
it is next to impossible to bring into  exact coaptation.   Their tegu-
mentary borders are closed and agglutinated with facility; but collec-
tions of blood, lymph or  pus, which are soon established underneath,
sooner or later compel us  to re-open them,  and favor the development
of purulent centres, and  phlegmonous erysipelas, a hundred times
more formidiable than  a wound which has been left to discharge by
second intention.  Unless, therefore, the ganglion removed should be
smooth (unique) and the wound exhibit great regularity, I would  not
advise in these cases to attempt union by the first intention.  I have
now (1838) performed extirpation of lymphatic tumors on near a hun-
dred persons, and none of those who have been dressed in the manner
I am about to describe, have  experienced serious accidents; whilst I
have almost always found phlegmasias and suppurations supervene in
those in whom I have attempted the cure by immediate union.  I first
introduce small balls of fine lint into the bottom of all the cavities, and
fill up in this manner the entire wound, which I cover over with per-
forated linen, then  with  plumasseaux, compresses and  a containing
bandage.  When the blood flows in  abundance, without there being
any large arteries to tie, I pile up these balls in such manner that they
may exercise a sort of compression under the  bandage.  I use but a
small number of them on the  contrary, and such as are  of the most
pliant kind, when there is nothing to fear in regard to hemorrhage.  In
proceeding in this manner the  dressing is prompt and easy, and  the
results simple.  At  the end of  two or three days we may, without
inconvenience, remove the whole dressing down to the perforated
linen.  A day or two more gives time for the exudation from the wound
to saturate the balls which fill it, and to allow of our  removing them
without any effort and without  occasioning any serious  pain.  Each
day we deposit in the wound a less quantity of these balls, and  no-
thing is so rapid as  cicatrization in these  cases, so much so in  fact
that most of the patients are cured in  the space of from fifteen days to
a month.  It is besides remarkable that out of near 100 patients ope-
rated upon by me for these kinds of tumors, there are up to the pre-
sent time, but three who have died,   I am so much the more surprised
at this,  because in a great number of them, the operation was long,
laborious, painful and really serious.   Though in some of these  pa-
tients  there  still remained  other  degenerate lymphatic ganglions,
though  in two or three of them these new tumors continued after-
wards  to undergo a great enlargement, it is certain that  in the great
majority of cases, the cure was prompt and radical, and that the gan-
glions that were left have, in the greatest number of instances, ulti-
mately retrograded, by gradually re-assuming their natural condition.
Up to the present time I have performed extirpation of lymphatic
tumors only in the inguinal, humeral, axillary, supra-clavicular, sub-
maxillary, parotid and  sterno-mastoid regions. 
6
NEW ELEMENTS OF OPERATIVE SURGERY.
                  § I.—Ganglions of the Groin.
  Lymphatic tumors of the inguinal region present three modifications*
which it is important should not be confounded : those which are con-
nected with a venereal affection ; those which depend upon some dis-
ease of the foot or leg; and those which belong to the class of cancers.
In those cases where their origin depends upon a syphilitic infection,
we must never, however ancient they may be, attempt their extirpa-
tion before having submitted the patient to the specific treatment of
venereal disease.   If the alteration of the lower limb which has been
the cause still exists, it is also prudent when practicable, to effect the
removal of this before  every thing  else.   But if, when these pre-
cautions have been attended to, or are not practicable, the tumor is
hard, of a certain volume, and has existed more than six months, after
having  been unavailingly attacked by  topical applications and  the
suitable general remedies, then is the operation indicated, and  it  be-
comes proper to perform it.  We should not nevertheless under these
circumstances,  undertake it in cases of cancerous affection, or where
the chain  (chapelet) of lymphatic  ganglions which is prolonged into
the iliac fossa was  at the same time implicated in the least degree of
engorgement.   In cases of hypertrophy, however, or of simple degen-
erescence whether fungous or tuberculous, a slight degree of engorge-
ment of the supra-inguinal ganglion would not be a formal counter-
indication ; as the removal of the principal tumor would have the effect
in many cases to cause it to disappear.  The  extirpation of lympha-
tic tumors in the groin is one  of the  delicate  operations of surgery.
The proximity  of the crural artery and vein, and their branches,  and
of the internal saphena vein, and the femoral nerve, will always render
it difficult and formidable.  The dangers it involves are  nevertheless
not the same in all cases.  So long as it is a question only of sub-cutane-
ous ganglions, it is  in fact possible,  with a little  address and anatomical
knowledge to accomplish it without danger; but if the deep-seated gan-
glions formed the tumor, it would become necessary to renounce it, or
to decide upon tying the vessels on  the side of the iliac fossa, for chance
alone would enable us to avoid them during the operation.  When we
operate for the extirpation of the lymphatic glands enveloped in the sub-
cutaneous fascia, we may also find ourselves placed in two different po-
sitions.  Sometimes in fact, it is the sub-inguinal ganglions that are to
be extirpated, while  in other  patients it is the glands in the inguinal
groove itself.
  A. Sub-Inguinal Tumors.—Here the tumors have no relation with
the crural vessels properly so called ; they are separated from them not
only by the fascia lata, but moreover by the internal border of the sar-
torius muscle.  It is upon the line of the saphena vein that they are situ-
ated, and not in the direction of the crural artery, unless however, thev
should be  prolonged  as far as to the external orifice of the crural ca-
nal  above.   The patient being placed upon his back, should have the
limb reversed upon its outer side and moderately flexed.   An assistant
fixes it in this position, while another looks to and prevents the move-
ments of the pelvis.  The surgeon  placed on the outside and provided
with an ordinary bistoury, divides  the integuments from above down-
wards for the right thigh, and from below upwards for the left  thigh, 
LYMPHATIC  TUMORS.
7
as has been said above.  We might in like manner place ourselves
always on the right, in order that the incision might always be made
from above downwards, or on the left side if we  preferred perform-
ing it from below upwards for both sides.   We may go with the first
cut and without fear down to the sub-cutaneous layer.   After hav-
ing isolated each side of the wound  from the corresponding parts of
the tumor,  wre raise up the  latter  and give the erigne to an assistant,
who should carefully follow all the movements of the operator.   Af-
ter having  dissected it upon its  sides to nearly as far as  its root, the
surgeon detaches it by small cuts from below upwards,  and  in such
manner as  not to wound the internal saphena vein.  If, however, the
situation of the  tumor, or any particular circumstances  should have
led to the wounding of this vein, it would suffice to compress it below,
and afterwards to manipulate the instrument with extensive  strokes,
in order to terminate the operation rapidly.  Nevertheless the sur-
geon ought to be then aware that in this region the upper end of the
veins sometimes gives rise to a  pulsating (saccadee) hemorrhage, suf-
ficiently obstinate to oblige him on his part to compress the  artery,
or even to  apply the ligature to it.  However, it rarely  happens  but
in approaching  their upper extremity, that it becomes  advisable to
adopt serious precautions in  relation to the arterial vessels.   Upon
the supposition that we  should  have occasion here for the semilunar
flap of which I have spoken, it would be better to turn its free border
inwards than to the outside;  in the same manner  that we should di-
vide the inner rather than the outer lip of the  simple incision, if we
preferred using  the T incision.  As to the dissection of the ganglions
themselves, prudence requires that we should perform it on the inner
side first, then on the outer side,  then  from below upwards,  and to
terminate at the inguinal extremity.  In this  manner nothing would
then prevent us, should they appear to be. prolonged by means of a
pedicle into the  crural canal and to the side of the vessels, from stran-
gulating  their root before  completing  their excision.  If immediate
union can be attempted after extirpation  of lymphatic  tumors, it is
assuredly in the region under  consideration.   We should have re-
course to it if the wound is regular, if the cutting instrument has suf-
ficed for the division of all the tissues, and if after the  ligatures  are
applied, the sanguineous exudation has  a tendency to cease of itself.
For this purpose the limb is straightened, after which, by means of a
sufficient number of strips of adhesive  plaster, we approximate and
keep in contact  the two  lips  of the  wound.  A perforated  linen, a
large gateau of lint, and some turns of the roller bandage with a spica
to the groin, complete the dressing.  In the contrary case, the solution
of continuity is filled  with small balls of lint before  applying  the
other  portions of the dressing of which I have just spoken.  In either
case, we afterwards place the  ham and the leg  upon a pillow in a
moderate state of flexion.
  B. Inguinal Tumors.—In the fold of the groin, lymphatic tumors are
situated sometimes on the inner and sometimes on the outer side, or on
the side towards the pubis or that  of the spine of the ilium, and some-
times  even  on a  line with the femoral artery.  This difference of situ-
ation as may be imagined, renders their removal either very simple
or exceedingly difficult:  In a man in whom ten months  before I had 
8
NEW ELEMENTS OF OPERATIVE  SURGERY.
extirpated a cerebroid cancer from the scrotum, I wras obliged to re-
move a tumor of the same  nature which had developed itself in  a
lymphatic ganglion external to the symphisis pubis, and which, hav-
ing acquired the volume of the first, had extended outwardly as far as
upon a line with the femoral vein.  In another case I saw  a  purely
lymphatic tumor which occupied the entire space comprised between
the antero-superior spinous process of the ilium and the track of the
vessels.  A woman upon whom I operated in 1830 at the hospital of
La Charite, had in the fold of the groin a lymphatic fungus of the size
of an egg and which had been ulcerated for  more than  a  year and
was situated in the front part of the crural canal itself.  Such facts
are not rare, and it would be easy for me  to show numerous  exam-
ples of them.   To perform the operation the patient should be  placed
and held as in  the preceding case.  Nor can any  precise rule be
given here for the direction  of the incision of the integuments.  If
the straight incision would answer, it should be made in the direction
of the fold of the groin or of the long diameter of the tumor.  If the
curved incision should be preferred, or become necessary to be em-
ployed, the free border of the flap must be made upon the outside and
below, in which direction also the outer lip of the first incision  should
be divided, provided the T incision should be  thought most advisable.
Internal tumors  should be dissected  in -the  manner of sub-inguinal
tumors, first  upon  the inner side, then outwardly^ and finally from
below upwards.  The external ganglions should be dissected by a rule
directly the reverse, and this in order to reserve for the last thing the
most delicate stage of the operation, to wit, the isolation of the tumor at
the most proximate point to the vessels. By means of these precautions
we may proceed without any very great degree of danger as high up
as to Poupart's ligament, or on a line with the  apex of the fossa iliaca.
When the diseased ganglion  occupies the middle of the groin, we iso-
late it successively upon its two sides up and down, in order not to lay
bare the pedicle until the  last thing.  So long as the surgeon, in order
to effect this, is not obliged to divide the aponeurosis, there is nothing
to fear, and should the tumor not be prolonged into the iliac canal, he
may cut off its root without a previous ligature.   But should he at
all apprehend the extension of the pedicle of the tumor to the  neigh-
borhood of the trunk of the saphena, he will,  after having reduced it
to a small volume,  surround it with a ligature and strangulate  it with
force before excising the ganglionic mass on the outer side.  In the
case of the woman I have just mentioned, I was obliged to  lay bare
the saphena vein as far as its entrance into the crural vein; but by
dissecting the tumor horizontally I was  enabled to  isolate it without
any  ligature,  though  the artery was afterwards  noticed upon the
inner side of the bottom of the wound.  I would not  hesitate, there-
fore, to attack lymphatic tumors in this manner, even in the iliac fossa,
should they be prolonged  to that part, provided they were situated ex-
ternally to the vascular trunks.   Even  if it were necessary I would
divide the ligament of Fallopius, in order that we might by means of the
finger, tear out these tumors or enucleate them in such manner as not
to run any risk of  wounding the principal arterial branches.   But as
I  have  already said, I would no longer hazard such an attempt if the
tumors were cancerous, or the vessels surrounded as  it were  by the 
LYMPHATIC TUMORS.
9
tumors, and that there was ground for believing that there existed de-
generate ganglions in the neighborhood of the lumbar region.  The
dressing in the groin presents some difficulties in addition to those of
the preceding case.   The application of adhesive straps in this place
offers but a feeble resource. The tissues of this region are less homo-
geneous, and the disposition of the skin there is very illy calculated for
primitive agglutination.  Nevertheless, if the wound  is uniform and
in the direction of the inguinal  groove, a  slight flexion  of the thigh
may be found sufficient to maintain the two lips of the wound in co-
aptation.   With  this  exception the dressing flatwise, by means of
small balls of lint, the perforated linen, the  gateau of  lint  and the
spica, appears to  me to be decidedly preferable.
   [Having purposely devoted a great deal of personal investigation
and practice  while at the Seaman's  Retreat Hospital,  to dressing the
ugliest kind of shelving, jagged and leaden-edged, deep, sinuous, and
irregular wounds left in the hollow  of the groin in syphlitic cases, by
burrowing abscesses and discharges succeeding to buboes and mercu-
rial drugging, and where the wound penetrated sometimes to the depth
of  an inch and a  half or more,  and  as high up as the crural arch and
inguinal canal; I can testify to the  pre-eminent advantages  of tight,
forcible strapping by multiplied and very long strips of adhesive plas-
ters, decussating  each other on the abdomen and down and across
the thigh in every direction, so as to form a firm stellated support, or
covering, requiring only a slight inward flexion of the thigh and per-
severing use  of this mode to hasten  granulation from the bottom, and
a  perfect coaptation of the edges with great rapidity and without the
necessity of any auxiliary means but stimulating injections every few
days this dressing is renewed.  If they succeed thus with the  gene-
ral constitutional  treatment in such desperate chronic anfractuous and
cavernous  wounds, surely they  should never be neglected in the fresh
wound left by extirpating lymphatic glands. T.]

               §  II.—Lymphatic Tumors of the Arm.

   Although lymphatic tumors may become developed upon the track
of the cephalic vein and in the  deltoid  region, it is nevertheless al-
most exclusively  upon the inner side of the  arm that these tumors
have  been noticed.   Here they may  be found at all  the  different
points of the  track of the  artery.   Nevertheless it  is at an inch 01
two above the inner condyle that they are most frequently met with.
To extirpate them in  this region  the arm  must  be held  off from
the trunk,  and the fore-arm extended  in supination.  A longitudinal
incision ordinarily suffices.  Commenced  above  and  terminated be-
low the tumor, it  almost always allows of our arriving  immediately
upon the pedicle of the latter.   It is moreover important during the
dissection,  that the lymphatic  mass should be properly drawn out
from between the lips  of the wound by an  assistant provided with
an erigne, while another assistant should always stand ready to com-
press the brachial artery in the direction  of  the axilla.   The tumor
having been detached from the  biceps in front and the triceps behind,
may afterwards  be isolated upon  its deep-seated face  without any
very great difficulty, and without  the danger  of wounding  any- 
10            NEW  ELEMENTS  OF OPERATIVE SURGERY.

thing, if the surgeon is careful to carry the point of his bistoury par-
allel with the plane  of the  interior  surface of the arm, and to graze
with accuracy the  ganglionic  tissue.   The ulnar nerve,  the median
nerve, and the  brachial artery, which it quite frequently touches,
would nevertheless  oblige him to strangulate the pedicle of the  tumor
with  a  strong ligature,  should it send  off any prolongations  be-
tween them, or should it appear too difficult or dangerous  to complete
its enucleation either with the fingers or the handle of the scalpel. Here
also union of the wound by first intention, offers some prospect of suc-
cess.  Circular strips of adhesive plaster and a graduated compress
on  each  side, the perforated linen, gateau  of lint, square compress,
and roller bandage, will always offer a facility  for this, unless there
should be particular difficulties in the way ; we should therefore have
recourse to it in the greater number of cases.  If however, the  slight-
est accident  should supervene, or  the least, difficulty  interfere, we
should recur immediately to the small balls of lint and the simple dress-
ing.  The limb is then placed in semi-flexion and upon a cushion or
pillow, until the stage of the primitive accidents has passed by.

             § III.—Lymphatic Tumors of the Axilla.

  The hollow of the axilla is a  region where the lymphatic ganglions
frequently become engorged and degenerate.   Diseases of the  breast
and all those  of the  thoracic limb, occasion there a sympathetic  action
(retentissement), which makes the hollow of the axilla the  locale (cen-
tre of an infinity of tumors of  different kinds, but which almost  all
of them, have the lymphatic ganglions  for their seat.   If it  be true
that surgeons rarely decide upon extirpating these kinds of tumors,
it is in part owring to their nature, which does not allow of our always
considering them as a local and independent disease, and again, be-
cause the operation is in itself of a delicate nature, and one which is in
reality serious.  The axillary vein and the branches which it receives
in the first  place expose us to  a sufficiently  abundant hemorrhage
when we happen to wound them, and afterwards there is danger of
that introduction of  air which appears so frightful and  so difficult to
prevent in certain regions, (see Vol. I.)  The artery of the same name
which it may be impossible to avoid,  and the nerves of the brachial
plexus also constitute so many circumstances to arrest the  hand of the
operator.   In adding to these that the manipulations of the bistoury
are also necessarily restricted  by the arrangement and relations of
the pectoral  muscles in front, those of the shoulder behind and  on
the outside, and of the chest on the inner side, we have  a sufficient
explanation of the  reserve  exhibited  by surgeons in this  matter.
Having, however, frequently encountered lymphatic  tumors  of the
axilla which nothing  could  disperse,  and which were gradually
conducting the patients to the tomb, I have  thought nevertheless that
I could surmount those objections,  and now extirpate tumors  of the
axilla, after the same indications as those for the inguinal region; it is in
fact an operation which, since the year 1837,1 have performed a great
number of times, and under circumstances greatly diversified.  From
whence I have acquired the conviction that this operation, as I am
about to show, is in  fact much  more frightful [effrayante, i. e., in ap- 
LYMPHATIC  TUMORS.
11
pearance, T.] than in reality dangerous.   Many of the patients upon
whom I have performed it, had tumors of an enormous volume, which
raised up the pectoralis major, surrounded the brachial  plexus  and
vessels, or were prolonged  at their upper  part  as  high up as the
supra-clavicular depression.   Out of an aggregate of about 25 exam-
ples which I could enumerate  at the present time, there have been
only two cases of deaths; one of which  was a young woman upon
whom I  operated  in 1828 at  the clinique of M.  Bougon.   The
tumor, which was of the size of the head of an adult, completely filled
the hollow of the  axilla, ascended as high up as above the  cla-
vicle, and  required an extremely extensive dissection.  The patient,
after  having exhibited some encouraging indications of a cure, was
seized with a pleuritic effusion  and died  at the end  of three weeks.
The second patient was a woman nearly sixty years of age._  All the
ganglions of the axilla had to be torn out, one after the other ; an enor-
mous cavity was the  result, which, however, was in great part filled
up when a diffused (ambulant) erysipelas  supervened and carried the
patient off.  A third patient who had undergone a similar dissection,
died at the expiration of two months, in consequence of accidents
disconnected with the operation.  All the others operated upon re-
covered, the" most of them  very rapidly, that  is to say, within the
space of fifteen days  to a month or six  weeks.  An inconvenience
which retards the cure in this operation, where  we are  obliged to
liberate  the part from its ganglions, is the interruption to  the circula-
tion of the lymph, and a tendency to engorgements and infiltration of
the hand and fore-arm.  There may also result from it so great a con-
traction  of the  hollow of the axilla, that the movements of the shoul-
der and  the separation of the arm, especially from the trunk, may be
greatly obstructed.   The manner of performing the operation, though
varying  according to the size and precise situation  of the tumor, is,
however, reduced  to  two processes: one which consists in penetra-
ting into the hollow of the  axilla without dividing the muscles; the
other in  dividing at first through  the lower border of the pectoralis
major muscle, or even the whole thickness of the two pectoral mus-
cles as high up as to the neighborhood of the clavicle.
   A.  By the hollow of the axilla.—It rarely happens that the incision
at the hollow of the axilla does not  answer for the operation in ques-
tion ;  the preferable position of the patient beingupon a bed, rather than
seated on a chair.   One assistant is to draw the arm towards  him,
while  another  stands ready to compress  the subclavian  artery upon
the first  rib.   The surgeon, provided with a straight bistoury, makes
his first incision which comprises the entire length of the great diame-
ter of the hollow of the axilla,  and extends from the upper part of the
arm to  below the  tumor or even  to the side of the chest.  Upon
the supposition that this first incision will alone answer for the whole
dissection, it is  better  to place  it rather behind than too near the ante-
rior border of the axilla; in the contrary case,  should it  become ad-
visable to divide its posterior border, it is more proper to place it al-
together in front.   Having thus divided the integuments, sub-cutane-
ous fascia and  aponeurosis, we introduce a  finger into the wound to
tserve as a guide for the simple or double erigne, which is immediately
to hook up the  mass to be removed.  The surgeon then dissects the 
12
NEW ELEMENTS OF OPERATIVE  SURGERY.
tumor in front, and behind, and on the inner side, and finally from be-
low upwards, in proportion as the assistant draws upon it in the direc-
tion required.  Having arrived into the hollow of the axilla itself and
upon the side of the arm, I have often succeeded in detaching it com-
pletely by means of short strokes with the  bistoury, while the fore-
finger of the left hand directed backwards and deep, by raising up the
brachial plexus or the vessels, acted as a director.   This stage of the
operation, which sometimes enables us to dissect the important organs
in the hollow of the axilla in the same way as for an anatomical prepa-
ration, is too delicate and hazardous to permit me to lay down a ge-
neral precept.  The best mode then is to tear out gently, though with
force and  by means of the finger, all the lobules of the  tumor which
appear to  be interspersed among the vessels or nerves,  or which are
prolonged to too great an extent in the direction of the  clavicle and
the regions of the neck.   Should the engorgement of the  ganglions
be prolonged only by a pedicle above and to the outside, it would be
still more  easy to surround it with a triple thread and to strangulate
it forcibly, in order to excise the whole gland immediately below it.
By means of these precautions we remove  with  promptitude and
facility, tumors which do  not exceed the size of an egg.   We also
extirpate without danger or any very great difficulty, those which
are too much enlarged and  which present themselves under the as-
pect of bunches of grapes when occupying principally the thoracic
wall of the axilla.  There are no real difficulties or dangers therefore
but for those tumors which rest against the root  of the arm or articu-
lation of the shoulder, and for those  which  are  prolonged to above
the clavicle.  Ordinarily during the entire operation there are but  a
small number of arteries opened.  These are the branches of the ex-
ternal  mammary artery,  those of  the anterior  (anterieurs) thoracic
arteries, of the common scapular artery, and rarely the  internal  cir-
cumflex artery.  We might apply the ligature to them  in proportion
as they are divided, but there is but little inconvenience  in  causing
them to be covered temporarily by the extremity of a finger, and in
waiting until the end of the operation before tying or twisting them.
I have no need of remarking that if unfortunately the axillary artery
should have been wounded, as in the case mentioned  by M. Wolf,
(Graefe und Walther Journal, t. VII., p. 261,)  it would also become
necessary to apply the  ligature instantly.   The hemorrhage at  this
time, which is most troublesome, is almost  always furnished by the
veins; so much the more so because in the  axilla as in the groin, the
venous reflux which  might  under  these circumstances  extend back
even  to  the heart, is not  yet entirely  annihilated.   This  kind of
hemorrhage moreover which we first  arrest with the  finger,  after-
wards readily yields  to tamponing and compression.  The proof of
this I  have from having seen the  axillary vein itself opened  in an
operation of this kind.  I lay it down as a  principle not  to attempt
immediate reunion in these cases.   For they are of those  in which
the extirpation of the lymphatic tumors leaves  a cavity too anfrac-
tuous and a wound too irregular to make it possible to  hope for  pri-
mitive agglutination.  I place therefore small balls of soft lint upon
all the points of the traumatic cavity, until it is well filled with them and
that they produce a certain degree of compression, should it seem requi- 
LYMPHATIC  TUMORS.
13
site to adopt any precautions against the  flow of blood.   A perfo-
rated linen, a  gateau of lint, and one of the ordinary bandages for
the axilla, serve to complete and to  sustain  the dressing.
   B.  In front of the axilla.—If owing to its absolute volume or prim-
itive situation it should become impossible to enucleate the tumor by
the hollow of  the axilla; if, as I have seen it in attendance with MM.
A. Berard and J. Cloquet, in a young subject aged ten years, the tumor
should appear to be situated between the two pectoral muscles, or seem
agglutinated as it were upon their posterior surface, it would  be better
to divide the anterior wall of the axillary region than to operate in the
manner I have just described.  In a young girl whom I have spoken
of farther back, and whom  I  operated upon  in  1828, it became ne-
cessary to divide the tissues obliquely from above  downwards and
from  before backwards, from the inner  third  of the  clavicle to the
lower border of the latissimus  dorsi muscle.   Another incision par-
allel to the posterior border of the axilla  thus  circumscribed four
flaps, two smaller which I reversed downwards and backwards, and
two very large which  I dissected,  reversing  one of them  upon the
side of the sternum, and the other upon the shoulder.   These two
last, comprising the entire thickness of the pectoral  muscles, enabled
me to detach little by little from the front part and side of the chest,
the totality of the  tumor, which it  afterwards became necessary to
isolate  behind  from the sub-scapularis muscle,  from the border of
the clavicle above and in front, and from the whole brachial plexus
on the outside, and finally to extirpate it from the supra-clavicular
depression, where one of its  roots of a sufficiently large size  had been
prolonged.   We might here easily  avoid the necessity of  posterior
flaps by substituting the T for the crucial  incision.   The horizontal
branch of  the T being  placed behind and  parallel to the  posterior
border of the axilla, would put it in our power to fall upon it with
an incision  which would be vertical or more or less  oblique, and
which should set out from the  front part of the  clavicle.   The two
large  triangular flaps  circumscribed in this manner, would give
every facility desirable, and  would accommodate themselves in a re-
markable manner to every possible  mode of dressing.  If the tumor
should be more projecting in front than above, it would be  practica-
ble to lay it bare with still greater ease  by means of the  semilunar
flap of which I have so frequently  spoken.  The free border of the
half-moon  in  this case  might be   turned  downwards towards  the
axilla, inwards towards the sternum, or outwards towards  the arm,
according to the form of the tumor  or the particular indications.   It
would be necessary for the same reason to cut it out upon a  curve
of greater or less depth, and more or less elongated.   This flap, being
raised up upon its  base, would allow as readily as the others of dis-
secting out the  tumor up to  its termination, and  would be  attended
with the advantage of reducing the operation in fact to the condition
of a simple  incision.  The section of the fleshy  fibres  which might
here interpose, presents nothing in itself serious.   What I have said
of the division of the tendons and  muscles (see Vol. I.) is  sufficient
to show that  misapprehension had  prevailed in  this  matter.   If
the operation, therefore, by this division would be made more simple
and less dangerous, we ought not to hesitate ; we should operate also 
14
NEW ELEMENTS OF OPERATIVE  SURGERY.
in front rather than at the hollow of the  axilla.  The dressing after
extirpation of tumors of the  axilla by this process, enables  us bet-
ter than the other to undertake immediate union.  Whatever may be
the form of the flaps, they should be brought together and approx-
imated in  such manner as to leave a void only at the depending
point of the axillary cavity.   They are to be consequently replaced
in such a way as to reconstruct, as completely as  possible, the an-
terior wall of the axilla.  But I would recommend to leave a meche
or tent, or some rouleaux of lint  between the lips of the lower part
of the wound, so as to provide at that place for the egress of the dis-
charges.   This mode of reunion  is effected  at  the  axilla  as  every
where else, by means of simple strips of adhesive plaster, aided by po-
sition or the suture.  I ought  to  remark  before concluding, that in
operating at the hollow of  the  axilla, should  the simple incision not
answer, we might equally substitute with advantage for  the T or
crucial incision, that  of the semilunar, taking care  in that case to
turn its free border backwards and outwards. In whatever way the
operation and dressing may have been performed, the arm should be
kept immovable  and slightly raised up towards the  shoulder.  After
the first dressings, it is important, however little the  purulent matters
tend to  stagnate, to open  a passage for them.  It is at this period
therefore that we must prevent the too rapid union of the lower por-
tion of the wound, separate the arm  a  little from the trunk, substi-
tute  emollient cataplasms  for the lint,  or even have recourse to
emollient and detergent injections into the traumatic cavity.  Acting
upon these principles I have frequently removed tumors from the hol-
low of the axilla, which many practitioners had refused to extirpate.
(Dufresse,  Joum. Hebd. 1835, t.  IV., p. 276.)   The tumor in the
form of a  bunch of grapes, which almost equalled the size of  an
adult head, and which M.  Goyrand (Lancette Franc, t. II., p. 256)
successfully removed  under the impression he was operating  for a
scirrhus, was probably a lymphatic tumor.  M. Lallemand (Lafosse,
Clin, de Vhdpital Saint Eloi, p. 4) who employed the suture to unite
the wound, and who also supposed he had extirpated a cancerous
tumor, likewise as it appears to me  removed only  degenerate lym-
phatic ganglions.   Though no one moreover up to the present time
had laid down precise rules in respect to the operative manual in the
extirpation of tumors  of the axilla, it  is nevertheless true that some
surgeons occasionally  had  recourse to this operation.  We already
find even in F. de Hilden the rule  to cut down upon them, and to draw
them  towards us  and tie  their  pedicle deep  down, before  com-
pletely detaching them from the body.   It would be abusing the pa-
tience of the reader to say now that we should  proceed in the same
manner for scirrhus, colloid, encephaloid, melanotic,  fibrous, fungous,
or any other form  of  tumors  other than  those that are lymphatic.
The only point which it is important not to lose sight of under such
circumstances, is this, that we should not undertake the extirpation
of malignant tumors,  if the least particle of them is to escape from
the  action of the bistoury or  the ligature in mass ; while  tumors
purely ganglionic or tuberculous, may be extirpated with considera-
ble  chances of success, even though we are forced to abandon some
of the engorged ganglions in  the axilla or above it. 
LYMPHATIC  TUMORS.
15
             § IV.—Lymphatic Tumors of the Neck.

  There exists in the neck so great a number of lymphatic ganglions,
and these  ganglions  are  distributed  upon so many different points,
that it is scarcely possible to study their extirpation separately  in all
the situations in which they  sometimes give rise to the formation of
abnormal tumors.  It has happened to me on two or three occasions
to extirpate them where they were situated behind the sterno-cleido-
mastoid muscle, and seemed to  repose  upon the outer side of the
trapezius.   In that position we may lay them bare freely by a simple
incision, directed from  above downwards  or a little obliquely.  As
in this region there is no important  organ to  avoid, we  may, after
the incision of the integuments is made, and the  tumor is properly
secured with the hook, proceed with free and rapid strokes of" the bis-
toury.  From the natural tension of the parts rendering it almost im-
possible to keep in perfect contact the walls of the cavity which re-
sults from this operation,  we have the reason why immediate reunion
scarcely ever takes place, and that it is more prudent in fact to  dress
flatwise and with small  balls of lint, rather than  by the exact ap-
proximation of the parts.  If, as I have seen in two or three cases,
the tumor, which was in all situated behind the sterno-mastoid muscle,
should occupy the upper third of the neck or the neighborhood of the
occipito-mastoid region, we  might  proceed otherwise, and treat the
division of the integuments as an ordinary simple wound.  Between
the os hyoides and thyroid cartilage, where lymphatic tumors of the
neck are sometimes developed ; between the sternum and the thyroid
gland, where they have  also been met with in some patients, they
should be  treated as  will  be  mentioned in the article upon operations
which are performed upon the neck.   But it is necessary to consider
the extirpation of lymphatic tumors  separately, in the  parotid, sub-
maxillary, carotid and supra-clavicular regions.
  A.  Parotid Tumors.—Having to treat elsewhere of the removal
of the parotid  itself, when this gland is degenerated,  I  could  only
repeat here the details into which I shall then be obliged to enter,—
(see Extirpation of the Parotid, infra.) I will say only in anticipation
that those tumors formed by the  parotid gland  of which so much has
been said, have all of them, or almost all  of them, for their basis or
point  of departure the lymphatic ganglions properly so called.   It is
from having frequently ascertained the  truth of this position that  I
take  the liberty at the present time to affirm it  positively.
  B.  Sub-maxillary Tumors.—The sub-maxillary  tumors that are
most common, are observed in the mylo-hyoid space; but they are
met  with also  directly  under the  chin, quite frequently under the
angle of the jaw, and sometimes  also upon the external face of this
bone  in front of the masseter muscle.   In a young girl aged ten
years, who had one of the size of a large nut under the chin, I  made
an incision, which being carried from the symphisis of the jaw to the
level of the os hyoides, while the head of the child was  held back by
an assistant, enabled  me to hook fast, dissect out and completely  extir-
pate the tumor with ease.  The wound which was united by first inten-
tion by means of a band of adhesive plaster passed under the jaw  in the 
16
NEW ELEMENTS OF OPERATIVE  SURGERY.
form of a bridle, was completely closed up in less than fifteen days. In
another patient who had one of them on each side the median line, it
became necessary to make two such incisions.   As these tumors were
in part softened and as they left quite an irregular cavity, I deemed
it. advisable to dress them with small balls  of lint and to treat them by
secondary reunion; the cure nevertheless was  completed at the end
of three weeks.  The  lymphatic tumors which  at this part are some-
times sub-cutaneous, at least situated in front of the muscles, are not
approached by any large sized  artery.  The sub-mental is  the only
one that may be wounded and require a  ligature.  Nevertheless there
sometimes exudes from the wound a sufficiently considerable amount of
blood to oblige us to give the preference  to tamponing to dressing sim-
ply with adhesive plaster.   Under the angle of  the jaw the ganglions
may acquire the size of a nut, egg or fist.  Being in that part situated
outside of the digastric muscle, and sub-maxillary gland, and in front
of the sterno-mastoid muscle, they approach sufficiently near the in-
ternal jugular and the carotid arteries to create  some little apprehen-
sion in those who should desire  to attempt their  extirpation.   Never-
theless I have frequently removed them and always found  that the
operation was  simple and  sufficiently easy.  For that  purpose, the
patient being inclined a little towards the  sound side, and having the
chin slightly raised up, should be kept in  this position by assistants,
who should at the same time depress his shoulder  upon the  diseased
side.  Should the tumor be of medium  size, I lay it  bare by means
of a curved incision, modelled in some measure upon the curvature
of the sub-maxillary region.  If the lymphatic  mass is  of a certain
volume, I give to this  incision  a very decided  semilunar  form, in
order to obtain a flap which may be raised upon  the side of the jaw
from below upwards and from behind forwards.   Having then seized
the tumor with a  hook, which  an assistant is charged with making
traction upon in the proper direction,  I proceed to the dissection.
The finger holds apart and stretches the lamella? in proportion as the
instrument divides them, and when we  reach near the deep-seated
parts, completes the enucleation should there  be any  organ there
which ought not to be exposed to the point of the bistoury.  Whether
the wound forms a semilunar flap or  a simple  curved incision, it
ought not to be completely closed except in extremely simple cases.
In the aggregate we are exposed to fewer inconveniences when  we
treat it by gentle tamponing, than when we endeavor to unite  by
first intention.   The tumors on the outer side of the jaw  however are
sufficiently rare.  I have removed some which  were situated exactly
upon the Irack of the facial artery.  There can be no positive rule
for the direction of the incisions in such cases, and the great diame-
ter of the  tumor must serve as our  guide for  their  location.   We
must be prepared moreover to  wound the external maxillary artery.
inasmuch as it is often enveloped as it were by the ganglions which
we have to extirpate ; but  this  vessel is not of  sufficient importance
to create the least uneasiness, and the surgeon  has only need of re-
collecting that it is generally advisable  to tie or twist both  its lower
and upper end, in consequence of the reflux which takes place  from
the coronary arteries or the angular artery.  The wound here being
on  a fixed plane might be closed  by  primitive  agglutination, if it 
LYMPHATIC  TUMORS.
17
were found in other respects under  conditions which would author-
ize our undertaking this kind of union with reasonable chances of
success.
  C. Mylo-Hyoid Tumors.—The triangular  space bounded on the
inner side by the mylo-hyoid or  the hypo-glossus muscle, outwards
and upwards by the inner  face of the jaw, and outwards and down-
wards  by the supra-hyoid aponeurosis  and the platysma myoides
muscle, and in which space is  situated the sub-maxillary gland, also
includes a variable number of lymphatic ganglions, which frequently
become diseased, and  sometimes enlarge to such extent as to ac-
quire the volume of an  egg or greater.   These tumors becoming de-
veloped in consequence of diseases of the face or anterior region of
the cranium, or of the interior  of the mouth or of the gums, fre-
quently exist under the character  of a local affection in persons,
who in other respects, are  in the  enjoyment of good health, and who
have no other kind of  lymphatic  engorgement.   It is in such cases
that I  have most frequently practised  extirpation of the glands of
the neck, and where the operation succeeds the best.  In addition to
the examples which I have elsewhere published, I could at the pre-
sent time add a great  number of others.   The  tumors of which  I
speak are globulous, generally  ovoid, movable,  hard  or elastic, and
exceedingly  prominent below the jaw.  In  pressing  them  at the
same time through the mouth and at the supra-hyoid region, one
would suppose that  they  were  isolated (a nu) under the mucous
membrane and under the skin.   But this appearance should  not de-
ceive us.  Lymphatic tumors of the sub-maxillary region, are neces-
sarily sub-aponeurotic, and the surgeon must expect to search deeply
for them, if he expects to  remove every part that is diseased.  As
for the rest, provided their surface has not undergone  any degeneres-
cence, is  not ulcerated, nor has  contracted any unnatural  adhesion
with the surrounding tissues, the  removal of the larger  sized ones is
not essentially more difficult or dangerous than that of  the smaller.
   I. The operative process, moreover, is sufficiently simple; and the
incision of the integuments may be performed in three ways.   1. An
incision parallel to the  lower border of the jaw or to the great diam-
eter of the tumor, ordinarily  suffices; only that it is  advisable to
place  it  sufficiently low down, in order that after the operation it
may not be drawn towards the base of the bone.  The  wound being
thus reduced to a simple  slit,  leaves only a linear cicatrix, which is
naturally concealed under the jaw, and is scarcely perceptible.
   II.  If the  straight incision should not give sufficient freedom, as
happens  when the tumor  exceeds in volume a large  sized pullet's
egg, a vertical incision upon the  lower lip of the first wound, would
procure a division in T, with two lower flaps, which should be dis-
sected and reversed, one to the front and the other backwards.
   III.  In this case I would still give the preference to the curved in-
cision  and semilunar flap, over the T incision.   This flap, raised up
from the neighborhood of the os hyoides to the face, would enable us
to lay bare the entire cutaneous surface of the tumor, and would af-
terwards fall by its own weight over  the  cavity of the wound.  In
whatever way we proceed, the patient being placed upon the bed and
inclined as has been described  above, should have the chin raised and
                                2 
18           NEW  ELEMENTS  OF OPERATIVE SURGERY.
the head thrown backward.   The incision of the integuments should
be made boldly and as far as to the most projecting point of the tumor.
Its anterior angle may be prolonged without apprehension of wound-
ing any important artery.  But posteriorly it is not the same; there
it  may be possible that  the  facial  vein, or  even the external max-
illary vein has been raised up by the lymphatic tumor and rendered
more superficial than usual.   Most frequently, however, these ves-
sels are  situated rather behind and on the inner side of the posterior
extremity of the tumor.  It  is sufficient to say that in these cases,
the dissection of the parts should commence from above, or from be-
low, or at the anterior half of the degenerated ganglions.  Being se-
cured and  drawn forwards  and outwards by means of an erigne;
these tumors are afterwards disengaged from the bottom of the mylo-
hyoid fossa by means of the  finger or the  handle of the scalpel, as
much as by the  cuts of the bistoury.  If the facial artery should, as
frequently happens, be wounded,  there  is no cause  to  be greatly
alarmed. The ligature is to be applied immediately, or what is as well,
it is to be temporarily closed by the finger of an assistant.  Were
we not prepared for this, we  might in fact, in a great number of in-
stances, suppose that we had opened it, when it is the secondary
branches only which enter into the tumor at the apex of the gan-
glions, that have been  divided.  The disease sometimes produces
such enlargement  in these branches  that we  not unfrequently find
them to have acquired the dimensions of a crow's quill, and  throw-
ing out blood with violence at the  moment that they are divided by
the bistoury.  We may while dissecting out these  tumors be com-
pelled to penetrate as far posteriorly as  the  sides of the  larynx and
in front  of  the carotid  arteries.  I have frequently seen pulsating
naked before the eyes of the  operator, and at the  bottom of the cav-
ity previously occupied by the tumor, the lingual artery on the inner
side, the internal carotid behind, and the external maxillary without.
This cavity which at first has something frightful in appearance and
which could easily contain the  fist, may be prolonged also as far as
the median  line in front and  the  os hyoides below.  M.  P.  Eve
(Southern Medical and Surgical Journal, January, 1838 ; and Gaz.
Med., 1838, p. 17) penetrated in this manner as far as the outer side
of the tonsil to remove a tumor of half a pound in weight, and cured
his patient.   I assisted M. Vidal in a young  man in  whom he  re-
moved three degenerated ganglions which occupied one entire side
of the supra-hyoid region.  Unless the tumor be uniform and small
in size we must not attempt to close this cavity by first intention.
Tamponing and the mode by second intention, offer an infinite deal
more of security and without materially retarding the cure.   It is to
be  recollected, only that after  the first eight or ten days,  that is,
when the balls of lint become no longer of any use, the upper lip of
the wound, drawn upon as it is by the  border of the jaw, has such ten-
dency to be raised up towards the face, as to require some preventions.
It is then that a strip of adhesive plaster,  placed on the outside of and
along the lower border of the jaw, serves to  retain it  and  crowd it
downwards and  prevent  its  retroversion  (renversement).   This
strip would become still more advisable,  if in  place of the usual
incision, we had employed the semilunar  flap to lay bare the tumor. 
LYMPHATIC TUMORS.
19
By this  kind of primitive secondary union we  are protected from
erysipelas and purulent collections, while we produce notwithstand-
ing, in the space of fifteen days to a  month, a  perfect cure, with a
cicatrix nearly linear.  This mode of  extirpation, for which no per-
son had given the process when I pointed it out in the year 1825,
has now been performed a great number of times successfully by
M. Begin at Strasbourg, (Malle  Arch. Med. de Strasbourg, 1836,)
by M. Sedillot, (La Presse Med.,t. I., p. 139,) and by M. H. Larrey
at the Hospital of  Val-de-Grace.   For  myself, there is  not a year,
that I have not had recourse  to it, on from ten  to fifteen  patients;
and I have not seen up to the present  time any operation whose con-
sequences are  less serious.  Every thing  goes  to show that  in this
region, the introduction of air into the veins is not to be apprehended,
notwithstanding some  facts which have been related in favor of a
contrary opinion.  Unless therefore there should be some particular
complication or counter-indication connected with the general consti-
tution of the patient, the extirpation of  lymphatic tumors from the sub-
maxillary region, should be recognized in practice as a systematized
operation of surgery.
   D.  Tumors of  the  Carotid Region.— After the mylo-hyoid de-
pression and the carotid region, the sterno-carotid groove  is that on
which lymphatic tumors are  the  most frequently met with.  The
chain of ganglions which occupy this groove, is composed of such
numerous glandules (grains) that they are  noticed on every part of
its length from the supra-sternal fossa  to the angle of the jaw.   They
are distributed, moreover, in such a manner, that some repose directly
upon the anterior surface of the vessels, while others lie entirely con-
cealed,  either  by the internal  surface or by the posterior  border of
the sterao-cleido-mastoid muscle.   I have, however, never found them
to be absolutely superficial, though I  have  sometimes  met with them
all around the carotid  artery or jugular vein,  while  others were at
the same time prolonged under the posterior surface of the pharynx
or oesophagus.  If in  this region the tumors are numerous, deep-
seated,  and but little prominent, or should raise up the sterno-mastoid
muscle, in place of projecting towards the side of the neck  or larynx,
it is better not to  meddle with them, or to attack them  only with
general remedies and  local applications.   If, on the  contrary, they
present themselves under the form of one  or more movable lumps,
(bosselures,) making a projection  between the sterno-mastoid muscle
and  the middle of the neck, and  if their  totality constitutes  a mass,
independent of the thyroid body, the  carotid artery, or jugular vein,
without  having any prolongation  in  the direction of the chest, it is
allowable and practicable to undertake their extirpation.   Upon the
supposition that the tumor situated transversely, and strangulated by
the sterno-mastoid muscle should be  bilobate, in such manner as to
present  one of its  halves posteriorly, and  the  other  in  front, there
would still be ground to attempt its removal, should the uniting bridle,
in other respects, be so thin as to allow  of our avoiding the neighboring
vessels  and nerves.   To perform the operation, the patient is to be
placed upon his back, taking care that his head is raised sufficiently high
upwards.   In this position the sterno-mastoid muscle being stretched
and thrown backwards, pushes the tumor forward, and in this manner 
?-0           NEW ELEMENTS OF OPERATIVE  SURGERY.
renders it more superficial, while at the  same  time it gives it a
greater degree of fixity.   The surgeon making  his  incision  from
above  downwards, divides the integuments to  an extent which
should  exceed the limits  of  the tumor  by nearly an inch.    As
soon as the front part  of  the tumor is laid  bare, he detaches the
lips of  the wound upon  the outer  and then upon the inner side.  It
is  at this  moment that he hooks  his erigne into  it,  in order that
an assistant may secure it,  and  hold  it aside while the dissection is
being proceeded  with.  This dissection has  nothing about  it par-
ticularly difficult  until we  arrive  near the  bottom of the  carotid
region; but setting out from there,  the finger  should always pre-
cede the point of the bistoury,  and no lamella of tissue ought to  be
cut without having been previously stretched by means of the fore-
finger.  By inclining the extremity  of the instrument towards the
ganglionic surface, we avoid with certainty all the large vessels which
are situated behind.  I have, moreover by  adopting the mode of
enucleation, several times succeeded in detaching some more deeply
situated lobules, which were  entangled behind  the jugular vein, or
carotid artery, and  sometimes  between  those  two vessels.   It is,
moreover, a matter  of  little  importance,  whether the deep-seated
surface of the tumor should be isolated from above downwards, or
from below upwards.  We  must be prepared to find by this operation,
as has  happened to me in quite a great number of cases, that we have
extensively denuded the carotid artery, the internal jugular vein,  the
pneumo-gastric nerve, and  the great sympathetic.   It suffices to re-
mark that these organs  might be interfered with, and that we must
be on our guard against wounding them.   [See  case in our Vol. II,
under  the head of the nerves, in which the pneumo-gastric imbedded
in a tumor recently removed by Dr.  McClellan, of Philadelphia, had
to be completely  divided,-which, however, did not interfere with the
restoration of the patient.  T.]  It was in  a case of this kind that
M. Fouilloy (Ansiaux, Clin. Chir., p. 238, 2d  edit.) was compelled to
tie the carotid artery.   There  is  every reason  to  believe also, that
the tumor successfully extirpated by  M. Voisin, (Gaz. Med.,  1835, p.
447,) and which obliged him to dissect upon  the carotid, was one of
the class of those of which I am speaking.  We may conceive also,
that an opening  into the internal jugular vein, would in this part
endanger to a greater degree than in most other regions of the body,
the  introduction  of air into  the heart, and the fearful accidents
which are the consequence of it.   In a young  man in whom I  had
 removed one  of these tumors on the  right side of the larynx, there
 was heard at  the moment  of my dividing one  of the  anterior veins
 of this region, near the jugular, a hissing and gurgling sound,  which
 at first gave me great uneasiness, the more so from the patient utter-
 ing a  piercing cry that he  was  dead !  There followed, however, no
 serious symptom, and the  consequences of the operation were ex-
 ceedingly simple.  I have  already stated (see Vol. I.) that a woman
 in whom I had been obliged to penetrate  as  far as  to the posterior
 surface of the pharynx, was seized to an extreme degree with the
 symptoms which  indicate  the entrance of air into the veins, at the
 moment when I had wounded the upper part of the internal jugular.
 Without asserting that these facts are very conclusive in respect to the 
LYMPHATIC TUMORS.
21
entrance of air into the venous  system, it is proper, nevertheless,
that we should not forget them, and that we should reflect upon the
circumstances which may produce them, when we have decided
upon the extirpation of lymphatic tumors in the carotid region.  When
some of the lobules of the tumor are situated at, and  project towards
the posterior border of the sterno-mastoid muscle, it is not uncommon
to see them have a tendency to move forwards, and conceal them-
selves to a certain extent  under the muscle, in proportion as we ex-
tirpate the anterior lobes.   Their removal also, greatly embarrasses
the operation, and admits  of the question, whether  it would not  be
more advisable to attack  them separately, by means  of an incision,
independent of the first, and before commencing the other  part of
the operation.  Having in one case adopted this plan, I found that
the rest of the tumor, thus liberated from all kind of adhesion poste-
riorly, advanced  freely forward, and yielded readily to the tractions
that it was afterwards necessary to make upon it.   In case of still
greater complication, as for example, where besides these two lobes,
anterior or posterior, the tumor  should be exceedingly  thick at its
neck, I would not hesitate  in order to lay it bare, to divide the sterno-
mastoid muscle,  and in  such  manner as to transform the  entire
wound into a large T incision, whose stem should  be placed trans-
versely.  Here  #lso, more than in the  sub-maxillary  region, the
dressing by second intention should have the preference over imme-
diate reunion.  The lamellar character of the tissues, the natural and
unavoidable  mobility of  many of them, and the great  number, or
the importance  of the vessels which have suffered, do  not  allow in
such  cases of our counting upon a  free primitive agglutination; and
the  danger of  purulent  abscesses in the direction of the chest,
either above or  below, is too formidable to incur this risk by  at-
tempting to shut up the wound by first intention.
   E. Supra-Clavicular Tumors.—The hollow, or species  of cavity
which is noticed above the clavicle, also contains lymphatic glands,
whose  degeneration is  not uncommon, and  which come under the
same considerations of pathology, therapeutics and operative surgery,
as the preceding.   Nor should I,as they are surrounded with numerous
or important vessels and nerves, any more recommend their extirpa-
tion to be undertaken unless in a case of necessity ; the more so, as it is
often difficult to ascertain in  the beginning, whether they are con-
tinuous or not, by chains of the same nature as far  as the axilla, or
in the direction  of the chest.   A young lady who had  one of these
tumors upon the  front, and outside of the scalenus anticus muscle,
was desirous of getting rid of it.  Before being enabled to complete
its removal, the surgeon, a celebrated practitioner at Paris, found that
it made a  prolongation inwards, and that there was a  similar one
in front of the carotid vessels.   In  his  attempt to extirpate this last,
he opened  extensively into the internal jugular vein, near its junction
with the subclavian.  A copious hemorrhage followed :  the operation,
nevertheless, was finished, but symptoms  of purulent  infection, or
phlebitis,  soon made their appearance,  and  the  unfortunate lady
perished on the eighth or  ninth day, causing to  her afflicted relative
who was a physician, and greatly attached to her, the most poignant
regrets.  I would, therefore, not extirpate lymphatic tumors in the 
22
NEW ELEMENTS OF OPERATIVE SURGERY.
supra-clavicular region, unless they were perfectly movable, isolated,
and without any ramification towards the anterior region of the neck,
or towards  the axilla or thorax.  Another reason which would pre-
vent me from interfering with them except under these circumstances,
is this, that  if the introduction of air into the veins is really danger-
ous any where, it ought to be so in  the supra-clavicular region more
than any where else.   Up to the present time, I have performed this
operation only upon five patients.   In three of them the tumor, which
did not exceed in volume a large nut or small egg, was so well isola-
ted and movable that there was no serious difficulty to be surmounted.
The two others had each a ganglionic mass,  which was prolonged as
far as the brachial plexus, and subclavian vessels.  This dissection
was tedious, but no accident supervened, and the cure was completely
established.   The patient should have  the  chin  slightly  raised up,
the head inclined towards  the sound side, and turned back, and the
shoulder of the diseased side depressed, and also directed backwards.
The surgeon placed on the same side, makes an incision  parallel to
the clavicle  if the tumor exceeds the volume of an egg; and in the
contrary case, parallel to the  axis  of  the body.   In whatever way
made, this incision should be of sufficient extent not to embarrass the
consecutive  steps of the operation.  Supposing after the first incision
we should be under the necessity of making another, we would then
freely divide the upper lip of the  wound in the first  case, and the
outer or  posterior lip in the other.   Perhaps, also, it  would  be more
advisable, in lieu of these different modifications of the ordinary inci-
sion, to substitute a large semilunar flap, taking care to turn its free
border  outwards and downwards. The  integuments being  now
held  aside or turned back, the  surgeon seizes  the  tumor with the
erigne, and  hands it over to an intelligent assistant, that he may raise
up or incline the diseased mass according as it may be required during
the remainder of the operation.  The  dissection  is also  to be per-
formed after the same rules as in the preceding regions.  It is better
in commencing, to do this from above, then outwardly, than to begin
on its inner  border or inferior portion, since the internal  jugular or
subclavian vein lies on  one or  the other side  of it..  Having ar-
rived at its deep-seated  surface, we should isolate it after the same
rules (dans le meme sens), and here still more than in any other re-
gion, would there be occasion for  strangulating its root completely
below it, if it should appear to be too hazardous to detach  it up to its
termination  by means of the point of the bistoury, and that the finger
would not suffice for enucleating it.   This operation, which is ordina-
rily very painful, in consequence of the numerous branches of the
cervical  plexus, which are dispersed throughout the whole extent of
the supra-clavicular region, compels us also, in most cases, to divide
the external jugular vein; but this vessel is of too little importance
to  make us hesitate  about sacrificing it.   I  would not  hesitate,
then, to  divide it in the beginning, and afterwards to tie  its upper
end and  even its lower, if I thought it could cause the least incon-
venience.   We should have to respect, also, and  to tie them should
they be  divided, the transverse cervical artery, the supra-scapular,
the ascending cervical, and even the inferior thyroid.  As to the dress-
ing, I would regard it as  exceedingly imprudent to wish to run  the 
LYMPHATIC TUMORS.
23
risk of union by the  first intention.  In whatever way we may pro-
ceed, the internal surface of the  flaps or lips of the wound cannot
be applied with  the required accuracy against the bottom of the
solution of continuity.  Suppuration  being thus rendered unavoid-
able, and  having no issue, would expose to the risk  of purulent ab-
scesses and  diffused  inflammations, of which it would be difficult to
arrest  the progress  or avert the  danger.   The  flat dressing by
means of  pliant balls  of lint, perforated  linen and  plumasseaux,
secures us from these apprehensions, and does not perceptibly retard
the definitive cicatrization of the wound.
  Can it be necessary  now to add, that lymphatic tumors may be
developed everywhere, where there naturally exist  ganglions of the
same name, and that everywhere  also  it would be advisable to attack
them by conforming ourselves to  the rules established in  the preced-
ing paragraphs 1  Until practice shall have acquired  a certain exten-
sion on this  point, it would be useless, as I consider, after  having laid
down the general rules, to detain ourselves with the  projection (sup-
position) and description of special processes.
   [Lymphatic  Tumors or Lymphatic Cysts, those in fact called by
the French cold abscesses  (abces froids),  have been  treated success-
fully by Dr. G.  Capelletti, of  Trieste,  (Giornale per servire, &c,
January, 1842 ; Arch. Gen. de Paris, 4e ser,. t. III.,  p. 346-347.) by
means of injections of nitrate of silver (2 to 3 grammes of the nitrate
to 500 grammes of water) ; injecting through punctures first made
in various  places by the trochar in order first to evacuate the con-
tents of the tumor.   The tumor is to be filled with the injection,
and the  action of the  latter aided by uniform and  continued pres-
sure.
   One of  trie most  remarkable  and  mysterious cases of a general
hypertrophied condition of all the lymphatic glands on the external
sub-cutaneous regions  of the body in an adult woman from one of
the provinces of France, aged 38  and  otherwise perfectly healthy,
occurred  to the  excellent  author of  this work, M.  Velpeau, in his
own service at the  Hospital of  La  Charite, at Paris,  during the
year 1845.   These enlarged  glands in the only account  of them we
have' yet met with (Annates de Therapeutique, Paris, April, 1845, in
Cormack's  Lon.  fy Edinb. Month. Journ., June, 1845, p. 459.) are,
it is stated, found in this woman in masses, as it were,  or strung in
chaplets varying from the  size of an almond to a hen's egg, in every
region externally where such glands exist, viz.: in the axilla, groins,
neck, elbows, legs and trunk.  They roll under the finger, are with-
out pain  or change  of  color on  their surface.   They appeared al-
most two  years before without  any appreciable  cause.  The wo-
man had previously enjoyed excellent health ; she is even now robust
and suffers nowhere, except that  the tongue is a little white, and the
digestive  organs are occasionally  out of order.   She says she has
lost flesh, but she is  still rather stout; the skin has a slightly yellow-
ish tint, but  not approaching to icterus ; she has perspired copiously
through the night for some time  past.   No one of her family, so far
as she knows, has been  affected in a similar way, and none of the in-
habitants of the  country where she resides  have  any thing similar.
Her place of residence is well aired, and from  her occupation she 
24           NEW  ELEMENTS OF  OPERATIVE SURGERY.

passed most of her time in the open  fields.  M.  Velpeau retained
her in his  ward as a subject of study; she was put on the extract
of walnuts for nearly two months, but no favorable change occurred ;
the health of the patient seeming rather to decline.   This case seems
to call in question the  pathological accuracy of the opinion that the
enlargement of the sub-cutaneous glands is necessarily  connected
with a scrofulous  temperament, and the evolution  of which temper-
ament, so far as these glands are implicated, generally takes place in
the early period of childhood.  In this woman nothing is  found but
general hypertrophy of the glands; the serous membranes are in a
good state, the  osseous  system exhibits no  alteration, and there are
no  knotty  cords  in the course of the  lymphatic  vessels, as is the
case in some kinds of erysipelas.   It may be termed a sort of gene-
ral ganglionitis;  but it does not follow that it is true scrofula, since
there are  none  of its constitutional symptoms.   Nor is  there any
thing of cancerin  this case,  though this affection is by some thought
to have its origin in chronic lymphitis.  T.]
                        CHAPTER IV.

                NEUROMATIC  TUMORS (Nedromes).

  Pathologists have frequently mentioned small tumors, usually sub-
cutaneous, the distinguishing feature of which is that of causing from
time to time, and upon the slightest occasion, painful irradiations ex-
cessively acute, which yield to no remedy and  are a source of tor-
ment to  the  patients.   These tumors,  which many persons have
located in the nerves, with which however they must be disconnected,
if Dupuytren and  M. Wood (Trans. Med. Chir. of Edinburgh, vol.
Ill,,  p. 317), which M. Jaumes (These No. 266, Paris, 1828), ranges
among cancers, that Boyer was  desirous of considering  as scirrhous,
which are  bodies sui generis, according to  some others, and upon
which  MM.  Arronshon  (These,  Strasbourg, 1822), Clerambeault
(Obs. de Med et de Chir., 1829),  Wood, Descot  (Affections locales
des nerfs, 1825, p. 208 to p. 286), and Alexandre (De tumor nerv.,
etc.,   Leyden, 1810),  have  published interesting observations,  are
much more common than would be  imagined according to  classical
authors.  Not having to decide in this place what may  be their real
character, I will confine myself to  saying that for the most part they
have been found on the track or in the substance itself of the nervous
cords, and  that they have  sometimes presented themselves to me
with the characters of tuberculous  masses, and at others under the
aspect of tumors  that were truly scirrhous  or encephaloid in  the
crude state ; while in other cases it would have been utterly impos-
sible for me to have compared them to any other morbid production
or degenerate  tissue.   It is incorrect to assert with Descot (Op. cit.,
p. 208,)  that their size varies from that  of a grain of wheat to that
of a  bean; for I  have met with some whose dimensions exeeeded
that  of the fist, and we  shall see farther on that other observers 
NEUROMATIC TUMORS.
25
have met with  similar examples.   It would  be more correct to say
that their volume varies from that of a grain of wheat to that of the
head of a new-born infant.  Descot, in his work (Ibid. p. 209,) which
was prepared in great  part under the dictation of Beclard, commits
another  error in  saying  that these tumors are scarcely ever multi-
plied.  M. Wood, in fact, speaks of a patient who had three of them.
Siebold  had  two of them above the  instep,  and I counted  nineteen
upon the same patient at the hospital of La Charite, in  1836.  In
giving to these tumors the name of ganglions, under which Hippo-
crates and Galen appear to have designated them, and in the attempt
to distinguish them under the name of nodatio from tumors called
nodus, Jean  de Vigo  has but attempted a futile division; but at
the  present time not having it in our  power  to adopt any name to
the exclusion of others, they are still designated  under the title of
knots (noeuds) after Pare ; painful sub-cutaneous tumors as they are
called by the English  practitioners  especially; or neuromata (neu-
romes), or chondromata (chondromes), which is the epithet used by
Odier, and which has been generally sanctioned  by the  French
pathologists.   The accidents they cause, the excruciating (atroces)
pains  they excite, and  their usual resistance to  every kind of
remedy, induce most  patients affected with these tumors to demand
of themselves to be relieved from them by extirpation.  It is in fact
the only efficacious means that surgery has  to oppose to them.   No
doubt that by attacking them with caustic as Siebold the father did
upon Siebold the son (Alexandre, Op. cit., p. 21) we may also some-
times succeed in curing them; but the operation by this mode would
be longer, less certain and in reality manifestly more painful.  Am-
putation  of the part, which Louis (Encyclop.  Method., partie Chir. t.
II., p. 442), Odier  (Manuel de Med. Prat, cite a I'art. Excision des
Nerfs), and  M. Warren, (on Tumors, etc.,  p. 62), are still in the
practice  of, would not be justifiable at the present time, unless by
means of its  degeneration the tumor had effected a profound altera-
tion in the limb.   As to extirpation, it would always  be  easy and
simple, if it  were true, as the title  of  sub-cutaneous tumors would
seem to indicate, that neuromas were always found immediately un-
derneath the skin; but observation has now  shown that the deep-
seated nerves as well as the superficial, become  the  seat  of these
tumors.  It follows from this that  the removal of neuromas  may
sometimes become a serious operation.  They have moreover  been
encountered upon  almost every region of the  body.  Franco (Traite
des Hernies,  p. 484.)  speaks  of a woman who carried one for ten
years upon the tibia.   Another woman, mentioned by Loyseau (Obs.
de Med.  et de Chir., p. 56.) had one upon the inner part of the thigh,
and  the same  practitioner met with one in another woman upon the
outer part of the same limb.   Whether the small nodule removed by
Pouteau  (QZuvres Posth., t.  I., p. 5.)  was  or was not a neuroma
rather  than a simple inodular induration,  it was found nevertheless,
in front of the malleolus at the place where the saphena is opened in
bleeding  of the foot.   M. A. Petit  (Discours sur la douleur, p. 15,
an VII.)  also  relates that he had met with them almost exclusively
upon the  legs, though he had seen one also upon the fore-arm. In the
case mentioned by Valsalva, as related  by Morgagni, (De sedibus et 
26
NEW ELEMENTS  OF OPERATIVE SURGERY.
 causis morb., epist. 50,) the tumor was situated upon the malleolus.
 In the case of Cheselden, (Anat. of the  Human  Body, p. 256, tab.
 28, fig 7,) it was seated in the ulnar nerve.   Petit (Mem. de VAcad.
 de Chir., t. I., p. 90,) mentions another in which it existed upon the
 arm.   In one  of the female patients of Camper (Demonstr. Anat.
 Path., lib.  I., cap. 2.) it was upon  the outside of the elbow ; and in
 another woman mentioned by the same  author, upon the front  part
 of the knee.   The patient amputated  by M. Warren  (on Tumors,
 <$fc, p.  60) had  one upon the tibia below the knee.   The  tumor
 spoken  of by  E.  Home,  (Trans, for the Improvement of Med. and
 Chir. Knowledge, vol. II., p. 92,)  and which was removed by Hun-
 ter, was also situated upon the  arm : and in the patient of E. Home
 himself, the tumor had  to be seized in the hollow of the axilla.   A.
 Dubois, (Spangenberg, Archives  de Horn., t. V., p. 306,) in one case
 saw the neuroma in the neighborhood of  the patella, and on the mid-
 dle of the arm in another.   The tumor dissected by Hasselbach
 (Alexandre, p. 22) occupied the ulnar nerve, and that of Siebold (Ibid.
 p. 21)  the  space between the two malleoli. Neumann (see Siebold,
 1.1., p. 54) encountered one on the lower and middle part of the fore-
 arm.  One of the patients of Rieche, (Alexandre, op. cit.,) had the
 tumor on the  inner part  of the arm, and the other outside of the
 condyle of the humerus. M. A. Cooper (Trans.  Med. of Edinburgh,
 vol. III., p. 640,) and  M. Warren (on  Tumors, p. 63,) have  met
 with them in the breast or below it.  Nicod (Descot, op. cit., p. 244,)
 mentions to have seen them on the chest, and M.  Marjolin (Ibid., p.
 245,) on the scrotum.  In the patient of Short, (Obs. de Med. t. IV.,
 art. 27,) the tumor was situated upon the thigh; while M. Warren,
 (on Tumors, fyc, p. 63,) saw one in a boy of sixteen years, below
the great trochanter.  With respect to myself, I  have met with them
on the sole  of the foot, on the outer side and inner side of the leg, in
 front and on the inner and outer side of the thigh, twice even in the
depth of this limb, on the right and left side of the thorax in two dif-
ferent women, on the right  portion of  the epigastrium, near the
wrist, and on many points of the fore-arm ; in the  body of the biceps
muscle,  on the track of the  musculo-cutaneous nerve, and in the
depth of the carotid region.  What  I have  observed, and which is
in accordance  with what is related by authors,  proves, in contradic-
tion to what Descot (op. cit., p. 210,) alleges, that  these tumors are
more frequent  in adult or old age, than in children.  One of the  wo-
 men whom I had an opportunity of examining  was  sixty years of
 age and upwards; another was  40, a  third 36, and the youngest
 21.   The same has been the  case with the men, who were 30, 40,
 and 50  years  of age, and even  older.   If one of the  patients of
 Reiche  was only 19, the  other was 44;  those of  Morgagni  and
 Petit  were young  girls, and the cases of Camper,  E. Home, and
 Louis were clearly women.  Nor were those of Dubois and Hassel-
 bach young subjects, while the case of Neumann was 60 years of
 age.  These details prove moreover, that if M.  Wood has met with
 neuroma in women  only, this  must be ascribed  to  accident only,
 since numbers of men have also been affected by  it.  We must add
 that  cases  of  neuroma have been  noticed  also by Bicet, Pearson,
 Broon, Newbigging, Swan, Hall, Windsor, Laing, Walker, Hey, 
NEUROMATIC TUMORS.
27
Simson, Gooch, Jacopi, Monteggia, Craigie, Mojon, Capel, De Haen,
Leduc, J. Bell, W.  Blizzard, Marandel, Beauchene, Richerand, and
some others, all  of  which have been  collected  by M. Wood in his
Memoir  (pages  324,  326, 329, 330, 334, 345, 350, 353, 354, 390) ;
and by Descot in his Monography (pages 252, 253, et seq.)  As
to the efficacy of extirpation in neuromas, it is no longer at the pre-
sent day allowable to  call it in question. The woman operated  upon
by Franco had been for ten years in a perpetual torment.   The tu-
mor, which was of the  size of a small nut, had scarcely been re-
moved, when  the suffering ceased  forever.  In the two examples
cited by  Loyseau, the pain, which became excessive as soon as the
patients began to get warm in bed, also disappeared immediately af-
ter  the  operation,  which  the surgeon believed he  could  render
more effectual by afterwards cauterizing the wound.   The same re-
sult was  obtained by Pouteau, though  in the case mentioned by this
practitioner, the pains were so excessive as to occasion convulsions
in the left side.  One of the most curious facts of this kind is that of
Short.  In fact,  though epilepsy appears to have sometimes  origin-
ated from some  small  tumor of this nature, or from a nervous  cica-
trix, and  that Lassus has been enabled to cite Hippocrates, Galen, Cel-
sus, and  Alexander  of Tralles  in support of this, we find in none of
these authors an example  so conclusive as  that of the English  Phy-
sician.   A woman affected with epilepsy for twelve years had up to
that time had the paroxysms only once a month ; but they now be-
gan to appear four  or five times a day, and  to continue for an hour or
an hour and a half.  As they began always with a pain at the lower
and inner side of the calf, Short examined  the leg of the patient du-
ring one  of these paroxysms.  Plunging in a scalpel to about two
inches in depth, he felt a small body which he separated from the  mus-
cles and  excised.   It  was a hard  cartilaginous mass, or sort of  gan-
glion, of  the size of a  pea, situated upon a nerve which the  surgeon
divided with the same stroke of the instrument.  The patient, who
was immediately relieved of her paroxysm, cried out that she was
perfectly well, and never had an attack  afterwards.  The young
girl mentioned by Morgagni, and in whom  the pains were so acute
that she  would have cut off her foot herself had she  not been pre-
vented, was also very speedily cured by the removal of the  tumor.
The same occurred in the case of Petit, who also  speaks of the in-
tolerable pains.   In the  patient  of  Cheselden,  who experienced a
numbness only at certain  times, but suffered  acute pains upon the
least shock, the operation was no less fortunate;  as it was also in the
two women operated  upon by Camper, the one  treated by Hunter ;
and the  patients of Dubois, Siebold, M. Reiche, &c.  Surgeons of
the present day, therefore, who would decline an operation of this  kind,
would be censurable.  There is every  reason to believe for example,
that a patient who  after  an amputation of the thigh, continued for
two years to suffer the most excruciating pains, which he referred to
the extremity of his foot, might have been relieved of his misery, if
the species of swelling or  tumor which had formed above a  portion
of a branch of the sciatic nerve which had been included in  the lig-
ature of  the vessels,  could have possibly  been extirpated.  (Portal,
Anat. Med., t. IV.,  p.  289.)  The  case, mentioned  by Portal,  who 
28
NEW ELEMENTS OF OPERATIVE SURGERY.
 states that he saw the specimen  at Montpellier in the museum of
 Lamorier, reminds  me  of an observation:  those  nervous sympa-
 thetic pains, which occasionally persist for so long a time, and  which
 many who have been amputated refer to limbs which they no longer
 have—are they not imputable to the fact that nervous filaments have
 in reality been included  in the ligature with the vessels ?  [See re-
 marks on this subject in Vol. I., under Bleeding;  and Vol. II., under
 Nerves.~\

      Article I.—Extirpation  of  Neuromas  in General.

   Neuromatic tumors, in relation to their cure by extirpation, present
 three varieties.  Some are situated between the aponeuroses and the
 integuments,  and  others are found under the  aponeuroses at a depth
 which ordinarily corresponds with the track of the nerves.   If there
 are some which seem to be continuous with the nervous cords, there
 are others which appear  to have no kind of connection with this de-
 scription of organs.

                 § I.— Sub-Cutaneous Neuromas.

   Whether they be  continuous or not with the  nervous branches,
 sub-cutaneous neuromas  should, nevertheless, be extirpated nearly
 in the  same  manner in  all cases.    An  incision   of sufficient
 length is  first made upon  a line with the tumor  itself.   After
 having thus divided  the skin and cellular tissue, the surgeon secures
 the tumor with an erigne and causes it  to be raised up by an assis-
 tant  while he  isolates its sides.   With  a stroke  of the bistoury or
 scissors, he then immediately after detaches its upper  portion, then
 the deep-seated surface, and then  its lower  extremity.   In this man-
 ner he annihilates with the first cut of his bistoury, by separating the
 nodule from its nervous centres, those painful  irradiations sometimes
 insupportable,  which he  would otherwise  occasion  before having
 terminated the operation.   Prudence would require that a layer of
 cellulo-adipose tissue of sufficient  thickness should be removed with
 the neuroma.  Unless the tumor  should  have acquired an extreme
 volume, that of a  small melon for example, as in the patient ampu-
 tated by Louis, or that of Ant. Dubois,  the simple incision ought to
 be sufficient.   A neuroma which should  equal the size of a pullet's
 egg,  as in the two cases  reported by Reiche,  would in almost all
 cases exact nothing more.  As these tumors are usually sufficient
 regular, their dissection generally is easy.  The tissues  moreover by
 which they are surrounded, being  in  the normal state, are placed in
 excellent conditions for immediate reunion.   It is on  such occasions
 therefore, if ever, that we should approximate as accuratelv as pos-
 sible the flaps  or borders of the wound, and attempt the cure by first
 intention.   Having a regular point d'appui or  sort of barrier or pro-
 tecting plane  in the aponeuroses or bones which are  found under-
neath the integuments, the surgeon experiences no difficulty in effect-
ing the exact coaptation of the two opposite walls or lips of the solu-
tion of continuity.   If, however, these tumors should  have required,
 either in consequence of their volume, their degenerescence or some 
NEUROMATIC TUMORS.
29
anomaly in their form, the  formation of numerous flaps, or a caver-
nous wound, we must proceed in the manner  mentioned in the
article on Lymphatic tumors.  In other respects the wound which is
made by the extirpation of sub-cutaneous neuromas, is a simple
wound,  and is to be considered in no other point of view.

                  § II.—Deep-seated  Neuromas.

  Whenever it becomes necessary in order to reach the neuroma, to
divide  the aponeuroses, the operation ' becomes  manifestly more
serious.   The limits of the tumor being less perfectly ascertained,
do not enable us at first to regulate the extent of the incisions with
all the precision desirable.   To detach a sub-cutaneous neuroma we»
scarcely ever  are  in  danger of wounding any  important  artery;
some veins only can then embarrass the surgeon.  In subaponeu-
rotic neuromas, on the contrary, we have to guard against enormous
vessels, and the same  organs as in the case of lymphatic  tumors.
The incision  of the integuments being made, we again endeavor by
means of the finger carried to the bottom of the opening, to identify
the exact position and size of the tumor, in order, without arresting
the  operation,  to enlarge the external wound  should it be  deemed
necessary.  Dividing afterwards the aponeurosis with free cuts from
without inwards, should  there be neither  large sized arteries, veins,
or nerves in  the neighborhood; but on the contrary, by puncture at
first, and from  within outwards, and on a grooved sound, when we
have to proceed with caution; the surgeon then stops to examine
anew the* precise seat of the neuroma.   While an  assistant keeps the
lips  of the solution of continuity properly held apart, he continues to
divide the tissues with care, and layer by layer, until the tumor is laid
bare.   He then secures it with a hook and causes it to be drawn
upon by a second assistant, in order to facilitate him  in isolating its
two sides either by dissection or enucleation.   Before separating it
above or below, it  is necessary to  know if it belongs to  a small or
large nerve.   In the first  case, in fact,  there is no necessity of our
having  recourse  to a minute dissection in order to  detach it, and
to isolate it from the nervous filaments which surround it.   We  may
without danger cut freely and completely through  its two extremities,
since the  interruption of the functions of such  nervous filaments,
cannot  create  any very great degree of disturbance in  the uses of
the part which sustains them.  If on  the  contrary the nerve is im-
portant and voluminous, we should  endeavor, unless the thing should
seem wholly impossible, to disengage it from the tumor and to dis-
sect and isolate from it the filaments sometimes dispersed through it,
(eparpillees.) and do every thing  in fact  to preserve  its  continuity
while removing the neuroma. If, however, as has happened in a great
number of cases, the nerve and  the tumor are perfectly confounded
together, we should  decide upon  removing the part degenerated,
taking care to  commence the section at the upper part of the tumor
in order that the remainder of the operation may not be made more
painful.   In this manner it  has been found practicable to remove one
or two inches of the ulnar, radial or median nerve, without any very
serious  accidents, or permanent paralysis resulting therefrom.   The 
30
NEW ELEMENTS OF OPERATIVE SURGERY.
tumor being removed, whatever be the process, we must proceed to
the ligature or torsion of the arteries, the arrestation  of the hemor-
rhage by the known means, and the treatment of the wound  in the
manner described  under operations in general;  not forgetting that
even under  these circumstances  the  attempt  at  immediate reunion
presents numerous chances of success.   Nevertheless  as  we have
here the supple and lamellar cellular tissue which separates the mus-
cles, to transport inflammation and  suppuration to distant points, we
should  not be too anxious for the immediate closure  of the wound,
when we find  it  impracticable to keep the different portions of it in
the most exact coaptation possible.

    Article II.—Extirpation of Neuromas in Particular.

                  §  I.—Superficial Neuromas.

  Whatever be the region in which they exist, sub-cutaneous neuro-
matic tumors  are to be extirpated by a  process which  is  the same
every where, and for  which the rules above given will be found suf-
ficient.
  A. At the sole of the Foot.—The limb being  flexed and turned
upon its outer side, I made an incision opposite  the neuroma  of an
inch in length  and  parallel to the axis of  the limb; having secured
this tumor with an erigne, I glided underneath it the point of a straight
bistoury, and readily  separated it from  the neighboring tissues, first
behind  and then in front.   No arterial branch being  opened, I was
enabled to close the wound immediately, and to  keep it  thus united
by a circular strip of adhesive plaster.  The cure was accomplished
at the end of a week.
  B. On the internal malleolus,  and on  the  whole antero-internal
side of the leg we are to  proceed,  and would succeed  in  the same
manner.
  C. On the knee and in  the neighborhood of the patella the limb
should be extended or flexed, according as the tumor is more or less
movable; but we must not turn it  upon its outer side.   After hav-
ing laid bare  and  removed the  tumor and united the  wound, the
limb should be placed also at the  ham in a state of moderate flexion
upon a pillow or large cushion.
  D. For the  anterior, inner, or outer side of the thigh, we should
proceed in the same manner, without any necessity of more serious
precautions after the operation.   If the tumor was situated upon the
outer or  posterior  region either of  the  leg  or  thigh,  the surgeon
would find some advantage in making his  patient  lie upon  his  belly.
Nevertheless the incision  of the  skin, the excision of the  neuroma,
and the dressing, would be as in the preceding  cases; and for  the
rest we should take care not to let the limb press upon the diseased
region.
  E. Neuromas of the hand ox fore-arm  are  to  be removed after
the same rules.  In all cases the  limb should be  placed  so that the
tumor should present itself in front  of the operator, and in all cases
also the wound could be united by means of strips of adhesive plaster
or any other bandage.  In the case of Neumann the tumor which had 
NEUROMATIC tumors.
31
existed for more than thirty years, was situated upon the lower and
middle part of the fore-arm.  After having divided the skin, it be-
came necessary to tie several arterial branches, though the neuroma
was only the size of a pea, and appeared to occupy a  branch of the
cutaneous nerve.  It is difficult, however, to  understand why Neu-
mann was fearful of proceeding any farther, or that he should have
thought it advisable to  confine himself to narcotics  and  afterwards
caustics to complete the operation.   I have already said moreover,
that the patient, who was seventy years of age, died of apoplexy be-
fore being cured of his wound.   If, as in  one of the cases of Cam-
per, the neuroma should be  situated  outside of the elbow,  and  on
the track of some of the branches of the musculo-cutaneous nerve,
we should after having separated the limb from the trunk, keep it in
a state of moderate extension during the whole course of the opera-
tion.  It is important here that we should guard against the synovial
capsule, and not penetrate deeper than  is  indispensably necessary in
the direction of the articulation.
   F.  Upon  the  continuity of the arm, wre should also have  to turn
the limb inwards or outwards upon its axis, according as the neuroma
was placed more on one side than the other, and we should also have
to guard against wounding the basilic or cephalic veins and the sub-
aponeurotic organs.  The thoracic limbs moreover, are  those in which
the dressing  is  most simple, and where the wound would  have the
best chance of cicatrizing by the first intention.

                 §  II.—Deep-seated Neuromas.
   A. The Thoracic Limbs.—The extirpation of  deep-seated neuro-
matic tumors has already been performed upon a great number of dif-
ferent regions.
   I.  I do not know if it has been employed upon the  fore-arm.   In
all such cases we should have to divide the integuments and isolate
the tumor in this region, in the same way as for cutting  down upon
the radial, ulnar  or median nerve.   In the  case of Cheselden it is
clearly perceived that  the tumor occupied  the middle of the ulnar
nerve;  but  it is not mentioned if it  was in the arm or  fore-arm.
Having separated the muscles apart and isolated the tumor, it would
be necessary to detach the nerve from  the artery before completing
its double  section.   The median nerve  being  nearly at  an equal
distance from the two  principal  arteries of this region, might, so far
as regards  any immediate  danger  in  the manipulation, be  excised
with less apprehension.
   II. In the arm the neuroma may occupy the radial, ulnar or median
nerve, or the cutaneous nerves,   a.  E. Home says that the tumor ex-
tirpated by Hunter, in a woman aged 20 years, was situated upon the
musculo-cutaneous nerve; having laid bare the neuroma  by a proper
incision, he excised about three inches of the nerve.   The loss of sen-
sibility,  which at first showed itself in  the thumb and  forefinger, did
not long continue, and the patient was completely re-established.   A
woman, upon whom I operated in 1838 at the hospital of La Charite,
had at the middle of the left arm in  the  substance  of the biceps, a
small ovoid   movable  tumor with   painful irradiations, which  had
existed  for a great number of years, and produced the symptoms 
32
NEW ELEMENTS OF OPERATIVE SURGERY.
  which usually attend neuromas.   Having separated the arm from the
  trunk, I made an incision of two inches between the lower extremity
  of the deltoid and the origin of the supinator longus muscle.  Dividing
  the tissues, layer by layer, I arrived at the fibres of the biceps muscle
  without touching the cephalic vein, and then  reached the tumor,
  which I secured with an  erigne, and then excised.  The acute  pain
  which the woman experienced every time I touched this  neuroma,
  the greyish looking  stem which was prolonged above and below, and
  the numbness of the entire outer side of the fore-arm afer the opera-
  tion, sufficiently prove, as I think, that the tumor in reality occupied
  the trunk of  the musculo-cutaneous nerve.  The wound was united
  by first  intention, and except for a diffused  erysipelas which spread
  from  an issue which the  woman  carried in  her  arm, the cure would
  have been completed at the expiration of a week.
    b. Upon the large nervous  trunks the operation might be much
  more dangerous.  The neuroma  of the  size of a  melon, which ac-
  cording to Dubois, occupied  the median  nerve  of the right  arm, re-
  quired the crucial incision, and the excision of a considerable portion
  of the nerve.  The cure was accomplished,  but  the  sides of the
  fingers remained insensible.  It does not appear that Petit was under
  the necessity of making  use of a complex incision for  the removal
  of that  neuromatic  tumor of the  size of a  pullet's egg, which  had
  existed for seven years in the arm of a young girl.  As it was  sus-
  pended, according to the author, to a small nervous  cord, we may
  consider that it was situated  upon one of the cutaneous nerves.
    c. In  the  first case of Reiche, it was evidently situated  upon the
  ulnar nerve.  The surgeon, after having taken up a fold of the in-
  teguments, divided them to the extent of five inches.   The dissection
  of the tumor obliged him to divide many small branches of arteries,
  without, however, occasioning  any serious hemorrhage.  It became
  necessary to remove with it about four inches of the nerve.   The
  pains, which were very violent at first, afterwards diminished  and
  changed in their nature, and were soon followed by a numbness in the
  hand.  The wound was cicatrized in fifteen days, and nothing ensued
  from  the operation  but a slight degree of  insensibility in the little
  finger.  We  should  operate  here, therefore, in  the same way as for
  cutting  down to, and tying the brachial artery, with  this difference,
  that we  are guided  by  the tumor, and that while raising up this last
  during the dissection, it. is generally easy to reach the nerve and to
  excise it, by commencing in the direction towards its root.
    d. In  the  hollow  of the axilla,  neuromas may also have their  seat
  over the aponeuroses.   E. Home, who had to cut down upon one of
  this kind contiguous to the great axillary nerve, says, without designa-
  ting the process he adopted, that he effected its excision, and that the
  operation caused neither any great degree of pain, nor any other un-
  pleasant symptom as its  immediate consequence;  but he adds,  that
  a violent inflammation soon supervened  in the region occupied by the
  tumor, and that it occasioned the death  of the patient on the eighth
  day.  The arm in  these cases must be  held  wide apart from the
  chest, and the tissues are to  be divided after the rules laid down for
H a ligature upon the axillary artery, rather than after those for the ex-
  tirpation of  lymphatic  tumors.  Neuromas, in fact, will be found to 
NEUROMATIC TUMORS.
33
be resting against the root of the arm, instead of tending, like degene-
rate  lymphatic ganglions,  to  glue themselves against  the  thoracic
wall of  the  axilla.  The best means of avoiding the misfortune
mentioned by Home, in  such  cases, would be to dress the wound
with small balls of lint, in place of immediately attempting its union
by first intention.
  B. The Abdominal Limb.-^-l. Every thing goes to show that there
is no deep-seated nerve of the leg which is exempt from neuromas.
Up to the present time, however, the  extirpation  of these tumors at
the foot  and upon the whole length of the abdominal  member, has
scarcely  been  spoken  of except under  the  title  of sub-cutaneous
tumors.   The case of Short is  almost the  only one which would
appear to coincide with a profound neuroma.  Here no doubt can
exist, for the author says he plunged in  his scalpel to the depth of
about two inches, and that he was obliged to separate the tumor
from the muscles before extracting  it with the forceps.  We should
have to be guided, moreover, by the precise  situation  of the tumor
and the known track of the nerves of this region.
   II. It is not known whether the neuromas of the knee or in the neigh-
borhood  of the  patella, extirpated by Camper and A. Dubois, were
rather sub-aponeurotic than sub-cutaneous; but the natural arrange-
ment of  the  tissues of  this region, induces rather  to the opinion  that
they were in reality superficial tumors.
   III. Though it might appear that the tumors extracted from the thigh
by Loyseau, were situated between the aponeurosis and integuments,
it is at least certain that  in one of the patients whom I  have already
spoken of, and who had  them  on different parts of the body, the dis-
ease had its seat underneath (au-dessous) the fascia lata.
   IV.  This patient having died, we had an opportunity  of practising
upon the  dead body the operation that might  have been performed
upon him during life.   One of the tumors which was situated  upon
the antero-external lower third of the thigh, was laid bare by an
incision  two and  a half inches long.  Having  reached below the
aponeurosis, I had still to isolate it from among the fibres of the tri-
ceps muscle.  There it appeared to form an immense spindle-shaped
ganglion, of the size, of a  nut, upon the continuity of one of the
branches of the crural nerve.   A similar tumor located in the upper
third of the limb, was situated underneath the sartorius, and would
have rendered necessary the division of a part of this muscle.
   V. The sciatic nerve.   The most remarkable neuroma I have seen,
was situated upon the posterior part of the  thigh, at four fingers'
breadth below the breech.  The tumor, which had existed for many
years,  and had developed itself without any known cause, in a lady
aged thirty years and upwards, was of the size of the head of a new-
born infant.  Assisted by M. Gorsse, the physician  of  the patient,  I
extirpated it in the following manner.   Being placed upon her belly,
with a pillow under the trunk, Mile. H. was held in  this  position,
while the leg was kept extended by other assistants.  Having made
an incision in the integuments parallel to the  axis of the trunk, and
six inches in  length and commencing at the outer border of the
ischium, I had to cut through the sub-cutaneous fascia, the fascia lata
and sundry adipose layers  before perceiving the tumor.   Having
                              3 
34
NEW ELEMENTS OF OPERATIVE  SURGERY.
 isolated it on its posterior surface, it was secured with a hook and
 drawn backwards, while I detached it on  its inner and outer side by
 means of a careful and delicate dissection.  I  disengaged it  in this
 manner from the  long  portion of the biceps, which was pushed
 inwards with the semi-tendinosus and semi-membranosus.  It was
 not until then that it became evident that the sciatic nerve supported
 the whole of this mass, of which it formed as it were the axis.   The
 fear of inducing gangrene, or at  least an incurable paralysis of the
 limb, by excising a nerve of this volume, caused  me  to hesitate an
 instant.  Seeing however that the tumor was perfectly free at the
 middle of the great cellular track, (trainee,) which extends from the
 ischium to the ham, I asked  myself the question, if it might  not be
 possible to divest it of the nervous filaments and  to remove it alone.
 After  having therefore detached its whole circumference  and dis-
 sected the nerve, first above and  then below, as for  an anatomical
 preparation, I recognized tl\at  there was  nearly a third of it intact,
 or as it were enchased merely upon the anterior plane of the neuroma.
 The two other thirds of its cords were dispersed  in the manner of
 the grill-work (rayons)  of a  cage or  oyster pannier  upon the two
 sides of the  tumor.   Encouraged  by the extreme fortitude of the
 patient, I proceeded to isolate each one of those filaments by means
 of the bistoury,  and  succeeded  in  disengaging nearly the whole of
 them while pushing them towards their  common centre in front.
 The neuroma thus  removed  left a cavity as large as the two fists,
 which tfirst filled up with small balls of lint, and then treated by
 secondary immediate  reunion.  The cicatrization of the wound ap-
 peared complete at  the end of five weeks.  An evident numbness
 and partial paralysis of the outer half of the foot and of the neighbor-
 hood of the corresponding malleolus, were the  only accidents ealcu-
 culated to give me any uneasiness during the first week or two after
 this serious operation; but these symptoms subsided by degrees, and
 the cure, which  was completed at the expiration of three  months,
 remained permanent.  It was in 1831 that the operation was per-
 formed.  Mademoiselle H. married, and at  the present  time (Decem-
 ber, 1838) is in the enjoyment of perfect health.   Messrs. Roux and
 Chelius have each published a similar case, except that in the patient
 of M. Roux the tumor, which was of a cancerous nature, reappeared
 and terminated in death.              ' -
   VI. I am not aware that other physicians have spoken of neuromas
 in the neck ; for myself, however, I have every reason to believe that
 the tumor mentioned by M. Berard, senior, and  which I have spoken
 of under the article on Excision of the nerves, was one of this kind.
 I will add that in a dead body dissected by M. A.  Thierry, I ascer-
 tained  the existence of a spindle-shaped tumor of the size of a small
 pullet's egg, and of a reddish tint, on the middle of the continuity of
 the great sympathetic nerve at its cervical  portion.   It seemed as if
 this tumor might be a nervous, ganglion excessively hypertrophied,
 and as it was no more adherent than normal nervous ganglions, it
 would  have been evidently practicable to have cut down  upon and
 extracted it, had it during life caused any  serious  symptoms.   Pro-
ceeding in the same manner as for a ligature upon the carotid artery,
it might have been  removed without difficulty; and I do not think 
NEUROMATIC TUMORS.
35
the excision of a portion of the great  sympathetic in a case of this
kind, could be followed by any very formidable disturbance  in the
animal economy.
  VII. Upon the thorax I have in four instances removed  neuroma-
tic tumors.  Madame de T. for many years suffered neuralgic pains
in the right side of her chest.  A little tumor of the size and form of
an almond, which had been  noticed by M. Rayer, and  which ap-
peared to be the source of her sufferings, was situated between the 10th
and 11th ribs, precisely at the place where the cincture of the gown
is worn.   To reach it, I was obliged by means of an incision of two
inches, to divide the integuments, the sub-cutaneous fascia, some fibres
of the latissimus dorsi and obliquus  externus muscle, and afterwards
the fibro-cellular layer which covers the external intercostals.  Being
hooked fast to and raised up  by an  erigne, the tumor caused a vio-
lent paroxysm of pain, and as it  prolonged  itself in front  and back-
wards by a yellowish  stem, it  presented to me completely the ap-
pearance of a nervous ganglion.  Having excised  it posteriorly and
then in front, I found  there was no artery to tie, and drew the lips of
the wound together by two strips of adhesive plaster, which I  cover-
ed with a pledget of  lint  and body bandage.  Some slight suppura-
tion ensued, but the cure was nevertheless completed after the expi-
ration of a short time.  In the following year, that is, in the  month
of March, 1837, I was obliged to subject Madame de T. to a similar
operation.  A new neuroma had shown itself at an inch below and
behind the first;  the operation and its results were the same^and the
patient has, up to the  present time, (December, 1838,)  remained free
from  any new trouble from this source. -  A young girl of 19 to 20
years of age, whom I  operated upon at the hospital of  La Charite in
1836, had at the same place, but upon the left side, a trilobate tumor
of the size of a large nut, and which also presented the characters of
neuroma.  In this case an incision of three inches was required, and
the tumor was almost  entirely sub-cutaneous.   Having dissected and
removed it, I was nevertheless not  enabled to close the wound by
first intention, and the cure was not effected until at the  expiration
of five weeks.  Another neuroma which I  also met with on the tho-
rax of a woman,  was  likewise situated  at the same height.   Are the
constriction or frictions made there by the cord of  the petticoat or the
cincture of the frock, the cause  in these cases?  The case of the man
which I have  already several times alluded to, and who had so many
neuromas dispersed over the chest and limbs, had one also between the
cartilaginous  border of the tenth rib and the umbilical region.   In or-
der not to be incommoded by the natural depression of the side, I laid
bare the tumor in this case by means of a transverse incision slightly
convex below.  It became necessary therefore to cut through the skin,
sub-cutaneous fascia and externus oblique muscle,  for the tumor was
situated quite deep.   The extirpation was  not  in other respects diffi-
cult, but it required a  ligature upon two arterial branches  and left a
sufficiently extensive cavity  underneath the integuments.   This pa-
tient, though cured of the operation, having a cancerous affection of
the bones of the  left wrist, underwent  at a  later  period amputation
of the fore-arm, which terminated in death at the expiration  of twenty 
36
NEW ELEMENTS OF OPERATIVE SURGERY.
days in consequence of numerous  metastatic abscesses in the viscera
and an enormous effusion in the pleura.
  VIII.  Recapitulation.—Neurom&s as we thus perceive being ordi-
narily uniform and perfectly isolated in the midst of the other tissues,
may be extirpated without great difficulty in almost all patients.  If
they occupy small nerves it would be a useless precaution to endea-
vor to detach them from these, rather than to excise  the nerve and
the tumor at the same stroke.   In  the contrary case and especially if
the sciatic nerve were involved, we should do our utmost to detach
the nervous filaments from it, at least in part, as I succeeded in doing
in the case mentioned farther back.  If this separation were utterly
impossible and the accidents caused by the neuroma were really seri-
ous, we should still finish the operation, at the risk of interrupting the
continuity of a large nerve.  The facts which  I have related under
the article on Excision of nerves, and those which have been con-
sidered  in this chapter,  prove that  the consequences of such an
operation rarely compromise the life, that they do not always alter
the functions of the limb to an incurable extent, and that very fre-
quently in fact the phenomena of sensation and  motion which had
been believed to be permanently destroyed, are ultimately more or
less perfectly re-established.
                        CHAPTER V.

    LIPOMAS, OR FATTY (Graisseuses) TUMORS OR WENS (Loupes).

  Ever since  surgeons, aided  by the light of analysis, have sought
to distinguish tumors rather by their nature than their form, the word
wen (loupe) which was employed  at first to designate all tumors, is
scarcely ever used any longer except for such as are composed en-
tirely of fat, which are the only ones recognized at the present time
under  the name of lipoma  (lipome).   After the  example  of some
modern pathologists,  therefore,  I would understand by the word
loupe or lipoma, which was invented  by Littre (Hist, de VAcad, des
Sc, 1709), tumors  constituted  of pure or degenerate fat.  This  spe-
cies of disease which  belongs to the class of hypertrophies,  involves
no danger in itself, and in reality incommodes only by its volume or
weight, or the deformity it produces. Nevertheless lipomas appear to
me to be susceptible of many kinds of transformation or decomposition.
If is not impossible  perhaps that they may undergo even cancerous
degeneration ; the  putrescent  transmutation (la fonte  putride), howr-
ever,  is one of their most usual terminations.  As on the other hand,
however, these tumors scarcely ever disappear by resolution, and as
their augmentation has no determinate limit, surgery  must  necessa-
rily interpose its aid and devise means of disembarrassing patients of
them.  The remedies adapted to them are reduced to a small num-
ber, and  topical applications of whatever description  are devoid of
efficacy.   General remedies would be more dangerous than useful. 
LIPOMAS, OR FATTY TUMORS  OR WENS.
37
There is nothing in  fact in such cases, if we wish to do any thing
effectual, but the  mechanical or chemical destruction  of the tumor
that  can be  resorted to; so that the entire therapeutic of lipomas
definitively resolves itself into this principle : that is, to  destroy them
by caustics, the  ligature or  the cutting instrument, or  to do nothing
at all.   So long as the lipoma  possesses little volume, is imperfectly
defined, or scarcely causes -any inconvenience, or is deeply situated,
we may, if there is reason to  believe that  its  increase will not ulti-
mately  render its destruction more  dangerous, wait and do nothing,
or confine ourselves to some hygienic precautions.  On the contrary,
whenever the lipoma is  superficial, well-defined and easily accessible
to an operation, it is much better to attack them at once than to tem-
porize.   Though it should even be unfavorably situated, we ought to
advise the patient to get rid of it in good season, inasmuch as the
operation, the longer it is delayed, since it must ultimately become
indispensable, presents  so  much the  less chance of success, in pro-
portion as the tumor is  of older date or more  voluminous.  On this
point I will take the  liberty of making a remark.
  Fatty tumors  are far  from being  situated always in the sub-cuta-
neous tissue, as most  modern pathologists maintain.  Without men-
tioning those which are seen in the chest, abdomen and pelvis, they
are sufficiently often  met with also, underneath the aponeuroses and
even in the central portion of the limbs.   It is easy to comprehend
also that lipomas may exist wherever the adipose cells are naturally
intermingled with the other tissues; so that we ought to have reason
to be astonished rather  at their absence than their presence between
the muscular layers  and bundles (faisceaux).  There are, therefore,
under this point  of view, two  classes  of lipomas: the sub-cutaneous
or superficial, and the sub-aponeurotic or  deep-seated, in the same
way also as there are two kinds of neuromas and two orders of lym-
phatic tumors.   In respect to regions for which  they  have  a predi-
lection, it would  be  difficult to specify them;  for fatty tumors have
been observed upon almost every part  of the  body.   I have met
with them on the supra-hyoid region, on the cheeks and forehead and
in the  supra-clavicular region, upon the shoulder, at the  middle of the
arm, on the anterior border of the axilla, in front of the  sternum or
abdomen, at the nape,  on  the back, in  the fold of the groin, at the
perineum and upon  the thighs and legs.  Dupuytren (Journ. Hebd.
Uuiversel, t. IV., p. 28.) speaks of a lipoma which occupied the lum-
bar region.   Dorsey  (Elements of Surgery  &c, Journ. des Pr ogres
t. IX., p. 281.)  mentions the  case of a  lipoma  which was  situated
upon the dorsal region, where I have also seen them in two instances.
In the  patient of M. Graefe (Gaz. Med.,  1835, p. 169.) the tumor
was situated between the muscles of the abdomen; and below the
clavicle  in the case of M. Portulapi  (Bulletin de Ferussac, t. I., p.
240.  The Lancet, April, 1824, p. 24.)   In a patient mentioned by
M. Taramelli, the  lipoma extended  from the  groin to the perineum
(Bull, de Ferussac, t. XVI., p. 85.); while that  extirpated  by M. Tail-
lefer (Gaz. Med., 1837, p. 93.) was situated  in the dorsal region.  M.
Serre (Ibid., 1838, p. 266.) has  seen  one at the posterior region of
the neck and M. Syine (Edinb. Med. and Surg. Journ., vol. 137, p.
381.) met with a curious example of one in the hollow of the axilla. 
38
NEW ELEMENTS OF OPERATIVE SURGERY.
Thus, as I shall describe farther on, I have encountered enormous
fatty tumors in the posterior region and depth of- the thigh, upon the
acromion, on the arm, at the side, under the axilla, &c.; so that there
is nothing more variable than lipomatous tumors,  both  as regards
their  form, depth or volume, or the region where they are situated.
We may consult on this subject, Chopart, Louis, M. S. Cooper, Ali-
bert and M. Pautrier (These No. 6, Paris, 1834.)  There is scarcely
any other mode of curing  lipomas except by the ligature or extirpa-
tion.  Though the red-hot iron or caustics, properly so called, might
be applied without any very great danger to sub-cutaneous lipomas,
it would be a different case with those that are deep-seated.  It is
moreover a kind of remedy which is not suitable to  lipomas that are
greatly developed, and one  which in no case deserves the preference
over the two other operations which I have just mentioned.
  The ligature for lipomas, sometimes sufficient, rarely preferable,
and never indispensable, would not be conveniently applicable but to
those  which were pediculated or not of large volume.  It should be
applied, moreover,  with the same precautions and by the same pro-
cesses as for cutaneous and erectile tumors.  It would also be appli-
cable  for fatty tumors,  as  for all others,  to strangulate  their roots
after  having dissected them, if there should be any great difficulty
experienced in avoiding the  deep-seated vessels; but their extirpa-
tion is, in truth, the best, and I might say, almost the only resource.
In cases of sub-cutaneous  lipoma, nothing is so  simple as this opera-
tion.  If the tumor is but of little volume,  a straight smooth (unique)
incision  is first made through the integuments, either a T, or crucial,
or semilunar, or a V, or L, or an ellipse, or even stellated, if  any advan-
tages  are to result from it.   As the tumor contains no liquid, there is
no danger in  wounding its tissue while cutting  through  the skin.
As these tumors do not usually contract any intimate adhesions with
the neighboring tissues, they are generally easily isolated and de-
tached  from the surrounding cellular texture; though even  some
pelotons should be left behind, the cure would not on  that  account be
materially interfered with ;  and as they receive no large-sized vessel,
they may be  extirpated without incurring  the risk of any serious
hemorrhage.   The teguments with which they are surrounded being
scarcely ever  diseased,  may be  preserved, reversed, and then ap-
proximated  in  such manner, after the operation, as to  be brought
into contact at every point.  The bottom and flaps of  the wound
being almost constantly composed of sound tissues, surprisingly facili-
tate all the efforts at immediate union or primitive agglutination.
  The extirpation of lipomas is thus  one  of those operations which
are performed with  the least repugnance, and undertaken with the
greatest degree of confidence.  Nevertheless, it would be wrong to
decide upon it on too slight grounds.   An adult man, strong, and of
good  constitution, and about fifty years of age, came to the hospital
of Saint Louis, in 1822, for the removal of a lipoma of the size of the
two  fists, and situated upon  the postero-superior part of the right
shoulder.  The extirpation of this tumor, which was performed by
M. Richerand, presented  at first nothing peculiar.   But  an erysipe-
las, which ultimately extended  from  the shoulder to the nape, and
from  the neck to the cranium, soon put a period to  his life.  An old 
LIPOMAS,  OR FATTY  TUMORS OR WENS.
39
man who had a lipoma, larger in volume than the head of an adult,
appended as it were  to  the  posterior region of the neck, operated
upon by M. Roux, in 1825, at the hospital of the Faculty, also per-
ished in a few days.  When, therefore, we decide upon extirpating
lipomas,  it is important to guard against the general consequences of
operations, in  the same way as in the extirpation of  all other sorts
of tumors.


              Article I.—Sub-Cutaneous Lipomas.

   The arrangement of the incisions and the character of the operative
process,  ought moreover, in general, to vary, according to the size,
form, and seat of the tumor.  M. Gensoul (Pautrier,  These No. 6,
Paris, 1834,) who, like  MM.  Rust, Walther and  Textor  (Rust's
Hand, der Chir., t. VI., p.  683), first plunges  a  long  knife through
the root  of the tumor  to separate it, first on one side and then on the
other, has the advantage of terminating the operation rapidly; but
he  runs  the risk of sacrificing useful integuments and cutting out
irregular flaps.   It is better therefore to make use of the,bistoury, and
to divide the skin from  without inwards,  and to prepare  flaps of
suitable form and extent/to be well  adapted to,  and to cover over,
the  wound accurately after  the removal  of the  tumor.    Fabre
(Observ.  de Chir., in-12, 1778) after having laid them bare  by a
longitudinal incision, and passed a ribbon through their base in the
same direction, so as  to enable him  to draw them towards  him, re-
commends that we should strangulate their root by a ligature, which
being tightened gradually during the dissection, has the advantage of
pushing  out (chasser) the tumor and benumbing the pain;  but it is
doubtful if this process, which is not every where practicable, finds
many partisans at the present day.   Complex  incisions also are not
indispensable but for  lipomas  of a certain size.  By means of a
straight incision I was enabled to remove from the root of the shoul-
der a lipoma of  larger size  than a pullet's egg.  Nevertheless, if the
integuments should be too much attenuated, the tumor approach
the size of the fist or exceed it, or the skin have undergone the least
degenerescence, it would be preferable to have recourse to  complex
incisions, and even to sacrifice a portion of the  integuments, rather
than rely upon a simple incision.

                              §1-

   A young  girl from the country, whom M. Rayer desired  me to
operate upon in his wards,  at La Charite, had in front and below the
left clavicle a trilobate lipoma,  of the size of the fist.   After having
first made an incision through the tissues from the neighborhood of
the sternum to the root of the shoulder, I then  divided the skin from
above downwards to the  extent of two inches, making  thus  two tri-
angular flaps, which were dissected and reversed, the one outwards
and  the other inwards.  After the removal of the tumor these two
flaps were readily raised  up to the horizontal  branch of the T and
adapted  to the  bottom of the wound by means of strips of adhesive
plaster. 
40
NEW ELEMENTS OF OPERATIVE SURGERY.
                              §11.
  A man aged from 45 to 50 years, who had in the supra-clavicular
depression a lipoma, which a charlatan, by means of different caus-
tics, had transformed into a bleeding fungus, was received, in 1837,
into the hospital  of La Charite for the purpose of having his tumor
removed.   The integuments in this case being destroyed or degen-
erated, I was obliged to  surround  the lipoma  with two curved  in-
cisions, and to remove with it an ellipse of the skin and of the cellulo-
adipose sub-cutaneous tissue.   An erysipelas supervened, but the
patient, nevertheless, got  well in a  short time, as also did the young
girl whom I have just spoken of.

                             § III.
  A woman of more than usual embonpoint, had between the lowei
border of the axilla and the side of the thorax  a badly-defined lump
of the size of  an egg, which caused her, she  said, acute suffering.
For the removal  of this tumor, which was  continuous  and without
any line of demarcation, with the general  adipose tissue, I required
only a simple incision three inches in length, and parallel to the lower
border of the pectoralis major near  the chest.

                             § IV.
  Another woman from 35 to 36 years of age and whom M. Ribail
had  sent to me, had  in front of the  acromion and on  the  anterior
surface of the right deltoid muscle, a lipoma, slightly flattened, lumpy
(bossele), and of the volume of a pullet's egg.  I was enabled to re-
move this also by the straight incision, and  the cure was not inter-
fered with by any serious accident.  A young  girl who was sent to
me  by Doctor C. Piron, had a  lipoma of the same size as the  pre-
ceding on the acromial side of the left shoulder.   Here the adhesions
were such that I considered it proper to lay it bare by means of a T
incision, whose  stem was turned backwards and slightly outward
This patient was also cured.

                             § V.
  In the case of the young man mentioned farther back,  and  who
had a slightly elongated fatty tumor of the size of the fist, below the
lower jaw, I was equally  obliged to recur to the T incision ; nor did
any inconvenience result  from  it,  and the  patient soon recovered.
There is every reason to believe,  however, that a  semilunar  inci-
sion, with its free border below, would have  permitted me, by raisin <*
up by dissection the flap of soft parts thus circumscribed,  to con>
plete the operation with as much certainty and  security.

                           § VI.

  Having to remove a lumpy  (bosselee) lipomatous tumor of the
size of a small egg, and of very irregular form,  on the left side of the
waist of a woman who was admitted  into the hospital of La Charite
in 1837, I  limited myself to  a simple  incision  of  three inches in
length, and parallel to the direction of the neighboring  rib.  Imme-
diate reunion took place, and  the  patient was well in a few days,
and without  any suppuration.   Recently, on the  18th of December, 
LIPOMAS,  OR FATTY  TUMORS OR  WENS.
41
1838, I removed a similar tumor which a student of medicine had
upon his right side.  I made a vertical incision slightly convex pos-
teriorly, and in  five days after the  young  man was cured.  These
examples, I  presume, are sufficient to point out the different modes
of extirpating superficial lipomas of moderate volume.

                          §  VII.
  But  if the tumor should be of a larger size, we must proceed in
another manner, always, however, in conformity with the anatomi-
cal requirements of the region, or of the part where they are situated.
If the ancients had given more details of their experience, we should
probably  have  had evidence of large-sized lipomas having  been
noticed by them.  That horrible tumor of the size of the head, and
which subsided  and increased,  and  hung near the ear of a baker,
mentioned by Felix Plater,  (Bonet,  Corps de Med., t.  III., p. 14,)
was it  not  a  fatty tumor ?   The one called  steatomatous by Loti-
chius, (Bonet, t.  IV., p. 322,) which  was also of the  size of a man's
head, and likewise situated behind the ear, evidently belonged to the
class of lipomas.  We see also by a case of M. Serre (Gaz. Med.,
1838, p. 266,) that fatty tumors upon  the posterior region of the neck
may acquire an enormous volume, and  a  weight of at least seven
pounds.   The one I noticed in  1825, and which occupied the same
region, was not less voluminous than the  steatoma mentioned by
Lotichius or by F. Plater.  It appears that M. Miller even had extir-
pated  one of the  weight of  twenty  pounds, and  which  M. Warren
(Surg.  Observ. on Tumors, p. 55,) was enabled to show  entire to his
pupils.  Whatever may be the volume, lipomas of the posterior region,
of the neck or ears, are nevertheless extirpated nearly in the same man-
ner, as superficial fatty tumors in general.  While almost constantly
sub-cutaneous in  these regions, they have scarcely much greater
breadth to their root when very voluminous than when they are in
the  condition of small lipomas.  But the danger of their extirpation
lies  in  the depth of their root, and in the thickness of their pedicle,
much more than  in the totality of their  mass.  There is nothing to
 avoid there but  the occipital artery or the auriculo-mastoidean above,
and some branches of the cervical arteries below.  The  patient ope-
rated upon by M. Serre recovered perfectly well, and there is nothing
to induce us to think  that  the  operation should be more dangerous
here than anywhere else.  A steatoma of the size of the  head, which
was situated upon the  occipital region of a child two and a half years
old, was removed  by M. Seerig  with perfect success, (Arch. Gen. de
Med., 3e serie, t.  I., p. 115,)  while F. de Hilden, (Bonet, p.  83,) on
the  authority of a letter of Screta, speaks also of a child two months
old, and  which was operated upon  in this manner at  the hospital
of Strasburg,  for an enormous tumor which it had on its nape.

                             §  VIII.
   The  posterior region of the  trunk also  has frequently presented
these enormous lipomas.  The  alleged sarcoma of  such prodigious
size which formed between the shoulders in a  woman mentioned by
F. Plater, (Bonet,  t. III., p. 14,)  and which was successfully removed,
was probably a degenerate lipoma.  Dupuytren removed one of 
42
NEW ELEMENTS  OF OPERATIVE SURGERY.
 these,  which was partitioned off with several osseous plates, and
 which was situated above the lumbar region, in a woman aged sixty
 years.  Dorsey (Journ. des Progres,  t, IX., p. 280,) states  that he
 removed from the back of a man a lipoma which weighed twenty-five
 pounds.  The cure took place rapidly, and the figure  given by the
 author shows  that this tumor held on  to the trunk only by a sort of
 fold of the integuments.   A friend  of A. Petit, (Anat. Chir. de
 Palfin, t. II., p. 19,) by making use  of the ligature,  was enabled to
 separate from the dorsal region, a lipoma of twenty-eight pounds, and
 another of forty-eight pounds.  A patient, seen by Petit himself, had
 one upon the back, which must have weighed  at least sixty pounds.
 A lipoma in the same region, of four  pounds' weight,  was since extir-
 pated  by M. Taillefer,  (Gaz. Med., 1837, p.  93,)  who united the
 wound by suture, and  cured his  patient in fifteen days; so that on
 this plane of the trunk the extirpation of fatty tumors  presents numer-
 ous chances of success, whatever may be their volume and weight.

            Article II.—Sub-Aponeurotic Lipomas.

                       § I.
  Though lipomas may exist on the  anterior region of the body, the
remark, nevertheless, is true, that they are  less frequently developed
there than behind.   The largest sized one I have noticed on the ster-
num did not exceed the dimensions of the fist.   There is no proof to
show that the tumor shaped like a ball, of the  size of a man's head,
and which was situated in  the substance of the  parietes  of the ab-
domen, as mentioned by F. Plater (Bonet, t. III., p.  15), was a fatty
tumor,  rather than one of any other  kind.

                             § II-
  That which M. Graefe (Gaz. Med., 1835, p. 169,) extirpated under
the title of lipoma, and which was situated beloAV the obliquus externus,
was it in reality a fatty tumor ?  It is readily conceivable, moreover,
that the operation would not be sensibly more difficult in front of the
chest than in the dorsal region.  But in the abdomen the case would
be different if  the tumor  really  had  its seat underneath the muscles
or  aponeuroses.   The risk of wounding  the epigastric,  internal
mammary, lumbar or intercostal  arteries, would  here be among the
least of the  inconveniences to encounter from the operation.  It is
the  neighborhood of the peritoneum and the development of inflam-
 mations and of consecutive suppurations, which  would then be the
real sources of danger.

                             § III.
  The same dangers would exist if the lipomas were  developed in
the  sides or hypochondriac regions.  Lotichius (Bonet, t. IV, p. 321,)
 states that he saw in the hypochondrium of a patient, a steatoma of
 the  size of the head, and that the extirpation of this tumor undertaken
 by a charlatan, was followed by death  at the end of two days.  F.
 Plater  (Ibid., t. III., p. 15,) also speaks of a tumor which had a strong
 resemblance to the brain, and which existed in  a  young man, on the
 left side, near the back; but no one  had the courage  to undertake its 
LIPOMAS, OR FATTY TUMORS  OR WENS.
43
removal.  That case of a carcinoma, also, which occupied the right
hypochondrium, was of the size of a child's head, and extirpated with
success, and the history of which is given by Bartholin, (Bonet, t. IV,
p. 461,)  was it not, perhaps, a degenerated lipoma?  M. Warren
(on Tumors,  p.  57,) has extirpated a  lipomatous tumor  above the
side and hypochondrium, and which was situated between the ribs
and the lower portion of the serratus magnns.

                             §  IV.

   Be that as  it  may, it is in the vicinity of the root of the limbs and
upon the limbs themselves, or on  the  thorax, that the  largest sized
lipomas have been noticed.  I do not speak here  of the man whom
M. S6dillot showed me, and who  had the whole circumference of his
neck surrounded  by an enormous collar-shaped (bourrelet) indolent,
lumpy [bosselee] tumor, because  I am  no more certain that this was
of a fatty character, than I am that that was in  the child  mentioned
by M. Warren, (Ibid., pi. 14,  p.  428.)   Another  patient whom  M.
Lebatard sent to  me in 1838, had the whole of  the neck imprisoned,
as it were, in enormous  masses of a lipomatous appearance, at the
same time that similar tumors existed  in the axilla and groins ; but
neither here, also, am I certain that they were legitimate lipomas.

                              §  v.

   In the region of the shoulder  they  have been noticed above, in
front, behind and outside.  The patient  operated upon successfully
in 1823, by M. Portulapi, had  a lipoma of fifty-two pounds' weight,
the root of which was situated  in the subclavicular fossa.  Already
this surgeon, in 1814, had removed another lipoma weighing fourteen
pounds.  Dupuytren (Archiv. Gen. de  Med., t.  V, p. 430,)  removed
one  weighing  six pounds, situated on  the posterior  part of the
shoulder of  a patient, who recovered ; and I have,  as I have said,
observed many others of a certain size, which were situated also
upon the stump of the shoulder, properly so called.
   Though in the supra-clavicular depression, lipomas rarely acquire
an extreme volume, they present here at least some particular features
in connection  with their extirpation,  and  dangers and difficulties
which it is important not to be ignorant of.  Those which are sub-
cutaneous demand no further  attention there than elsewhere.  It is
when they are situated beneath the aponeurosis, that their diagnosis
and  removal may  be difficult.   The softness of the neighboring
tissues, the void  which  the hollow of the axilla  opens to them in
front and upon the outside, and the subscapular  cavity behind, admit
of their being depressed and flattened with extreme facility, and of
projecting or disappearing, so to  speak, in the manner of a conges-
tive abscess  (abces  par congestion) or varicose tumors, and of ap-
pearing soft like a hernia or abscess, or conveying the idea of a dis-
ease altogether different.  I had a woman for several  months at La
Charite in  1838,  who carried a lipoma  of this kind in the left  supra-
clavicular depression, and who in this manner became the subject of
very different opinions on the part of those who had  an opportunity
of examining her.  Another patient whom I operated upon with M. 
44           NEW ELEMENTS OF OPERATIVE SURGERY.
Maingault, had a tumor in the same region, whose size did not ap-
pear to exceed that of a  pullet's egg.   An incision extending from
the outer border of the sterno-mastoid  muscle, to the  apex of the
acromion  in  the direction of the omo-hyoideus muscle, enabled us,
after having divided through  the integuments and aponeurosis, to lay
the tumor bare.  In order to  isolate it, it became necessary to divide
many branches of  the cervical plexus.   Having arrived below  the
clavicle in front, and upon the anterior side  of the  border of the
scapula behind, we recognized that this tumor,  which seemed so  ac-
curately defined at first, prolonged itself into the hollow of the  ax-
illa, where it became necessary to penetrate the whole  depth of  my
finger to detach it  by enucleation from  below upwards, from among
the nervous cords  which  compose the brachial plexus.  I removed
in this  manner, by a laborious and  tedious dissection,  a completely
fatty mass of very irregular  shape, and of  the size of  the  fist.   We
left in its place an enormous cavity, which was filled with small balls
of lint, and which  ultimately  cicatrized so perfectly and in so simple
a manner,  that the patient was  enabled  to return from  Paris to
Rouen at the expiration of a month.

                             § VI.

  It is rare that lipomas  acquire in the arm  or fore-arm, sufficient
size to require our  attention to be called to them  as tumors  of a re-
markable character.  The thoracic limb properly so called, is in fact
one of  the  regions  of the body where  fatty tumors are the least fre-
quently observed.   Upon the  supposition that the species of steatoma
which was situated underneath the skin of  the fore-arm in a patient
mentioned by M. Galenzowski, (Journ. des Progres, t. VIII., p. 221,)
was a lipomatous mass, rather than a tumor of some other description
—this at least would be an exception; for I repeat  that lipomas of
the upper extremity rarely exceed the size of an egg, and it would be
difficult if  not impossible  to  cite a series of examples where they
originated  underneath  the aponeurosis.   Fabre  (Observ.  de Chir.,
in-12, p. 51,) however gives  a remarkable instance of one.  The
tumor was monstrous.   Extending  from the apex of  the  deltoid to
the external condyle of the humerus, it was prolonged  transversely
under the  cephalic vein, then between  the brachialis  internus and
biceps  muscles, continuously with the external  aponeurotic intersec-
tion of the arm.

                             § VII.

  The  thigh on the contrary has often been invaded by this descrip-
tion of tumors, and it is there  especially that we encounter them of a
remarkable size.  M. Taramelli (Bulletin de Ferussac, t. XVI., p. 85)
states that he successfully extirpated a lipoma weighing  eight pounds,
which reached from the root of the fold of the groin to the perineum.
A tumor which weighed eighteen pounds,  and  whose root ascended
into the pelvis  at  the perineum,  and which  M. Kohlrusch (Ibid.,
t. XII., p. 232) who describes it as a steatoma, succeeded in removing
so as to cure his patient, was evidently also of a lipomatous character.
M.  Benedict,  (Bull, de Ferussac, t. I., p. 239,) in fact relates, that he 
LIPOMAS,  OR FATTY TUMORS OR WENS.
45
extirpated from the thigh a fatty tumor, caused by a fire-arm, and
in which he found some pieces of money !  In 1838, I removed from
the  outer and lower part of the thigh, in a woman 40 years of age, a
fatty tumor of the  size of the head !  This lipoma, which had ex-
isted for years, and which might have been taken for an encephaloid
tumor, required an incision of ten inches in length in the direction of the
vastus externus  muscle,  and another much shorter, transversely in
the  direction of the ham.   The dissection discovered to us, that this
mass, in place  of penetrating beneath the aponeurosis in the ham, had
simply depressed  the fascia lata in the direction of the gastrocnemii
muscles between the tendons of the biceps  and semi-tendinosus, and
then in the external supra-condyloid groove of the knee.    No acci-
dent supervened, and the cure, which has remained  perfect up to the
present time, (January, 1838,) confirms what the dissection moreover
had authorized us to believe, that the tumor in question was a lipoma,
and not a cerebriform tumor.

                            § VIII.

  Also it is the same with lipomas of the thigh and  leg, as with
lipomas in every other region of the body; whatever may be their
volume, their extirpation  is generally attended with but little danger
when they do not go beyond the depth of the sub-cutaneous layer.  It
is no longer so however,  when their root is situated amOng the mus-
cles.  In such cases the patient cannot be relieved of them but  by
means of a dangerous operation; the more so as fatty tumors of this
description readily acquire a very large size.  There was one of this
kind at  the hospital of Saint-Louis, in 1837, the size of which was
equal to two  adult heads.  In a patient mentioned by  M.  Klein,
(Gra.efe und Walther Journ., vol. I. p. 112,) the lipoma reached from
the breech to the ham, and weighed near 28 pounds.  A woman who
was admitted into the hospital of La Charite in 1836 had a similar
tumor in the same region; and in 1837 I operated for another which
weighed 32 pounds in a man from the country, who had also a  lipo-
ma of the size of a child's head in the dorsal region.   Fatty tumors
therefore constitute in this region an extremely serious disease.  Ori-
ginating among the muscles, in the midst of pliant tissues, they ordi-
narily acquire great  dimensions in their  vertical  diameter,  before
becoming prominent under the skin. ^ In the woman I have spoken
of,  the tumor, which descended  down  to between the gastrocnemii
muscles, and ascended nearly as high as the attachment of the gluteus
maximus, and had extensively separated the muscles and vessels, and
was eighteen inches long and eight to  ten in thickness, nevertheless
weighed only  from  eight to nine pounds.   The one I removed in
1837, and which occupied precisely the same region, ascended about
five inches higher than the first and descended only to three or four
inches below the knee.  Though it weighed 32 pounds and was  of
enormous volume, as the cast  of it in wax which was  deposited in
the  museum of the Faculty shows, yet it had not deformed the sub-
stance of the thigh to a much greater depth than that of which I have
just spoken.  The patient  operated upon by M. Klein and in whom the
tumor singularly resembled in its  situation, nature and weight, that of 
46
NEW ELEMENTS OF OPERATIVE  SURGERY.
the patient on whom I myself operated, died on the ninth day, while
mine succumbed on the eighth.  The woman, on the contrary, whom I
have mentioned first, ultimately recovered ;  when at the end of three
months  and after having experienced several  attacks of erysipelas,
she left  the hospital,  she continued to walk for a long  time in the
wards, and the wound had completely cicatrized.   When called upon
to such tumors, the surgeon ought to put to himself a number of ques-
tions.  Knowing that the patient cannot be relieved of the difficulty
without endangering loss of life, he ought first  to ask himself if it is
proper to meddle with the case.  Should the tumor incommode only
by its weight and volume, and  had not undergone  any degeneration,
and had developed itself very slowly and made no further progress,
perhaps it would be more prudent to respect it  especially in  a person
in advanced  age  or  dyspeptic (cacochyme.)  In the contrary case
wre have no  resource but extirpation of the tumor or amputation of
the limb, as the dimensions of the pedicle no longer admit of the em-
ployment of the ligature and as caustics are inadmissible in any case.
Amputation  of  the thigh for a lipoma has something in it strange
and repugnant.   It is true that in order to remove  these enormous
tumors,  we may be obliged to divide a certain  number of the  poste-
rior muscles of this part  of the  limb; that the continuity of the femo-
ral vessels and of the sciatic nerve, run some risk of being implicated,
and that in every case we are  more or less compelled to create an
enormous wound, whose suppuration is necessarily exceedingly dan-
gerous.   But besides that most of the muscles, from being simply
spread out or widened apart, may if necessary be avoided, the lobes
of the lipomatous tumors are ordinarily sufficiently movable to allow
of their being readily enucleated  from the periphery of the vessels
and nerves.   Moreover, the division of the femoral artery or sciatic
nerve, would it necessarily result in gangrene  and death?   It is not
to be forgotten that  amputation  in  such cases is to  be performed
either in the articulation itself or very near the  great trochanter, and
that besides the slight prospect of success it  presents, there would
nevertheless, even under the most favorable circumstances  possible,
be thereby produced an immense amount  of  mutilation : while the
pure -and  simple extirpation of the tumor, which in the aggregate
would not be more dangerous than the extirpation of the limb, would
at least have the  advantage, should it succeed, of effectually curing
the patient.   I would not therefore  prefer  amputation of the  thigh
to extirpation of the  tumor, unless it should be found impossible  to
operate without wounding at the same  time the  crural artery and
nerve as well as the sciatic  nerve.   Of the two patients  I  opera-
ted upon, one it is true died, but  he  had been exhausted by  long-suf
fering and was near sixty years of age ;  the other however recovered,
though the dissection in  her during the operation  had been almost as
extensive as in the other.
   The extirpation of these lipomas, however, in  this region, is more
frightful or dangerous than really difficult:  to accomplish it I adopted
two different modes.  In the  first  case I  made  an incision which
went directly down to the adipose tissue, and  extended  from the
tuberosity of the ischium along the semi-tendinosus muscle as far
down as below the ham. Transforming this first into a  T incision I 
              LIPOMAS, OR FATTY  TUMORS  OR WENS.            47

divided the tissues outwardly as far as to the external  side of the
triceps muscle.   Having reversed  the two flaps of the T, I had only
to divide the two  thirds of the  long  portion of the biceps.   Then
dissecting the tumor with free strokes of the  instrument,  I detached
it first  on its outer side, then  inwards and then from above  down-
wards, either by means of the bistoury, or with  the fingers  or the
handle of the scalpel, completing  the  extirpation in less than five
minutes.   In the second patient the mass was so immense, and fur-
rowed by veins so numerous and so enlarged, that I deemed  it pro-
per to remove with it a large ellipse of integuments.  I was obliged
in this manner to  include in the incision a portion  of  the  biceps
muscle, and of the  semi-tendinosus, semi-membranosus and gracilis
muscles,  which were broadly spread out in the  manner  of a mem-
brane, upon the surface of the lipoma.  Having detached  this  gigan-
tic tumor from the  external parts  of the leg and thigh, I tore out a
lobe from  it from below the  breech, and  then a second from  the
hollow of the ham; but from its  having enveloped the  vessels in
its extension inwards, the dissection on this  part became difficult and
laborious.  The great anastomosing artery, which I could not avoid
at the distance of two lines only from the trunk of  the crural, made
me fear at first that I  had wounded this last.  The isolation  of the
sciatic nerve also  was not unattended with difficulty.  The  opera-
tion nevertheless, notwithstanding the rupture of two or three putres-
cent (putrilagineuses) cavities which I had to empty as I  proceeded,
was neither very  long nor very laborious;  it  did  not last over a
quarter of an hour.   In neither case  did the approximation  of the
lips of the wound present any difficulty.  But for the attacks of ery-
sipelas and some menaces of purulent infection which supervened in
the woman operated  upon in 1836, accidents which may be  devel-
oped after  an operation of the least serious nature, the cure certainly
would not have required  more than five or six weeks to be accom-
plished.  In the man who perished, and upon whpm I did not ope-
rate until  after  having taken the advice  of MM. Ribes, Larrey,
Marjolin, Sanson,  Laugier, Berard the  elder, Berard the younger,
Monod,  Robert  and all the other distinguished surgeons of Paris,
death appeared to have been the result of defect of reaction,  and as
it were  exhaustion of the  vital  principle.  These operations, how-
ever, up to the  present time have not been performed  sufficiently
often, to enable us to appreciate with exactitude  their value or their
danger.

                              §IX.
  I would  remark in conclusion, that lipomas, like lymphatic tumors
and neuromas, are so easily detached from the surrounding tissues,
that enucleation is  applicable  to them, and ought to be  substituted
to the employment of the bistoury, wherever  there would be danger
of wounding the large vessels or important nerves.  Being situated
independently, and as it were without  any organic attachment, in
the midst of the  tissues, they may moreover  be torn out without
fear by means of the finger or any other mode.   They are the kind
of tumors in fine whose extirpation, all other  things being equal, in-
volves the fewest dangers, and presents the best chances for success. 
48
NEW ELEMENTS  OF OPETATIVE SURGERY.
together  with  the  greatest degree of facility and simplicity in the
operative maual.
  [Fatty Tumors.—Our countryman,  Dr. Parker, a missionary in
China, has had much practical experience in a peculiar form of enor-
mous  cutaneous or fatty tumors, which he has seen or operated for
successfully during  his philanthropic labors.  In a recent memoir of
his, published in Cormack's Monthly Journal of Med. Science, (June,
1846,  p. 393, &c.) he mentions one in a beggar aged 35 on the right
side of his face, and which increased in ten years to two and a half
feet in circumference.  Dr.  Parker extirpated it without  difficulty
by two elliptical incisions, each eighteen inches  long.  It weighed
near nine pounds, and was of glandular  structure, with  a few cells
containing a  yellow or dark fluid, and was in  part  cartilaginous.
A slight paralysis only was left from the division of the portio dura.
The patient recovered so well in three weeks  as  to perform the
duties of  porter to the missionary hospital.  These excessive growths
of a lipomatous or with mixed cartilaginous  and  encysted  organiza-
tion, and  which in some cases have been seen by  Dr. Parker (accor-
ding  to the  paintings he  exhibited at  New York,) to extend like
wings from the whole posterior portion of the trunk and lower limb
on one side, appear  to be  the result of the excessive  indulgence or
gluttony  in the Chinese for farinaceous  and other non-nitrogenized
kinds  of food, that favor fatty growths and accumulations.   See note
on Mr. Mcllvalne's views  on this subject,Vol. II.]
                       CHAPTER  VI.

                    ELEPHANTINE TUMORS.

  The class  of  elephantine tumors, very  common  in  Africa, the
Indias, and many countries of Asia and America, but rare in Europe,
and especially in France, are met with only as an exception in other
than the genital organs either of men or women.  Being caused  by
an hypertrophy,  together with degenerescence  of the integuments,
or cellular tissue, and sometimes  of the  aponeuroses and  muscles,
they may acquire a development still more considerable than lipomas.
I have seen instances  of them upon the  nose, ears, feet and hands,
and some other regions of  the body.  In 1836, at the hospital of  La
Charite, a woman was brought to  me, of about forty years of age,
who had the hand, fore-arm and elbow three times their natural size,
in consequence of a degenerescence of this kind, and in whom  the
upper half of the arm, as well as all the other parts of the body were
in a perfectly sound condition ;  so that  the disease had  become sud-
denly arrested  at the  distance of two or three  inches above  the
humero-cubital articulation.   A man in whom I extirpated the limb
at the articulation, and  to whose case  I have elsewhere alluded, had
upon his  right arm a similar degenerescence, which extended from the
extremities of the fingers to the  shoulder, and. ultimately became 
ELEPHANTINE TUMORS.
49
complicated with a cancerous or colloid transformation at the centre
of the humerus.   I have met with many instances of persons who
had in this manner the foot  and the leg, either partially or wholly
enlarged to double, triple, or even quadruple their natural size.   In
one of these patients the elephantine  tumor abruptly terminated in
the form  of an enormous lardaceous collar, at some inches below
the knee.   In the greater part of them the disease imperceptibly dis-
appeared  above, and  in all of them the limb truly exhibited the ap-
pearance of the leg of an elephant.  Should the tumor be accurately
defined,  as  in  the  case of those I  have been  describing, and
should it  have been  of long  standing  and have resisted all  the
means indicated  by  a judicious therapeutic, we may,  should  the
person be in other respects in good health, propose its removal.  But
in such cases it  is amputation of the limb itself only, which presents
any chances of success, or that can be had recourse to.  In all cases,
on the contrary, where the elephantine degeneration shall appear to
be imperfectly limited or prolonged under the form of indurated plates
or radiations beyond  the tumor itself, properly so called; or com-
plicated with plates or projections of a similar nature, on other parts
of the body ; or we have reason to suspect the slightest alteration in the
viscera; or that the health of the patient  has  been  profoundly de-
teriorated, we must be cautious not to meddle with it, or confine our-
selves to palliatives.   I  shall, however,  return to these tumors  in
speaking  of operations performed on  each region of the body, in
particular, and especially upon the  scrotum or vulva.  The tumors
called keloid, (keloides) which I have  seen in the form of a firm,
reddish-colored  lardaceous plate, four to six lines in  thickness, and
two inches in breadth, upon the  shoulder of a young  lady, who had
already been operated upon for it, by M. Forget; which I have met
with  also, under the angle of the scapula,  in the dorsal region of
another female; and which M. Warren, (on Tumors, etc., p. 45, pi. 3,)
who  has  described them,  appears  also  to have  observed on  the
shoulder; should be destroyed by means of the zinc paste, or extir-
pated with the  same precautions as if they were of the character of
an erectile  or  elephantine  tumor.  Extirpation would be applicable
only to the eloid (eloides) tumors described by the same author (Ibid.,
p. 48, pi. 4), and which show themselves under  the form of a bunch
of agglomerated  enormous-sized leeches,  or  of  a  small intestine
coiled up upon a cirsumscribed point of the  skin.
   [M. Colson,  of  Noyon (France), describes  (see Journ.  des Con-
naiss. &c, de Paris, Mai, 1842, p. 189 et seq.) a remarkable case of
African elephantiasis  in a woman who died at the age of 53, after
fifty years of suffering from  that and the antecedent diseases which
appear to have led to  its production.   The privations of poverty, im-
poverished diet and constant residence in  a marshy situation (com-
mune  of Salency) predisposed  doubtless  to this  train of maladies,
which commenced in  infancy after small pox with a  large  tumor on
the right side of the vulva, which after some years' continuance was
destroyed by an empiric  by means of caustic.   The right side of the
abdomen  and thigh however began to  swell before  her catamenia
appeared, when another  empiric attacked these parts with the cau-
tery and caustics, applying these remedies both above and below the
                                4 
50           NEW ELEMENTS OF OPERATIVE SURGERY.

knee, the last of which caused  erysipelas  and gangrene of the leg,
and  denudation of the tibia.  This last wound partially recovered,
but continued an open, discharging ulcer  for  many years—the hy-
pertrophy of  the thigh also gradually increasing.  Worms were en-
gendered in these foul ulcers.   At the age  of 38 this wound  healed,
and ulcers were established at the malleoli.   The menses were most
of the time  regular, but the urine was occasionally suppressed, which
latter difficulty was relieved by  nitrate of potash drinks, bringing on
copious evacuations of this  secretion, which sometimes had a milky
appearance.  The thigh  at the  middle  part was over thirty-seven
inches  in circumference, covered on the posterior part, as was also
the dorsum of the foot, with  thick, offensive  incrustations, also in vari-
ous parts with  tubercles (as is common  in tropical elephantiasis),
while the leg  of the diseased limb was also hypertrophied in its lower
part  to the  dimensions of over twenty-one inches in circumference,
having enormous  red vegetations about  the ankles—the whole limb
being at least three times/the size of the  other.   It retained  to  some
extent  the powers of flexion and extension.   T.
                       CHAPTER  VII.

                      HEMATIC TUMORS.

  A kind of tumors whose pathology might constitute several spe-
cies, and which had scarcely been noticed before I described them
in 1826, and afterwards in 1833, are those which are caused by effu-
sions of blood.  These tumors which have a predilection for the sy-
novial bursae, and which sometimes form for themselves cysts in the
cellular tissue, are either solid, fluid, or semi-fluid, or sometimes  con-
stituted of a melange of concrete clots with matters that are altoge-
ther of a fluid nature.   I shall, when speaking of cysts (kystes), re-
turn to those which contain rather fluid than concrete matters ; at pre-
sent I shall  confine myself to solid hematic tumors.   These tumors
perhaps are more common than would  at first be thought.  I have
elsewhere remarked  (Traite des Contusions, Paris, 1833), that cer-
tain polypi of the uterus,  some tumors  of the prostate, with steato-
mas of the  head, breast, &c, often appeared to me to  owe their ori-
gin to  an effusion of blood or fibrinous concretion, and numerous
facts have since confirmed me in this opinion.   This much, however,
is certain, that most of the tumors described under the  title of steato-
ma or lipoma,  and which do not belong to the order of fatty tumors,
enter  into  the category of hematic tumors.   The tumor of  188
grammes in weight, which a patient carried for the space of twenty
years upon the right side  of his  head, under the denomination of a
lipoma, and which was successfully extirpated by M. D. Lasserve
(Cas  de Chir., pp. 21, 22, 23,'Perigueux, 1833) was to all appear-
ance nothing  more than a degenerate  hematic tumor.   The same
was the case  as I should think, with another tumor of  the size of an
egg, situated below the mamma to the left on the thorax of a man, and 
HEMATIC  TUMORS.
51
which the same practitioner removed; also with that which existed
upon the shoulder and  which he  also extirpated; the same with a
cyst filled with matter resembling  boiled rice and situated upon the
left cheek of a man; and with the cyst still larger, which a woman
had on her  knee, together with some other tumors, for which M. D.
Lasserve in like manner operated.   Hematic tumors differ from lipo-
mas in general, in this, that they  are  scarcely ever pediculated;  that
they rarely exceed the size of an egg, the fist or the head; that they
are almost constantly surrounded with an irregular cyst when they
are situated in the cellular tissue, but sufficiently regular, on the con-
trary, when they are formed in the bursae  mucosas or the synovial
cavities; in this also, that  the matter of which they are composed, is
either clotty or fibrinous or fibrous, and of a variable color, yellowish,
gray, sandy (rousse) or brownish;  and that serous or synovial  mat-
ter is  frequently found  mingled  with it.   Like lipomas,  hematic
tumors do not usually cause any pain, and incommode in reality only
by their  volume  or weight.  Like lipomas also, and perhaps more
frequently than them, they appear to be  susceptible of degenerating
and undergoing transformations  of a bad character.   No topical ap-
plication or internal medication  can  destroy them when they are of
old date or have acquired a certain volume.  Caustics, the ligature
and extirpation,  therefore,  are  the  only remedies we have at our
command.

            Article  I.—Hematic Tumors in General.

                               §  I.

   Plasters, liquids and all kinds of discutient (fondants) topical applica-
tions, by which we sometimes succeed in obtaining resolution of san-
guineous deposits, have  no longer any efficacy when we have under
treatment an  ancient hematic concrete tumor.  These means, eulo-
gized by M. Champion, as irritating injections have been by M. Asselin,
(Considerations sur les Bourses Muqueuses, Strasbourg, 1803,) pos-
sess in reality no value except in recent hematic tumors.

                               §  II.

   Caustics, besides their inconvenience of destroying integuments
which it might be advantageous  to preserve, would also be attended
with the objection of exacting a considerable space of time, and of fail-
ing in the majority of cases. A  surgeon mentioned by  Lombard,
(Opuscules de Chirurgie,  p. 108,  1786,) who wished to destroy
at every  possible hazard a tumor  evidently hematic, in  front of
the knee, by means of caustics, could not effect  his object, but caused
by this means several abscesses in the neighborhood of the patella.
At most, therefore,  escharotics under such circumstances,  could only
be employed in association  with the ligature, as was practised by F.
Aquapendente and has been since done  by Chopart and  Sabatier;
or in the case of those persons who peremptorily refuse every other
kind of operation. 
52
new elements of operative  surgery.
                             § III.
  The ligature upon hematic tumors is still more uncertain than for
lipomas.   As these tumors almost always present a very large base,
and have besides a more or less distinct cyst, they are badly adapted
to constrictive  means, and do not  find in such resources their best
remedy.

                             §  IV.
  It is to extirpation  therefore  that we must have recourse, if we
wish to relieve  the patient.  The question might then be asked,  if it
would not  be sufficient to lay open and empty the cyst ?   To this
first question we may reply,  that the simple incision, which would
doubtless sometimes succeed,  would most frequently prove unsucess-
ful, expose to more accidents than extirpation, and render the remain-
der of the operation obviously more difficult.  If Paroisse (Opuscules
de Chir. etc., p. 94, 1806,) was enabled to extract a cyst of this kind
by a simple incision, it was because  inflammation, excited in the cyst
by an irritating injection, had previously  isolated  it from  the  sur-
rounding tissues.   All that we can demand  in such cases is, to know
if it  is indispensable to carry away the totality of the cyst with the
tumor, or limit  ourselves to the excision of the latter.  Sainct Chris-
teau, (La Chirurgie Pratique, p. 180, 1697,) having restricted him-
self to emptying a steatoma of the size of the fist, which was situated
upon the  inner  side of the thigh,  found himself obliged to scarify the
internal surface of the sac, and to dress the cavity with an exciting
digestive before he could effect its cicatrization.

                             § V.
  Excision, properly so called,  is  of such doubtful  efficacy,  that
J. Fabrice, (QZuvr. Compl, partie 2,  p. 620,) was already aware of
it,  and in his time  recommends  that  we  should divide the  vessel
which nourishes the remains of the cyst.  This  mode, however, has
been  since lauded, first by Chopart  and also by Louis, or by Percy,
(Diet, des Sc. Med., t.  XXVII., p. 44, 45,) but  it is to  Mosnier,
(These, Paris, an XI.) and to Bourdet, (Essais sur les Loupes, p. 23,)
that  it is specially indebted for  having been rescued from  oblivion,
and been made to assume a kind of celebrity at the commencement of
the present century.   Mosnier pretends that after this operation, the
bottom of the wound is transformed into cicatrices, and takes the place
of integuments.   The  facts,  nevertheless,  advanced  by those ob-
servers, and which are  applicable  at  most to certain regions of the
body, have not been of a character to convince any one,  or to be
received as laws, and extirpation, properly so called, has continued
to be generally preferred.   Perhaps, however, we have gone too
far  in this respect, and  that it  would answer the purpose when
the posterior wall of the cyst cannot be dissected without too much
difficulty, that it should be left in its place and made to suppurate.  We
cannot see, in fact, and practice is nearly silent  on this subject, why,
after suppuration, the walls of a wound of this kind ought to have so
much difficulty  in agglutinating.   Only in this case I  would not
recommend that the integuments  should be  removed with the tumor; 
hematic  tumors.
53
at least we should preserve a sufficiency of them to enable us to cover
the bottom  of the wound.   It is nevertheless true that this practice
must  be considered as an exception, and that unless there are parti-
cular  objections, the extirpation of the entire hematic pouch ought to
have  the  preference.  The operative process also is sufficiently sim-
ple.   If the tumor  is very voluminous,  we remove with it an ellipse
or a star of the integuments.  In the contrary case, we lay it bare by
means of the simple incision, that of the T, or the crucial. Perhaps,
in such cases, the semilunar would be preferable.  The tumor being
concrete,  enables us to isolate its envelopes without fear, and at the
same time to reverse the entire  sub-cutaneous layer.   This first dis-
section being terminated, an  assistant  is charged with holding the
flaps of the integuments apart and of making traction upon the tumor
in the proper direction, while the surgeon detaches and carefully iso-
lates  it with the strokes of his bistoury from  the deep-seated parts.
As the hematic  tumors, which  may be extirpated  in  this way, are
almost always sub-cutaneous, their extirpation is scarcely ever accom-
panied with serious hemorrhage.   There are therefore  generally but
a small number of ligatures to place or arteries to tie.   If the totality
of the cyst has been destroyed, and the wound reposes every where
on pliant vascular tissues, and the flaps have been cut of proper shape,
there  is a prospect of success  by immediate reunion, and it ought to
be attempted.   Under opposite  circumstances it is better to dress
at first with the balls of lint, over which the flaps are to be brought,
and which in their  turn are to be covered  with  a perforated linen,
plumasseaux, compresses  and the simple  containing bandage, until
the wound has become completely cleansed and the flaps undergone
all their retraction.   By this means we  avoid the danger of nervous
accidents, purulent  collections, and erysipelas, but we  must be pre-
pared to find the wound cicatrize slowly, and the patient not tho-
roughly cured until after the expiration  of one or two months.

          Article  II.—Hematic Tumors in Particular.

   Hematic tumors  may develop themselves upon all the regions of
the body.   It is rare however, except in  the superficial or deep-seated
mucous bursas, that they are distinguished, as respects the operation,
from  lymphatic tumors or neuromas, since everywhere else their ex-
tirpation is subjected to the same rules for the operative process that
those last named tumors are.

                               §  I.
  Were it necessary to describe the process for extirpating hematic
tumors in  all those regions where synovial bursas exist,  I should have
to examine those of the temporo-maxillary region, chin, angle of the
jaw, the thyroid angle, spinous process  of the seventh vertebra, the
dorsal and lumbar  region, that of the ribs and  sternum, the  lower
angle  of the scapula, the acromion, inner condyle of the humerus, the
radius, ulna, metacarpo-phalangeal angles,  both  dorsal and palmar,
the phalangeal articulations, the spine of the ilium, the great trochan-
ter, condyles of the femur, spine of the tibia,  head  of the fibula,
the malleoli, heel, tarsus, first and fifth bones of the  metatarsus, club 
54
NEW ELEMENTS OF OPERATIVE SURGERY.
feet, those with feet amputated, who are humpbacked &c.; but there
are in reality no others but that of the knee and perhaps that of the
malleoli, which require in this respect particular mention.
  I have in three instances extirpated  hematic tumors which were
situated in the mucous bursas of the malleoli, in that of the outer an-
kle  in two cases, and in that of the inner in the third.  In such cases,
if it is the external malleolus, we must be on our guard against open-
ing into the sheath of the tendons of the peroneus longus and brevis
muscles behind, and wounding the synovial cavity of the tibio-tarsal
articulation below.   The danger  also of  purulent inflammation in a
region of this description,  ought  to deter us here  from attempting
union by the first intention, if the state of the wound or nature of the
flaps do not appear to be favorable to it.   At the internal malleolus
we  must be on  our guard against wounding the sheath of the tibialis
anticus muscle and the posterior tibial artery behind, and the articu-
lation and the sheath of the tibialis anticus  muscle below and in front.

               § III.—Hematic  Tumors of the Knee.

  In no place are the tumors of which I am speaking more frequent-
ly encountered  than  about the knee, and especially in front of the
patella;  nor  is there any region perhaps, where  their extirpation
exposes  to as  much danger.  A  tumor of the size of two  fists,
which was situated  upon  the left knee,  and  which M. Hip. Lar-
rey  (Gaz. Med., 1838,  p. 712,)  gives as an  example  of hematic
tumor, was extirpated at the Hospital of Val-de-Grace.   The officer
who was the subject of it was soon seized with general accidents
and with delirium, followed by death on the eighth day.  Two pa-
tients operated  upon for simple tumors, one by M. Roux, the other
by myself in 1825, at the hospital of Perfectionnement, died in the
same way and in as short a space of time.  M.  Hervez de Chegoin
(Journ. Hebd. Univ., t. III., p. 329,) who still gives the name of lipoma
to these tumors, and who confeses  that he does  not  comprehend
their character, has sometimes practised their extirpation with  suc-
cess, but he is far from dissembling also the gravity of the operation.
Extirpation performed by M. Warren (on Tumors, etc. p. 40) for a can-
cerous tumor in front of the patella, was also followed by death.  It
is sufficiently remarkable also that death in these cases should have
resulted from cerebral phenomena and ataxic symptoms, which are
scarcely explicable by the local accidents occasioned by the wound
itself.   I hasten to add, however, that in the great majority of cases,
the operation is not followed by any unpleasant symptoms, but  most
usually in fact, effects a complete and  sufficiently rapid cure.   Six
of the patients whom I have treated in this manner recovered per-
fectly.
   Operative Process.—The patient is to be placed upon his back and
his leg  maintained in a moderate state of extension; one assistant
takes charge of the foot and the  other of the  thigh.   If the tumor
has but little volume, the surgeon lays it  bare  by means of a longi-
tudinal incision.  In the contrary case, and where the skin is to be 
HEMATIC  TUMORS.
55
preserved entire, I prefer the semilunar incision, taking care to turn
its free border  outwards.  If the  simple incision has been used, its
two lips  are  dissected in succession, and reversed as far as to the
borders of the  patella.   With  the semilunar incision we carefully
detach the flap of the integuments  from without inwardly, and in
such manner as to reverse it upon  its base upon the inner side of the
knee.
  If on account of any particular  reasons, we should consider our-
selves obliged to give the preference to the crucial incision, we must
detach and reverse its four flaps upon their base, with the same care.
The same remark applies to the elliptical or to the stellated incision, with
this difference only, that we  should here  leave a portion of integu-
ment on the apex of the tumor.   In whatever  manner  performed,
the tegumentary envelopes having been turned back, we proceed to
the isolation of the  periphery and deep-seated surface of the cyst.
All the precautions required for this dissection, have reference to the
articulation of the knee and to the diseased cyst itself, there being no
large sized artery or nerve found in the neighborhood.  We must
therefore not forget  that upon the  outside, and both above and below
the patella, the synovial cavity might  be readily opened, and that the
same remark applies to the inner side; but that directly in front there
is nothing in this respect to be apprehended.  In no other region also
do hematic tumors exact more  attention in regard to the extirpation
of their  cyst.  However little  there may remain of its posterior wall
at the bottom of the wound, this cyst  retards and even prevents cica-
trization, and keeps up  a suppuration  whose consequences are not al-
ways devoid of danger.  A patient whom  I found at the hospital of
Saint Antoine in 1828, and whom  Beauchene had operated upon two
months before, retained a large purulent cavity in front of the knee.
The posterior wall of the cyst left at the bottom of wound, had taken
on all the characters of fibro-mucous lamellas of a new formation, and
exhibited no disposition to improve (a la mondification).  I  adopted
the  plan of  removing it  by a  careful dissection, and from  that mo-
ment the wound cicatrized  regularly and without any difficulty.  It
is necessary therefore, in these extirpations, to follow exactly the line
which separates the  natural tissues from the  thick  envelope of the
tumor.   Should some shreds  of the  cyst have at first escaped from
under the bistoury, we must immediately after seize them with a dou-
ble erigne or claw-forceps, (see Vol.  I.) and extract them before ter-
minating the operation.   The dressing  also deserves some attention.
The flaps having no other support  to rest upon than osseous or fibrous
planes, or tissues that are but little vascular, and being moreover usu-
ally very thin,  should not be brought over and maintained upon the
wound  except by means of a very moderate degree of  traction and
compression.  All the  pieces of dressing  also which are  to  cover
them, should be sufficiently pliant, and so lightly adjusted that no stran-
gulation  may be  produced either in the direction of the leg or thigh.
The  leg also,  by placing a thin  cushion under the ham, should  be
kept  in  a state of gentle flexion  rather than in complete extension.
At the first sign of inflammation also, it would become imperative to
envelop the knee in compresses or emollient cataplasms, and to cover
it with leeches  and renounce every attempt at immediate union.  At 
56
NEW ELEMENTS OF OPERATIVE SURGERY.
a later period, and when the borders of the wound have become ag-
glutinated and united to the subjacent tissue, but are at some distance
apart, it may on the other  hand become useful to place the leg in ex-
tension, and to maintain it in that manner by means of an immova-
ble dressing.  Unless that is done, the slightest flexion of the knee
brings the patella between the lips of the wound in the manner of a
wedge, and may retard the cure to an indefinite period.
                       CHAPTER VIII.

              CYSTS (Kystes) PROPERLY SO CALLED.

  Cysts form  one of the most numerous class of tumors, and have
among them a sufficient number of varieties.   Besides the purulent,
hematic and synovial cysts, there are the melicerous,  atheromatous,
steatomatous and hydatid, and such as are purely serous, all of which
sometimes reclaim the aid of surgery.

                 Article  I.—Sebaceous Cysts.

  Quite a  numerous order of cysts are those that are  formed at the
expense of  the follicles  of the skin.  The tumors which  result from
them  and which are generally known under  the name  of maggots
(tannes, or  worms) and meliceris, receive also other appellations
when they exist in the form of pimples (boutons), rugosities or simple
tubercles.   They  are frequently observed upon the scrotum and skin
of the penis, and not exceeding in size a pin's  head, yet susceptible
of being made to  yield  by pressure a clot of sebaceous matter.  On
the face these little tumors when they  inflame are called red pim-
ples (couperose), causing very small abscesses, which are also relieved
by strong pressure, after having perforated their apex with the point
of a pin.  But it is not with small Cysts  of this description that ope-
rative surgery has any particular connection..  When  the sebaceous
matter is accumulated in greater quantity  in the crypts, it distends and
enlarges them to such degree as to produce tumors, whose-dimensions
vary  from that of a pea to that of a pullet's  egg.  These  tumors,
which usually do not cause  any pain, which are unattended with any
inflammatory action or change  in the color of the  skin, and which
possess a great regularity in their form,  are soft (mollasses),  slightly
fungous and as it were semi-fluctuating.   The  cranium, face  and
neck  are their most, favorite localities.  They are noticed  also on
other  regions of the body.  I have met  with one upon the shoulder
of the size of a pullet's  egg; and also encountered them  on the legs,
thighs and fore-arms.  Even the fingers  themselves may be the seat
of these tumors.   A man in the country, whom I knew in  my child-
hood,  had upon the dorsal surface of the middle articulation of the
left middle  finger,*one of these tumors which was of  the  size of a
very large nut, in  such manner as to form there an enormous mass
which projected posteriorly.  A patient of M. Fisher operated upon 
CYSTS, PROPERLY SO CALLED.
57
by M. Warren (on Tumors, &c, p. 529, pi. 16.) had one of a most
singular description in front of the great trochanter.  Some  patients
have several at the same time, and this peculiarity is principally seen
where the sebaceous cysts are of but little size.  It is proper how-
ever to say, that I have met with  many of the largest  kind at the
same time upon the same individual
  The following case perhaps also belongs to tumors of this  descrip-
tion.  An officer  of health in  the  environs of Paris, a  robust man
aged 55 years, had for many years in the right supra-hyoid and paro-
tid region, a tumor which  ascended  as high up as upon a line with
the cheek bone and the  labial opening of the mouth on the outer side
of the jaw.  This tumor, which when I had an opportunity of observ-
ing it in the spring of 1838, had already undergone various degrees of
transformation, so much resembled an osteo-sarcoma that many expe-
rienced practitioners of the capital  had characterized it as such; its
extension towards the larynx below and the pharynx behind and in
the direction of the mouth, had even precluded  all idea of an opera-
tion, and  confined the  recommendations to the palliative  treatment
for cancerous  affections.   Under the impression that I recognized
something fluctuating in its most prominent lumps (bosselures), and
that there was also a certain mobility in  the tumor, and that ft pre-
sented neither the positive characters of cancer  or evidence of actual
adhesions with the maxillary bone,  I considered it  proper to lay it
open freely upon  one  portion  of it.   I was enabled  thereby to ex-
tract from it several ounces of a matter  either melicerous,  grumu-
lous or semi-purulent, which resembled neither fibrine, pus nor tuber-
culous matter, nor fat or gelatine,  nor the substance known as en-
cephaloid, colloid or melanotic (melanique),  and  which had in a
word no analogy with any of the substances which are usually found
in cysts.
   Sebaceous matter was the only substance  to which one could pos-
sibly in some respects  compare it,  that is to say, that this substance,
unctuous  in some portions of it and  friable, and  as it were desiccated
in others, had for  its receptacle a  cavity  whose walls singularly re-
sembled in their papillar (pointille)  or cutaneous aspect that  of meli-
cerous cysts.   Anxious to know what course to pursue, and wishing
moreover not to  influence his judgment, I confided a portion of this
material to M. Donne that  he might submit it to the microscope and
certain chemical reagents, without having informed him  of the inten-
tion I had in view.  This physician, at the expiration of  two  days in-
formed me, that he had  found nothing but fatty matter and particles
(paillettes) of epiderm, in  the substance which I  had transmitted to
him, and consequently it could  come only from a disease of the epi-
derm or of the follicles  of the skin.,  Am  I then right in concluding
that the tumor  in  question was in reality of the description of that
known as  a  maggot (tanne) and proceeding from a sebaceous cyst ?
Adopting the  affirmative, I  will add at the present time, that these
cysts in  breaking  up  (se decomposant) may undergo transformation
of a bad character; for a patient whom I  have  since exhibited at the
Clinique  and who  had a tumor of the same kind more advanced, and
in the same region, was ultimately attacked with a legitimate cancer
of the lower jaw.   Be  this as it may, melicerous cysts rebel against 
58
NEW ELEMENTS OF OPERATIVE SURGERY.
all resources except those of operative surgery.  When they have
acquired a certain volume and remain in the chronic state, we may
by compressing them upon their sides, or by dilating the little spot or
black-colored hole (pertuis) which we generally succeed in finding on
some  one of the  points of their periphery, and which is as  it were
their outlet, empty them and effect the discharge of matter resembling
worms ; but they are not cured by these means.   The sac soon after
fills up, and the tumor is not long in re-acquiring its primitive volume.
It is from proceeding in this manner,  that some have been induced to
believe that the disease actually consisted of worms coiled up under-
neath the skin.  The small black  point which gets out first, is taken
for the head  of the worm, and the sebaceous matter which threads
out in an undulating line as it comes  through the cutaneous aperture,
completes the illusion.  This has proceeded  to such extent, that hav-
ing presented for examination, a thread of this kind of two inches in
length which I had just extracted from  a maggot ulcerated below the
left breast of an adult man, the interne  at first and the physician af-
terwards,,assured me it was an entozootic worm and were preparing
to designate  its species, when I  disabused  them of  their delusion.
Topical applications,  whatever be their nature, have no  influence
upon this kind of worm.   The merely  laying them open, or exciting
inflammation in them by means of a seton, acupuncture, or needles
or threads passed through them, does not hinder them  from being re-
produced.  Even their excision in certain cases  does not always cure
the patient.   They must either be  extirpated  completely, or after
having emptied them by a large opening, carefully cauterized through-
out their whole interior.   The director of one of our  royal theatres,
had in front of the left temple a sebaceous cyst of the  size of  a large
bean.  As he did not wish to  submit to any sort of bloody operation,
I confined myself at first to the evacuation of the melicerous matter
by enlarging a little the opening of the  tumor.   The latter having re-
turned, I laid  it open with a  cut  of the lancet  and voided it again.
But it  again returned, and the patient  at length consented to have it
extirpated.
  A physician who was a member of the Royal Academy of Medi-
cine, had at the upper and posterior part of the right orbitar angle, a se-
baceous cyst of an  inch  in diameter.   It was frequently laid  open in
order to empty it, but the tumor invariably reappeared; he decided
upon having its whole cavity  cauterized, and was thus  cured.   In the
patient who had one  of these cysts  on the top of his shoulder, I ex-
cised all the projecting portion of it  and touched the remainder with
nitrate of silver.   Hardly any inflammation ensued ;  the epidermic
portion at the bottom of the wound sloughed off at the expiration of
eight "days;  the borders of the wound  were not approximated, and it
was the preserved portion of the sebaceous cavity which served the
place of the  cicatrices, and assumed  the appearance and  most of
the characters of cutaneous  tissues.  In conclusion, therefore, should
the • cyst not be of large  size, the best plan is, after having  circum-
scribed it in an ellipse  by two semilunar incisions, to seize  it with an
erigne and extirpate it.   If the approximation  of the borders of the
wound and immediate reunion should be interfered with by this mode
of excision, we should commence  with a straight incision, whose lips 
CYSTS,  PROPERLY SO CALLED.
59
should then  be dissected and carefully separated on each side, leav-
ing intact the tumor, which should be secured with a hook, and after-
wards extirpated.  By this mode the operation is longer, more diffi-
cult and more painful; besides which, notwithstanding all our precau-
tions, we most usually  cut into the cyst before having completed the
dissection, because the thickness of its walls can scarcely ever be
correctly ascertained beforehand, and moreover, are frequently found
intimately blended with the skin.
  A child three years of age, had upon the right external orbitar an-
gle and in front of the temporal  fossa, a sebaceous cyst of an inch in
diameter.  As there was a dread of any kind  of cicatrix, I laid it
bare  by  means  of a simple incision,   I  had already isolated two
thirds of it,  when  a movement  of the little patient caused me to cut
into it in front.   The tractions which  I  was constantly obliged to
make upon  it to get it out, had soon emptied it,  and I perceived on
terminating, that there was about a centime of it in breadth left at
the bottom  of the wound.  I touched this portion of it freely with
nitrate of silver, and the cure was effected perfectly.  The wife of a
distinguished magistrate of Paris had under her left ear,  a sebaceous
cyst, slightly elongated in shape, and of the size of a nut.   Desirous of
avoiding the slightest  trace of a wound at this part, and at the same
time to make the operation sure and prompt, I commenced by seizing
the tumor with an erigne, which I confided to M. Prus, the physician
the family, while M. Vasseur who also acted as my assistant, stretched
the integuments.  By means of two incisions slightly incurvated, I cir-
cumscribed a very long ellipse of integuments, which I removed with
the tumor,  and which enabled  me readily to enucleate  the latter in
front and behind, and then from above downwards,  by means of the bis-
toury.   The lips of the wound were easily approximated and the cure
completed in three days without any suppuration.   If on the contrary
the tumor should be very large, it would.be better to lay it open freely,
empty it with care, and then thoroughly cauterize its whole cavity.
 The same process also would be  suitable for cysts  that are less volumi-
nous, if there  were  no great  danger of  a  cicatrix  slightly de-
formed.   Finally, the  excision, or rather  the amputation of the  tu-
mor, together with cauterization of its deep-seated wall, would be  ap-
plicable  for those which have a large base, and which cannot be  ex-
tirpated  entire,  or which we do not wish  to submit to a simple in-
cision aided by caustic.  Upon the whole, we cannot cure sebaceous
cysts but by  extirpating them completely,  or  after having  excised
them, making use of their deep-seated wall as a portion of integument
to serve  as  the cicatrix.  As these are a kind of tumors, however, de-
veloped  in  the substance of the dermoid  tissue, or in the appendices
and cul-de-sacs of the skin, the  operations  employed for them  are
attended with very  little danger, and  rarely compromise the life.
Owing to their superficial position it is next to impossible in operating
upon them,  to wound  either arteries, veins, nerves, or any important
organ.   As  these operations, except we extirpate, do not oblige us to
go  as deep  as the sub-cutaneous fascia, it must be only  in very rare
cases that they can give rise to diffused phlegmon, phlegmonous ery-
sipelas, phlebitis, or purulent infection.  Erysipelas properly so called,
angioleucite, and  the  unpleasantness of a cicatrix more or less  de- 
60
NEW ELEME-XTS OF OPERATIVE  SURGERY.
formed, together with the pain, are the only inconveniences that can
occasionally result from them.
   [In America, and especially in the West India or tropical portion
of it, these diseased sebaceous follicles, wherever the heat of the cli-
mate and hot sun are constantly exciting the skin, are very common,
and particularly upon  the  face from its great exposure, and in that
part most frequent upon the dorsal surface of the extremity of the
nose and upon its alas.  Their  enlargement is unquestionably first
greatly accelerated by the vulgar practice of squeezing out these so-
called  worms, so accurately described  by our author.  Intemperate
persons,  addicted also to gross indulgences in  indigestible  food, as
crude fruits, fish, &c, and those most exposed to the  hot sun in warm
climates, as seafaring persons, seem most obnoxious to this hypertrophy.
In the remarkable case (to which I find no parallel on record) which
I operated  upon in Nassau, the  capital of the Bahama Islands in the
year 1825,  and which is inserted below, the cure was complete, and
there was no attempt whatever made by me to save any integuments
at all, as that was in fact impossible for the great breadth of base of
each tumor, as is seen in the accurate accompanying sketches taken
from life by myself.  The diseased parts, however, wrere carefully
and thoroughly shaved off en dedolant with the bistoury, while raised
up with the forefinger  in  the nostril, until I reached the cartilages,
leaving them in this manner, in fact the whole of the nose  from
above the limits of the tumor, perfectly raw.  It is in fact surprising
almost, considering the  heat  of the climate and weather, that gan-
grene did not take place.  The man lived many years with his new
and normal shaped nose, was  the  object of universal remark and
reference, and ultimately died of some other disease.

To David Hosack, M.D., F.R.S., Professor in the University of
                   the State of New York.

                                    New York, Nov.  19, 1825.
  Dear Sir,—Mr. John Russel, aged 54 years, a planter, of Abaco, one
of the Bahama Islands, of robust short stature, and of sanguine tem-
perament, was attacked in the year 1799 with small-pox, from which
he recovered after a severe illness.   His face remained much pitted,
and the surface of the nose was particularly rough.  Soon after, there
was a  perceptible  enlargement of the teguments covering the ante-
rior and  lateral  cartilages  of the  nose, which increased the  more
rapidly, as he imagined, from  the practice of squeezing out of the
end and sides of the nose what are vulgarly called worms, but which
are well  known  to be the secretion of sebaceous glands, indurated
and blackened externally by exposure to the air in the orifices of
their excretory ducts.
  Sir Astley Cooper has expressed an opinion that encysted tumors
may arise from obstruction in the glandular follicles of the skin, and
this may have been the first cause of the disease.   It is not uncom-
mon in the more remote and unfrequented, or what are called out-
islands in the Bahamas,  to meet with fatty  tumors of small size and
globular  shape, upon the teguments of the forehead, nose, and cheek.
I have heard them attributed, with plausibility, to the use of salt fish 
CYSTS,  PROPERLY SO CALLED.
61
 and crude  vegetable food.   Nothing however  like the gigantic
 growth of Russel's nose was ever seen in the West Indies,  or any
 where described in the annals of surgery.
   This patient came  to consult me at Nassau, island of New Provi-
 dence, about the middle of October, 1824.
   For the last twenty years the nose had not varied materially from
 the extraordinary dimensions and grotesque appearance which the
 sketch presents in Plate I.
   This enormous mass of disease  consisted of three lobular tumors,
 having the appearance of a tribolate pendulous excrescence from the
 nose.
   On examination I found them soft to the  feel, and not only pitting,
 but exuding, on  pressure,  through minute  and almost imperceptible
 pores, like those of a carbuncle, a thin, glairy, yellowish pus.  For
 years,  he informed me, he had been  daily in  the habit, during the
 warm weather, of sqeezing out through these pores (which are doubt-
 less the original  orifices of  the diseased sebaceous follicles) a tea-
 spoonful or more of  matter  occasionally mixed with  blood.   They
 were  so movable as  to be easily turned up upon the forehead, so as
 to  exhibit  the openings into the nostrils underneath,  which in their
 natural position,  hanging down upon the mouth, they entirely con-
 cealed.  The middle tumor  extended  down as  far as the lower lip,
 upon which it rested, interfering very much with drinking and eat-
 ing, and also with articulation.  This, the  largest of the three, was
 about two inches  in breadth, and, measuring from the anterior to the
 posterior surface, an inch and a half in diameter: the  lowest part of
 it incurvated over the  nostrils.   The  shape was  spherical, as also
 that of the two lateral tumors, which were  more globate, and about
 one inch in diameter.  Each lateral tumor was seated upon the ex-
 ternal surface of the  ala of the nose, leaving the rim of the inferior
 part of the ala in its natural state, but  closely adhering to the carti-
 lage above this by a broad base nearly co-extensive with the diame-
 ters of the tumors.  The middle lobe, however,  involved the whole
 of the  tip  of the nose,  had a larger base  and attachment than the
 lateral  lobes, and was more  firmly adherent than them to the carti-
 lages  upon which it was  situated.   The  middle tumor  was  also
 entirely separated on each side from the lateral tumors by a deep
 fissure, leaving each tumor upon a distinct base.   These fissures had
 been made deeper, he said, by constantly handling and wiping out
 the clammy matter secreted between  the  tumors.  The teguments
 upon  the  diseased  part were of the same  flushed color and rough
 appearance as upon the rest of the face.
   The  remarkable tumors upon the nose  of this patient had been
 familiarly known  for  years throughout the Bahamas,  as well  as in
 many  parts of the West  India islands;  and so extraordinary and
 unique were they considered, that he was in his travels everywhere
 proverbially designated by the cognomen of Big-Nose  Russel.   The
 sne'ering and sarcastic observations many  persons had unfeelingly
 made upon  his misfortune, had  for the last ten years,  he told me,
 almost prevented  him from going abroad.
  There was no  pain or irritability on handling the diseased mass,
but the weight  of it at  night was so unpleasant as to inconvenience 
62
NEW ELEMENTS OF OPERATIVE  SURGERY.
his respiration, unless lying on his back ; in which posture, also, the nose
interfering with the mouth, would cause him frequently to spring from
bed during sleep, with a sense of strangulation.   The weight may be
imagined from  the deep wrinkles upon the forehead and around the
eyes, occasioned by the incessant and powerful action of the occipito-
frontalis and adjoining muscles, in their effort to sustain  the tumors.
  After having proposed the operation to the patient, and with much
difficulty made him  understand that no serious consequences were to
be apprehended from it, he went home to Abaco, and in a few weeks
returned to Nassau,  for the purpose of having it accomplished.
  In the meanwhile, the proposition I had made became generally
known; and on his return  to Nassau, most of his friends, and one or
two  practitioners  of the place, secretly  dissuaded him  from it, and
told him that an operation  of such moment  rendered  it advisable that
he should go to London, and consult Sir  Astley Cooper or Mr. Aber-
nethy.
  These recommendations, the  motives  for which,  in several of his
advisers,  it was by no  means difficult  to interpret, had the  effect
which was intended;  so much  so  that when, after he  had been at
Nassau several weeks, I again suggested the operation, he positively
and unequivocally declined.  I had almost  despaired of again bring-
ing his mind to the resolution of having the deformity removed, until
at length, on Tuesday, November 23d, 1824, I succeeded in gaining
his entire assent.  The operation was performed about noon of that
day,  in presence of  Mr. Brydon, Assistant  Surgeon of the Forces at
Nassau, in the following  manner: passing the scalpel first on the
outer edge of  the left lateral tumor until  it was removed smoothly
from the cartilages  to which it was attached, then  doing  the same
with the right lateral tumor, and  finishing  in the same manner, with
the middle lobe ; the whole operation being  completed in five minutes.
Several large compreeses were then placed over the nose across the
face, secured by a bandage round the head, to check the hasmorrhage,
which  was not  more  than  eight  ounces. Openings  were  made
through the compresses to  admit light to  the eyes.   In four days the
dressings were removed, and in exactly  two weeks from the  moment
of the  operation, the wound having (under the carbon, bark, and
alcohol poultice, and tonics internally) kindly granulated by the first
intention, the patient, to the astonishment of an assembled multitude,
who  thronged  after him,  appeared at  the public  vendue with a
s?nooth, handsomely  formed nose.  The  chagrin which this spectacle
occasioned to those who had endeavored  to defeat the operation, may
be much more easily imagined than described.
  On passing  an  incision  through  the  different tumors, they were
found to consist entirely of a  dense, homogeneous, adipose or fatty
substance  of a white color, each containing near  its centre one or
more small spherical cysts  of about  a quarter of an inch in diameter,
filled with a thick, pappy, or a theromatous fluid of a yellow color.
  Plate II. exhibits the appearance of the face and nose after the cure.
                              Yours, respectfully,
  Dr.  Hosack.                           P. S. TOWNSEND.
  From the account of the case as published by me at New York,
1825, p. 1 to p. 8, inclusive.  T.] 
CYSTS, PROPERLY  SO  CALLED.
63
Fig.  1.
An exact likeness of Russell's Face and Nose, as taken by P. S. Townsend, M.J
         a few days before the operation, which was on Nov.. 23d. 1824.
Fig. 2.
An exact likeness of Russell's Pace and Nose, as taken by P. S. T.,
                three weeks after the operation. 
64
NEW ELEMENTS OF OPERATIVE SURGERY.
                  Article II.—Hematic Cysts.

   When the unabsorbed extravasations of blood do not give rise to
concrete hematic tumors, they become perverted in their nature and
result in the formation of cysts which contain sometimes a melange
of fibrinous clots and of  a  more or less yellowish-colored, red or
brown serum, and sometimes concretions which have been designated
as  free (libres, i. e. loose) cartilages, and  as hydatid  granules  and
lymphatic  productions, which are found floating  in  the midst of a
more or less abundant unctuous, lactescent or diaphanous liquid ; so
that the whole conveys the idea of grains of barley or rice as seen
in a  potage, or of cartilaginous or  plastic plates  or bodies, or
laminae qr septa, sometimes  free, at  other  times adherent to the
interior of the pouch.   Nor is it rare to find the whole contents of the
cysts transformed  into a homogeneous liquid, sometimes of a reddish
color and  ropy (sirupeux),  sometimes  milky  or  rose-colored  and
of an unctuous feel, or at other times wholly serous  or slightly lemon-
colored.

                § I.—Hematic Cysts in general.
   The various kinds  of hematic cysts do not differ in any respect as
regards  the progress, duration or consequences of the tumor, but
render certain remedies better adapted to  some than  to others.
   A.  Thus cysts that are purely liquid sometimes disappear  under
the use of resolvent topical applications, compresses  saturated with
a solution of sal ammoniac or iodine, frictions with mercurial oint-
ment and that of hydriodate of potassa.   Temporary blistering also
succeeds quite  frequently.
   B.  A remedy much more powerful than the preceding, and besides
much more simple, consists in incising  the cyst on some depending
portion of  it and emptying it completely.  This being done, accu-
rate methodical  compression enables us to bring its walls into imme-
diate contact and in this manner sometimes to obtain agglutination
by the first intention.   Otherwise it suffices to keep the incision open
for four or five days by means of a meche (tent),  that inflammation
may be  established within the  cyst and render its  agglutination
almost unavoidable.
  C. But the best  remedy in such cases evidently consists in  irrita-
ting injections, such as are employed in hydrocele.  A puncture with
the trochar empties the tumor without difficulty ; immediately inject-
ing through the canula of this instrument a certain quantity of tinc-
ture of iodine, in the proportion  of a third of the tincture to  two-
thirds  of water, I obtain  a  moderate  inflammatory  action, which
causes but little pain and almost always terminates  in the perfect
cure of the cyst.  Up to  the  present  time I have not  found that the
tincture of iodine has produced any of those inflammatory accidents
and  purulent abscesses which some  practitioners charge to vinous
injections, eulogized, and also employed successfully a long time ago
by  M.  Asselin, (These sur les  Tumeurs  des Bourses Muqueuses,
Strasbourg, 1803.)   Hematic cysts therefore that  are  purely liquid,
have no need in my opinion of excision, extirpation or caustics, and 
CYSTS,  PROPERLY SO CALLED.
65
the most they can require after resolvent topical remedies, temporary
blisters, iodine injections and the simple incision, would be multiplied
incisions.   The cyst being well circumscribed, allows neither  the
liquid nor the inflammation, when the latter is moderate, from  be-
coming infiltrated or diffused into the neighboring cellular tissue to
such extent  as to create the least uneasiness, while the disease may
be compared in every respect to a hydrocele.
  D.  If in  place of matters purely liquid, the cyst  should contain a
variety of the concrete  clots which I  have mentioned, there might
be necessity for operations somewhat more complicated.   Then, in
fact, it is rare that the irritating injection and puncture, or simple in-
cision, suffice.  We might, however, make trial of one or the other
of these operations, where the cyst reposes in every portion of it, in
the midst of soft  tissues.   Emptied of the liquid matter it contains,
the tumor,  if afterwards submitted to compression and the action of
discutient applications or temporary blisters, might possibly become
concrete and transformed into a nodule that would  ultimately dis-
appear by simple resolution.   In  other cases,  and where  the  cyst
assumes most of  the characters of synovial tissue, it would be illu-
sory to count on  the efficacy of such means.
   E. In such cases, massage, also, crushing, and the  sub-cutaneous
punctures, might  be made trial of.   The fact is known, that sero-sart-
guineous liquids, when they once become encysted or enveloped in
a sac, whether serous or fibrinous, are reabsorbed with extreme diffi-
culty; whereas,  when infiltrated  into the  cellular tissue,  they in
general readily and rapidly disappear.   Every thing, therefore, goes
to show, that  if by massage, or any kind  of compression whatever,
we could succeed  in rupturing the hematic cysts, we  should have
reason to hope for a cure.  By inserting a needle under the integu-
ments, so that it might pass  obliquely and break up the sero-san-
guineous pouch, we should also be enabled to force the morbid fluid
to effuse itself into  the neighboring cellular  tissue.  If we should
combine with this process, compression or  temporary  blistering, it
might also be frequently attended with success. With  these excep-
tions, we must come to the seton and complete incision into  the cyst
or the multiplied incisions.
   F. Seton.—The treatment of hematic cysts by the  seton, is not a
new mode of cure.   Surgeons of all ages have occasionally boasted
of its efficacy.  We may  conceive, in fact, that this  means, by the
inflammation and suppuration which  result from it, might bring about
the fusion (fonte), evacuation, and cleansing of the sac.  The  ope-
ration,  then, may be compared  in  every  respect to  the  one for
hydrocele, by the same remedy.  It is just to remark, however, that
the clots, concretions,  and various layers, which  are then  degene-
rated  (denaturees) in the interior  of the  cyst, often  prevent the
seton  from succeeding, and that  the  inflammation thus produced
sometimes takes on a serious character, and but rarely progresses in
a manner favorable to the cure.
   G.  Incision.—When kept up by the presence of morbid fibrinous
concretions, hematic cysts would seem to demand, above all things,
that they should be extensively laid  open in order to extract from
them these foreign bodies.  Under this state of things, we should
                               5 
66
NEW ELEMENTS OF OPERATIVE  SURGERY.
 proceed in the same way as was done in the time  of Celsus in the
 operation for Hydrocele by incision; that is to say,  that after having
 freely laid open the tumor by means of a  sharp-edged  bistoury, we
 should empty  it  and thoroughly evacuate it both of its liquids and
 all kinds of concretions that might have accumulated there.  Having
 thus properly  cleansed it out, it is to be filled with small balls of soft
 lint,  and then covered with the perforated linen, a plumasseau, com-
 press and containing bandage.   When the process of suppuration
 has sufficiently saturated this  first dressing, the  different portions of
 it are to be daily renewed, and we proceed to the end  of the treat-
 ment the  same  as for an abscess,  dressed flatwise  and largely
 opened.   This method, which  is without contradiction one  of the
 best, has,  nevertheless, the disadvantage  of not  being applicable
 without danger in  every region  of the body.  In the first place, it
 would be  hazardous to think of it for cysts which  exceed the  vol-
 ume  of the fist, in whatever  locality they might  be situated.   If,
 though, of less size, the tumor should be bridled  by certain tendons,
 ligaments, muscles, vessels  or important  nerves,   there  would be
 danger  in dividing it through  and through.   It is, moreover, useless
 to do that in the immense majority of cases.
  H. Multiplied Incisions.—It is besides sufficient for the treatment
 of this class of cysts, to cleanse out their interior thoroughly and to
 create many openings for the  fluid which  is constantly tending to
 become re-accumulated in them.  For that purpose I have been for a
 long time  in the  habit of treating them by incisions of about an inch
 in length,  and which should not be wider apart from each other than
 an inch  or two, so  that I make a variable number of them according
 to the dimensions of the tumor.  The first being made by puncture,
 enables  me to introduce into it my finger, which then serves as a guide
 and support for the others.  Directed through these incisions more-
 over, the finger enables us to detach and extract whatever there may
 be of a concrete or foreign nature in the tumor.  In order to pre-
 vent their primitive agglutination I frequently pass  from one  to the
 other a meche of ravelled (effilee) linen, in form  of a seton, and
 which I do not permanently withdraw until  after the complete estab-
 lishment of the suppuration.  To set  out from this period the disease
 is to be  treated like a vast abscess: emollient cataplasms, and then
 resolvents and compresses saturated with lotions of the same nature,
 are the  only topical applications which rcan now be of use.  The
 concretions which  often adhere to the interior of  the  cyst in the
 form of concentric laminas, are fused  and gradually decomposed, and
 imperceptibly  detached and  eliminated by the  inflammation, and
 finally escape with the product of the suppuration.   After the dis-
 charge of all these foreign bodies, the pus,  which assumes  a  better
 aspect,  diminishes  in quantity, and allows  the engorgement  of the
 tumor gradually to subside, while the walls  of the cyst approximate,
 unite together  and  become consolidated.  It is precisely because of
 these concrete matters formed from the blood, that hematic cysts do
not generally heal  until after having been transformed into abscesses
 and submitted  to the treatment most suitable for this last disease.
 The seton properly so called, and the  simple incision, are of less
value than the multiplied incisions, because they do not like these 
CYSTS,  PROPERLY SO CALLED.
67
 last permit the immediate escape of the foreign bodies and the flow
 of the pus in proportion as it is formed; from whence it results that
 at a later period it becomes necessary most usually to superadd mul-
 tiplied incisions to the seton  and, simple incision.
   I. Extirpation.—Sanguineous like all other cysts, seem sometimes
 to be incurable except by extirpation.  But this operation, which is
 usually long and dehcate, and  sometimes difficult  and dangerous, is
 no longer  admissible at the present day, unless  the tumor should
 have undergone some degeneration of a bad character, or some lar-
 daceous or fibro-cartilaginous  transformation.   If the diseased cyst
 could-be removed in its totality, it would put it in our power to re-
 apply the flaps immediately  over  the bottom of the wound, and
 to treat the solution of continuity by first  intention.   In whatever
 manner done, it is easily understood that this  treatment would not
 be applicable except to tumors that were not of large size  and that
 were  sub-cutaneous or inter-muscular.  Multiplied incisions more-
 over, which almost  always succeed and which are applicable to all
 cases, do not exact  much more time than extirpation to accomplish
 a radical cure.  Extirpation, as respects  the operative process, the
 danger and the consequences of every description, is upon the whole
 infinitely more serious, without presenting more certainty of success
 than the multiplied  incisions, and apart from some cases of excep-
 tions, I cannot see that it can scarcely ever become indispensable to
 give it the preference over the latter.

 § II.—Sanguineous Cysts,  according to  the region  in  which they
                          are situated.
   Every effusion  of blood having  the power to produce an hematic
 cyst, there is  reason to believe that no  region of the body can'be
 exempt from this kind of tumor. Whether we examine them  in gene-
 ral  or  particular, it is nevertheless advisable  to distinguish  them
 always into two great  classes—cellular hematic cysts, and  the mu-
 cous and synovial hematic cysts.
   A. Cellular Hematic Cysts.—The first, that  is to say, those which
 are  formed in the midst of the cellular tissue, or external  to  the mu-
 cous bursas,  cannot  be studied separately as respects operative sur-
 gery.   I will remark only in regard to them, that every effusion of
 blood of this kind  should be treated, for a month at least,  by topical
 resolvents, compression, massage, crushing,  or  temporary  blisters,
 before coming  to operations,  properly so called.   Two principal rea-
 sons induce me to give  this counsel: the first is, that  every  hematic
 deposit  retains a  certain tendency to resolution up to the expiration
 of the  first month,  and that if inflammation should not supervene,
 crushing and blistering succeed quite frequently;  the second reason
 is, that in opening .the sac in such manner as to admit of the air pene-
 trating into it from without, we thereby usually excite in it an inflam-
 mation  of  a  sufficiently bad  character, which  readily takes on the
 form of erysipelas,  properly so called, or angeioleucite or phlegmonous
 erysipelas.   At  a  later period,  when the hematic collection becomes
 completely encysted, the chances of cure by simple means diminish
 from day to day.  while the  concentration of the organic lamellas,
which become  approximated to each other  in order to form the en- 
68
NEW ELEMENTS OF  OPERATIVE SURGERY.
velope to the deposit, diminish in the same proportion the dangers of
the operation.  The tumor now differs scarcely in any respect from
those which have been established in  a previously existing cyst, or
in a synovial sac.   As  for the  rest, the operations which may be
made trial of in such cases, are either the pure and simple incision on
a depending part of the sac, the laying of it open completely, or the
multiplied incisions.  Caustics, the seton, irritating injections, or extir-
pation, would in general  be insufficient or useless in such cases.   The
operation, moreover, will have  to be  submitted to the same princi-
ples, whatever may be the region of the body to which its application
may be useful; and it is  in anatomy alone that the surgeon must find
the rules  for his conduct in hematic tumors of this species particu-
larly.
  B.  Synovial Hematic  Cysts.—When the hematic cyst has estab-
lished itself in a previously existing mucous bursa, there is scarcely
reason to hope for its cure  by resolution after  the  first  three  or
four weeks of the  disease have passed by.  Should there be ever so
few clots or concretions in the cyst, it is almost impossible for topical
applications, injections  and temporary blisters to succeed,  and crush-
ing would both be  of  little effect and  extremely difficult.   In  those
cases, therefore, the operation, properly so called,  may be  proposed
without waiting as long as for hematic  cysts of the cellular tissue.
We  may easily conceive that all the  mucous bursas might possibly
become the seat of similar cysts; there are, however, some  in which
they are developed much more frequently than in others, and so to
speak, exclusively.
  I.  In the head, for example, hematic cysts have been but rarely ob-
served in the synovial bursas.   It is not the same we shall see with  the
cellular cysts, (see Hydrocephalus.)  Upon the temporo-maxillarv ar-
ticulation, at the angle of the jaw or on the symphisis  of the chin,  the
incision through and through would present no difficulty, might be per-
formed  as for the opening of an abscess, and might be preferable to
the simple incision, unless we should wish to recur to  puncture and
irritating injections.
  II.  The mucous bursa of the thyroid cartilage, and that of the di-
gastric muscle, should they become the  seat of  a sanguineous effusion,
are to be treated  in the same manner, unless the tumor shall have
acquired a great volume, or the walls  of the cyst have undergone a
great degree of attenuation.  In this last, the irritating injection, if
there are no foreign bodies to extract, and the multiplied incisions, un-
der opposite circumstances, should be substituted to the other method.
  III. What I have said of the  thyroid angle, is applicable in even-
respect to the  mucous bursa of the seventh  cervical vertebra, and
that of the anterior surface of  the sternum, and of the summit of  the
angular projections, (du sommet des gibbosites;) but when the cyst
is established upon the sides of the spinal column,  in the lumbar re-
gion, or on the external  surface of the muscles, especially the latissi-
mus dorsi, it is rare that the total incision of the cyst should have the
preference.   Supposing the tumor should  consist of matters purely
liquid, a puncture  to empty it,  and an iodine injection to inflame it,
would almost always effect a cure.  If grumulous products, concre-
tions and clots of degenerated blood existed in the sac, to such extent 
CYSTS,  PROPERLY SO CALLED.
69
as to render the success of the injection doubtful, we must then have
recourse to multiplied incisions and meches of ravelled linen, (see
above.)   Six incisions of an inch and a half each thus effected the
cure of  an hematic tumor  which had  formed between the spinal
vertebrae and the upper part of the arm of a man who was  admitted
into my division  of La Pitie in 1832.   A young man who had a simi-
lar  cyst  at the lower part of the lumbar region, was cured of it at
the expiration of a month by four incisions of the  same kind.   A
woman,  in other respects in indifferent  health, and whose life  has
since  been  threatened  by a  diffused erysipelas,  had for the space
nearly of a year, between the spine and the lower angle of the scapula,
a tumor, resulting from a blow, and having half the volume of an adult
head.  Having laid open this tumor freely on four opposite points, I
afterwards passed two setons through it, which were  removed at the
end of  a week,  and nothing further has been  required to  complete
the agglutination of the walls of the sac.
  IV.  The mucous bursa which covers the lower angle of  the scap-
ula, is quite frequently the seat of hematic extravasations.   A young
man formerly employed in carrying  a hod, presented at the hospital
of  La Charite, in 1836, an instance of a tumor  of this  description
which was equal in  size to two fists.   I opened it in three places, and
the cure ultimately  took place; but the natural  mobility of the osse-
ous angle and of the latissimus dorsi and trapezius muscles, presents
in this part such obstacles to the obliteration of the cyst, that at  the
present time I would  endeavor before all other things to produce an
inflammation in  its  interior by means of the  iodine injection, should
it not appear to contain too great a proportion of concrete matters.
The simple incision, to which a preference was given  in the patient
mentioned by Marechal, (Nouv. Bibl. Med., t.  I., p.  455, 1818,)  and
who had a bilobate  cyst upon the shoulder,  brought on a suppuration
which ended in death.
   V. Upon the dorsal portion of the acromion, hematic cysts might
be treated as in  the general track of the spine.   Those on the  con-
trary which form between the deltoid and  the scapulo-humeral cap-
sule, would require that we  should  confine  ourselves to the simple
incision, as I have done in tvyo instances, or to the iodine injection.
This last remark is  alike applicable to the sub-tendinous cysts of the
olecranon, the sub-muscular cysts of the  coronoid process,  and  sub-
bicipital cysts of the radius.   Upon the inner condyle of the humerus
they would require the  same treatment as for that upon the spinous
process of the seventh vertebra.   The same would be the case foi
those on the styloid processes of the  radius and ulna, and  for those
on  the dorsum of the metacarpo-phalangeal  articulations.  But the
sub-cutaneous mucous bursa of the olecranon, and the synovial cavi-
ties of the wrist, require in this respect some special precautions.
  VI. Hematic  Cysts of the Olecranon.—I have noticed in the sub-
cutaneous  mucous  bursa  at  the elbow all the varieties of hematic
effusions.  If the effusion is in a liquid state and we are called shortly
after the  accident, topical applications, compression  and the blister
should be first made trial of.  At a later period, if the tumor is volu-
minous and almost exclusively filled with fluid matter, puncture and
the irritating injection are almost always  sufficient.  Should the mu- 
70
NEW ELEMENTS OF OPERATIVE SURGERY.
cous cavity contain at the same time those granulations which resem-
ble rice, barley or millet seeds, and which some persons have mista-
ken  for hydatids or cartilages,  puncture and injections no longer
have the same efficacy.   Multiplied incisions should then have the
preference.  Though exposing to phlegmonous erysipelas, they are
less dangerous than extirpation and  succeed full as well, without re-
quiring so long a time for the definitive cure.   If, in the place of this
appearance of boiled rice or barley, the matters contained in  the cyst
should simply present the aspect of grumpus substances, concretions
or ordinary clots of fibrine,. the same treatment should still  be pre-
ferred.
  VII. Hematic Cysts of the Wrist.—I do not mean under this title
either the spiroidal (spiroides) tumors which sometimes form in the
sheath of the tendons of the  thumb on the outer side of  the radius,
or those bumps (bosselures) of the same nature which are sufficiently
often noticed upon the palmar surface of the fingers upon the track
of the flexor tendons of  those organs ;  but of the kind of cyst which
has for its special seat the synovial  cavity in the palm of the hand
and on the palmar surface of the wrist.   This tumor, of which some
examples are  found in  the ancient collections of  observations, but
which nevertheless  has  only attracted attention since the time of
Pelletan and Dupuytren, has this remarkable feature, that it is  divided
as it were into two parts by the anterior annular ligament of the car-
pus, in such manner that one of these portions projects from the palm
of the  hand, while the  other presents itself above it.  Conveying
moreover the sensation of a crepitation or  friction of granulous
bodies gliding upon  each other, and a kind of fluctuation when  alter-
nately compressed at its two  extremities,  it is in general easily diag-
nosticated.  Having sometimes found them filled with clots of blood,
which may still be recognized though comminuted (morceles) I have
ultimately come to this conclusion, that the grains of which they are
usually composed and which are  almost always found in them to the
amount of some hundreds, far from belonging to the class of hyda-
tids, as Dupuytren believed, or to that of  loose (libres) cartilages, as
others  have supposed, were in fact nothing else than fragments of
degenerated (denatured)  fibrine or plastic lymph.   Whatever  may
be their nature,  these tumors, denominated  bisaculated (en bissac)
tumors of the wrist, should be first attacked by every other kind of
remedy than  that of the cutting instrument, especially by repeated
temporary blistering, seeing that no actual operation can be employ-
ed for them without  danger.   The irritating injection, which would
be the mildest remedy for them, if liquid matter predominated in.the
cyst, is without efficacy in other cases.  A large seton passed from
above downwards through the whole length of the sac .might doubt-
less  succeed ; but inflammation so readily extends to the palm of the
hand, the tendinous sheaths  of the  fingers and the synovial net-
works and cellular tissue of the fore-arm, that it becomes  the source
of real dangers, and sometimes  proceeds to the extent of compro-
mising the life of the patient, or  at  least the preservation of the
limb.
  What I say of the seton  is  applicable also to  the simple incision
on  one of the prominences of the tumor, or to multiplied incisions, 
CYSTS,  PROPERLY SO CALLED.
71
or the laying  open of  the  whole  tumor, including in  this divi-
sion the anterior ligament of the carpus.  I know that F. Aquapen-
dente, Portal (Hist. Anat., t. II.. p. 227), Schmucker, (Bibl. Chir. du
Nord, p. 21), Gooch (Encyclop. Meth. Chir., 1.1., p. 545), ana1 Dupuy-
tren (Gaz. Me'd., 1830, p.  311, no. 34,) have met with success from the
incision, and that Warner  (Obs,  Chir., obs. 15 and 16, p. 88,) was
enabled to divide the anterior ligament of the carpus with impunity,
and thus effected cures ;  but I have seen such frightful results from
this method  at the Hotel-Dieu and Hospital of St. Louis, that I would
scarcely dare recommend it.  It is to  be added also, that under the
most favorable circumstances possible, the walls of the cyst operated
upon  in this manner,  capnot agglutinate without causing such ad-
hesions and confusion  of  the  tendons, wrhich  course through the
wrist, that a deformity  of the hand or of the fingers would  be the
almost unavoidable result.   In this region then, hematic  cysts are a
species of noli me tangere; and we should be on our guard against
meddling with  them so long as the patients are not greatly  incom-
moded by them, and not until  after  having made trial of all other
remedies, and forewarned ,the family of the possible consequences of
such an operation.
   a. As for the rest, when once decided upon, the operation which
I should then advise would  neither be  the seton, nor the simple in-
cision, nor the  complete  laying open (la fente totale) of the sac; I
should much prefer three  or four free (large) incisions upon the
principal  projections of  the cyst,  which I would then  treat as a
large (grand) abscess, by emollient topical applications, local sangui-
neous emissions, and all the different kinds of antiphlogistic remedies.
Having seen a young person operated upon by means of the simple
incision, by  M. Richerand,  on the point of dying from the inflamma-
tion which seized upon the, whole  hand and fore-arm, and knowing
the consequences  of this kind of treatment, as  pointed out  by Du-
puytren, I should  not venture upon it but  with the  greatest  repug-
nance.   The two patients in whom I used multiplied incisions  having
got well, encourage me, on the contrary, to commend this last mode
of operating,  without, however, presenting it  as exempt from all
danger.   I  should  add, that in a young man operated upon by me at
La Pitie, in 1832, the  hematic cyst though very ancient, contained
concretions  of fibrine and clots of blood still recognizable, but without
any of those grains of which  I have spoken  of above.   The four
incisions which  I made upon it above were followed by an inflam-
mation sufficiently intense  to give me  at  first some degree of un-
easiness;  but the  accidents ultimately  subsided, and the cure was
accomplished at the expiration of the second month.
   b. A puncture and  a  small incision  aided by  compression, have
also succeeded  so. well  with M. Champion, that  it is well to have
recourse to  it  again.  M.  Duval,  manufacturer  of cotton  fabrics,
consulted me (says this  practitioner in  a letter to me,) in the year
1810,  for a ganglion of a sufficiently large size, which raised  up the
skin in  the  palmar surface of the hand, and which was prolonged
upon the lower third of the fore-arm, by passing  under the annular
ligament of the tarsus,' which  divided it into two bellies.  Having
used the bandage of Theden for  the space of six weeks, without 
72
NEW ELEMENTS OF  OPERATIVE SURGERY.
success, I plunged a bistoury into the lower part of the tumor upon
the fore-arm, which brought out  more than six ounces of liquid, to
which there succeeded soon after,  about two teaspoonfuls at least, of
small foreign  bodies of the size of the eggs of the carp, and of a
reddish  color, and a slight degree of hardness.   The  compressive
dressing to the hand had  been reapplied before the operation, and  I
continued its application  to the cyst, and  the whole limb  as high as
the axilla, by means of a bandage  kept moist with oxycrat and salt,
cold.  The incision, which at first  was only four lines in length, had
to be  enlarged to effect a  passage for the small  granulated bodies.
No accident took place, and  scarcely any inflammation supervened.
The dressing, or the roller bandage,  was continued for a month, re-
stricting it soon to the surfaces which corresponded with the disease,
and the  cure was complete.  I operated, says M. Champion, upon a
second and similar case  in  1822 ;  only that  the  tumor was of less
size.  The incision gave egress also  to concretions, but in smaller
quantity, and the success was the same.
  VIII.  The Lower Limb.—If the  mucous bursa of the antero-supe-
rior spinous process of  the  ilium should  be transformed into an
hematic cyst, it would become necessary to attack it like that of the
olecranon.   It would be  the same  with that on the outer  border of
the great trochanter, and on the outer surface of the thigh.  I have
met with one example  in front of  the spine of the  tibia, and which
disappeared  under the influence of  two temporary blisters.   The
same  took place in the case of an hematic cyst at the head of the
fibula.  The sub-cutaneous hematic cysts upon the posterior surface
of the heel, and upon the  dorsal and inner side of the scaphoid  bone,
the projection of club feet, and the dorsal  and inner side of the first
and other  bones of the metacarpus, do  not exact  also other precau-
tions  than those of the corresponding  regions of the hand.  Upon
the stump of persons amputated, these tumors should not be treated
but with a certain degree of reserve, inasmuch as their suppuration,
from  their being  situated on the apex  of the bone, would  obviously
expose to necrosis.  Between the  great trochanter and  the coxo-
femoral  articulation, between the gluteus  minimus  muscle and the
same  articulation,  between  the obturator  internus  muscle and the
lesser sciatic notch, under the tendon of the iliacus internus muscle,
upon  the apex of the little  trochanter, between  the triceps and the
rectus femoris, under the ligamentum patellae and between the ten-
dons of the pes anserinus, between  the os calcis and the tendo achil-
lis, where I have met  with three examples, also on  the  plantar
surface of the foot,—hematic cysts if somewhat ancient, scarcely ever
yield  to the application of topical resolvents, nor  even to large tem-
porary blisters.  As on the other hand there is some danger of pro-
ducing suppuration, they should be treated  by puncture and irritating
injections, provided they contain a sufficiently strong proportion of
liquid matters.  In the contrary case,  I know not  in reality which
should have the preference, whether the seton, the simple or multi-
plied  incisions, or the complete division.
  IX. I have often observed hematic or sero-sanguineous cysts  upon
the dorsal and inner regions of the  metatarso-phalangeal articulation
of the great toe.  In this place temporary blistering and topical ap- 
CYSTS,  PROPERLY SO CALLED.
73
plications of all kinds should be  made  trial of before proceeding
farther.  Supposing such means should produce no effect, we should
not even then come to the operation, unless the tumor was in reality
a source of serious annoyance to the patient.  These mucous bursas
are so near the articulation, with  which moreover they sometimes
communicate, that we should  never divide into them  or lay  them
open, nor, in a word, carry the cutting instrument upon them unless
compelled to do so.  I  have  seen two  patients upon  the point of
perishing in consequence of such attempts, and  through means of a
suppuration, which after having  invaded  the .articulation ultimately
left therein caries which rendered  amputation necessary.  Platner,
(Coll. Acad.,partie  etrang., t. VIII., p, 43, du Discours Preliminaire;
also Paul, Suppl. a  la Chir. d'Heister, p.  50.) speaks of a ganglion
of the synovial cyst  of the tendo achillis, which  having acquired
an immense size, was followed by serious accidents, though nothing
had been done to it.   I saw, says M. Champion, a synovial ganglion
of the same kind eight years since, in a woman  aged 36 ;  it was of
the size of  the fist and  its form was elongated.  I recommended
puncture and compression, and rest for the  space of a month and
more.  The  patient more alarmed  at the period  of time than the
operation, consulted an officer of  health,  who  promised  he would
make a more speedy cure.  An incision was made  ; and soon  after*
a fungus formed on the inside surface of the cyst, and acquired a
very considerable size, ending in the death of the patient.
   X. The mucous bursa  on the dorsum  of the foot, which I  have
seen transformed into an hematic cyst in three instances, would re-
quire the same precautions, though there  might perhaps  be a little
less danger of the inflammation prolonging itself to as  great an ex-
tent as in the preceding case.
   XI. The malleolar  hematic, cysts I have met with, have all  been
treated by the multiplied incisions; but  it would be  prudent to at-
tempt their cure by irritating injections if they contained a large pro-
portion of, liquid  matters.   The neighborhood of the fibro-synovial
sheath of the peronei tendons on one side, and  of the tibialis posti-
cus on the other, together with the character of the tibio-tarsal arti-
culation, should  always make us avoid  as much as  possible the
establishment of a purulent inflammation in that quarter.
   XII.  It is upon the knee that, hematic cysts  are the most frequent-
ly met with.   Those which develop themselves upon  the outer or
inner condyle of the femur, rarely acquire a large size, and  may be
treated by crushing, sub-cutaneous puncture, or irritating injections,
when  they  have resisted both topical  resolvents and temporary
blistering.  There will be opportunity moreover after these means, to
attack them by a complete division or by multiplied incisions rather
than by the seton.
  XIII.  Those in front  of the patella  and which are so often
encountered  in practice,  and of  which  I have  seen  so great «a
number of varieties, require especially that I should allude a mo-
ment to them.  In this part  I have met with them  of the form of a
plate of little thickness, four or five inches long and  from two to four
fingers' width in breadth ; at other times presenting a bi-sacculated
appearance, or an  irregularly embossed (bosselee) mass, or hemis- 
74
NE.V ELEMENTS OF OPERATIVE SURGERY.
pherical. or taking on the character of a transverse bourrelet [like a
collar, T.]   I have seen them of the size of the fist, though ordina-
rily they do not exceed that of  a pullet's  or  turkey's egg.   Some-
times filled exclusively with liquids, either viscous, or purely serous,
or lactescent, and of a reddish brown or simply a roseate tint, they
very often  also contain clots of a fibrinous or reddish  matter, still
possessing  mosTof the characters of clots of blood; sometimes sim-
ple greyish or yellowish clots  that are friable, or  as it  were, carti-
laginous  and exceedingly  variable  in number ; at other times a
species of columns or movable bridles that are  hard and slippery
and of a cartilaginous aspect, and adherent by one of their extrem-
ities or even by both, so that in pressing them upon their exterior they
convey a sort of crepitation which is sufficiently  distinct and  alto-
gether of  a  peculiar character.  The  extirpation of these cysts,
which MM. Pezerat (Journ. Compl.  des Sc.  Med., and  Bibl. Med.,
1827, p 414)  and Ilervez (Journ. Hebd., t. III., p. 329,) still seem to
prefer in adducing facts in support of it, would not become indispen-
sable unless their walls should have acquired an  extreme degree of
thickness, and a fibro-cartilaginous density.  In such cases we should
proceed  in the  manner  pointed out for concrete hematic tumors.
When the cyst is not  of  a  very  ancient date  and  [its contents] al-
most exclusively liquid, it is advisable to commence with topical re-
solvents, compresses  saturated  with ammoniacal vinegar or any
other solution of sal ammoniac.  The temporary blister would come
in as  a second remedy.   I have  seen a  certain number of hematic
cysts of  the knee, which  had existed over three weeks,  dispersed
by employing this description of remedy.   [Our author (see Vol. I.)
means by temporary  blistering (vesicatoire volant) the  successive
application of small blisters composed as usual of Spanish flies, com-
binations of ammonia, &.c, left on for a short time and  changed in
their  locality.  Vesication  is not intended, but only a phlogosis or
commencing  inflammation,Tedness, &c, so as strongly to direct the
sanguineous and other currents to  the part.   So far however from
this temporary or transient mode of applying blisters, and which the
author much  insists on as  an extremely valuable  remedy, being a
reliable one here, we ourselves have,  on the contrary, found even in
these largest  sub-cutaneous mucous  (properly serous, see our notes
infra) bursas, of old date, i. e., a year or more, and covering the
whole patella of an adult, being like a large inverted cup, effectually
cured for a length of time by means  of a continuous copious  drain
of suppuration kept up on  the  dermoid surface  of the tumor by
thorough, repeated and full blistering, i. e. by the ordinary mode of
applying this remedy.  However, as  I have repeated, (Vol. I.) bursa
of the largest description, provided  their contents are  liquid, and
their walls  and the neighboring  tissues are not intensely inflamed,
are, whatever may be their.date, best and  most effectually and rad-
ically cured by percussion, i. e.ecrasement or crushing, &c. T.]  At a
later period we would have but little to expect from topical applica-
tions and the blister. We must then endeavor to ascertain if it is liquid
matter, or concrete, that fills the synovial bursa.   In the  first  case
iodine injections would have a decided preference  oyer every other
preparation.  I have  made use  of them on three  occasions^uider 
                   CYSTS, PROPERLY SO CALLED.                75

such circumstances, and the result has  been as simple as in a case
of hydrocele.   The trochar being plunged in at the summit of the
tumor from below upwards, while the leg is in extension, enters
into the cyst as it does into the tunica vaginalis, allows us to extract
all  the liquid, and  afterwards  to inject into the cyst the medicated
compound with the greatest degree pf ease.   Similar successes also
were obtained formerly by various practitioners, and  in our own
time by M. Asselin, who gives two fine, examples of them ;  also by
M.  Paul Guersent, as well as by M. Laugier.
  The efficacy of irritating  injections for cysts in front of the knee,
therefore, is at the  present day a point definitively adjudged.   When
the cyst, on the contrary, contains a sufficiently large proportion of
solid clots, it is probable, though not  yet demonstrated,  that the in-
jection might not be successful.   The most suitable  operation then,
is not that of the seton; the pure and simple incision, with the intro-
duction of a tent into the cyst, which I have done four or five times,
is far from being always successful.  The  walls of the tumor only
partially agglutinate, and the effusion generally is ultimately repro-
duced.   The tumor returned in three patientsthat I operated upon,
and the other  cases were cured  only by means of a violent inflam-
mation, which  speedily involved the  whole anterior portion of the
knee.  It  is necessary, moreover, in all  cases, that this  incision
should be'near an  inch long, if we wish to have 'no  difficulty in the
discharge and extraction of the foreign grumous bodies contained
in  the cyst.  The crucial incision also,  which  I have sometimes
made use of, and  which many practitioners have sanctioned, is an
operation too  serious in its consequences, and leaves  a wound of too
great length and too difficult of cicatrization to merit general  adop-
tion.   The same may be said of excision, which was  still employed
by Percy or by Laurent,  (Eloge de Percy, p. 25.)   Multiplied in-
cisions, consequently, are  those  to  which I give the preference in
these cases.   These incisions being made of about an inch in length,
and placed one above, another  below,, and one on each side, and as
near as possible to the circumference of the sac, and whose  aggluti-
nation is  prevented by means of a meche of ravelled linen during
the first four  or five days, enable  us to empty the sac completely,
and thus create an inflammation in it, which almost unavoidably re-
sults  in the consolidation of its walls.   Certain it is, that the  patients
treated by me in this  manner, have all been cured in the space of
from three to  six weeks.  I ought, however, to add, that in a man
operated  upon in this manner in 1837, at the hospital of La Charite,
for an hematic cyst at the elbow, the disease in consequence of an-
other fall on this part, was  reproduced in 1838.  We  must, more-
over, not  forget that sudden movements^ as well as the want of pro-
per care in the dressings, would incur at the knee more than in any
other part, the  risk of angioleucitis,  erysipelas, and diffused phleg-
mons of a formidable character.   I have only in three instances seen
the sub-ischiatic mucous bursa, transformed into a sanguineous- cyst.
In this region the disease may present some difficulties in the diag-
nosis;  but it should be submitted to the  same processes of operation
as in front of the knee, and the suppuration would be  far less dan-
gerous than in the  vicinity of this latter  articulation. 
76
NEW ELEMENTS OF OPERATIVE  SURGERY.
                  Article  III.—Serous  Cysts.

  Under the title of serous cysts, we should, strictly speaking, com-
prehend all tumors consisting of a pouch, filled with aqueous liquid.
We should thus designate under  this name  the greater part of he-
matic, hydatid, and synovial cysts, as well as all  serous  cysts  pro-
perly so called.  Under the title of serous cysts, however, I shall
speak only of those  tumors which are  independent of the  natural
mucous or synovial  cavities, and  which are constituted of an  unnatu-
ral accumulation of .diaphanous and exceedingly fluid liquid.  All that
I shall say of them, moreover, is  exactly applicable to synovial cysts
of the mucous  bursas, and to those tumors known under the name of
hygroma.   This description  of cysts does not belong only to those
exhalations, which sometimes take place in the midst of the  cellular
tissue,  and  without any  appreciable degeneration.  A  lymphatic
ganglion, or any glandular organ whatever, or the presence  of any
foreign  substances,  may become the source from whence it origi-
nates.   An enormous cyst occupied the entire supra-hyoid region
from one parotid cavity to  the other ; M. Malcolmson  (Gaz. Med.
1838, p. 743) excised an ellipse from it below the jaw, and the liquid
escaped together with a foreign body.   But a kind of gland was
noticed  at  the bottom  of the sac;  this gland being  secured with a
hook and excised, and, in fact, extirpated almost in its  totality, had
the appearance of belonging to  the sub-maxillary gland.   Was it
not, perhaps, a degenerate lymphatic ganglion ?  at least the serous
cyst was certainly dependent upon it.  Marchettis (Bonet, Corps de
Medec, t. III., p. 239, obs. 38) speaks of a tumor of the size of a pul-
let's egg, situated in the neighborhood of the trachea, and composed
of two cysts full of serosity, and imbedded one within the other.  The
author adds that there was at the bottom of the sac an excrescence
which it became necessary to excise, which authorizes us  in sug-
gesting that a lymphatic tumor had been the point of departure of
the  disease.  Muralt (Ephemerides des Cur. de la Nat., dec. 2, an.
III.)  also speaks  of serous cysts which contained either bone's or
other foreign  bodies, as  well as a pound weight of serosity.  In
1838, a man came to the hospital of La Charite,  who had a tumor in
the scrotum of the size of two fists, with all the characters of hydro-
cele, from which about two glasses of a rose-colored  serosity had
been already extracted by puncture a year before, and which was soon
afterwards reproduced.   Suspecting that this cyst depended  upon a
degenerate hematocele, I  operated  upon it  with  the multiplied  in-
cisions.   Various accidents  supervened, and the patient died at the
expiration of fifteen  days.  But this cyst, which contained more than
ten ounces of a liquid almost entirely serous, was the  result of an
encephaloid degenerescence of the testicle,  which latter, however,
had only augmented to about double its natural  volume.  I have,
moreover, seen cysts that were purely serous, form in the groin, under
the jaw, and in the sub-hyoid region, in consequence of previous dis-
eases in the lymphatic ganglions, or in the thyroid gland.
  The preceding  remarks were necessary  to show that serous  cysts
are far from always constituting  a simple disease, or from being all 
CYSTS,  PROPERLY SO CALLED.
77
of them  susceptible  of dispersion with the same certainty by the
action  of the  same  remedy.   I  will add, that after contusions or
bruises which occasion infiltrations or extravasations under the  skin,
we see quite often the coagulable and coloring  matter of the blood
disappear, and give place to a serosity or viscous or unctuous fluid,
which  is  almost  in  every respect analogous  to  the synovial fluid.
Serous cysts, in whatever way produced, may acquire an enormous
volume.   According to Percy, (Diet.  des. Sc. Med., t. XXVII., p. 50)
Levret  met. with one which extended from the dorsal region to the
ham.   Powel, (London Med. Jour., t. II., p. 144, 1785,) gives another
example of one which was cured by incision, and which descended
from the shoulder to  the spine of the  ilium.   Their ordinary size,
nevertheless, rarely exceeds that of a pullet's egg, or the head of an
infant or of an adult, [being at  the same time] more or less irregularly
deformed.   The  shape and size of a round loaf of bread, as in the
case mentioned by Saucerotte, (Mel. de Chir., t. II., p.  391,) is how-
ever by no means  extraordinary.  These cysts, moreover, may be
developed on almost all  the regions of the body.   All practitioners
know that the  free  border of the lips and eyelids are frequently the
seat of tumors of this kind, which rarely exceed the dimensions of a
small bean, and for the speedy cure of which, all that is requisite is to
lay them open and cauterize them with nitrate of silver.  Jourdain,
 (Malad. de la Bouche, t. II.,  p. 195,)  a long  time since, noticed the
presence of serous cysts in the substance of the lips.  M. PI. Portal,
 (Clin. Chir., p. 289,)  gives an example of one upon the  lower lip.
I  have met with them of the diameter of an inch or the half of  an
egg, once on the anterior region,  and another time on the side of the
right parietal bone.  M. Champion,  (communicated by the author,
 1838,) operated for one of the size of a small pullet's egg,  and  situ-
ated under the left temporal muscle.  In Heister also (Theses  de
 Holler,  t. V., p. 241, French translation,) we meet with an example
of a serous cyst as large as an egg, which had developed itself under
 the  ear.  In another  patient, whose case M. Champion has trans-
 mitted  to me,  the  tumor, which  was bilobate and situated between
the muscles, occupied the left portion of the supra-hyoid region, and
projected at the same time within the mouth as well as  below the
jaw, where  it was  equal in volume to a turkey's  egg.  I have also
seen, in the same situation, a similar cyst of the size of the fist, in  an
infant  aged twenty months.   In treating of the operations which are
performed on different regions of the neck, I shall have to return to
the serous cysts, which are sometimes produced by affections of the
thyroid or of the  salivary glands.   The surface of the thorax is suffi-
ciently often the seat of similar cysts.  Rudolphi (Jour. Analytique,
1828, No. 7, p. 103,) mentions one under  the pectoralis major, and
which  resembled a  schirrhus.  I  have also seen one which was of
the size  of two fists,  in a boy aged fifteen years, and which being
situated  in front of  the axilla,  presented the form and other appear-
ances of a firm and well-developed  mamma.   Heister speaks  of a
cyst of this description which was situated on the side of the spinal
vertebras ; and I have frequently met with  cysts on the different re-
gions of the back, which, though of hematic origin, were nevertheless
completely filled with serous  liquid.  Though M. Basletta (Bullet. 
78
NEW ELEMENTS OF  OPERATIVE SURGERY.
 da Ferussac, t. X., p. 9.3,)  was  successful  in cur'ng his'patient of a
• cyst  of the  size of an egg, filled with palish (pallacee) miller, and
 situated deep within the abdominal walls,  and  communicai'ng w th
 the peritoneum, it was not so with M. M'Farlane, (Kncyt-Iop. ihs Sc.
 Med., 1830,  p. 55,) whose patient died after the puncture of the cyst,
 which  was  between the peritoneum and  muscles.   M. Tavernier
 speaks of one which was situated between the abdominal muscles,
 and which, having made  an opening into the belly, also caused death.
 In the collection of M. Ouvrard,  we also find an instance of a serous
 cyst  of considerable size situated upon the back.   A serous cyst of
 the size of an orange was successfully removed by M. PI. Portal from
 the back of a man aged fifty years, (Clin. Chir., p. 281.)  Serous
 cysts  have been noticed upon the breech by  M. ryecamier,  (Uaz.
 Med.,  t. I.,  p. 319, No. 35,)  and a  great  number of other practi-
 tioners.  I have myself  often seen them  in this region ; but it is at
 the fold of the grohi where they are most frequently found, and where
 I have met with them of the size of a child's head.
   M. Jaudard (T!ies:\ Strasbourg, 1810, p. 14,  obs. 4) states that he
 saw one at Lyons in the  service of M. Bouchet, which was situated
 about the middle of the  inner part  of the thigh.   That mentioned
 by Paroisse  (Journ. Gen. de Med., and t)ict. d:-s Sc. Med., t. XXII.,
 p. 133,) occupied at the same time the thigh and the \eg'.  I have often
 had occasion to meet with  them on the different regions of the arm
 and fore-arm, on the body of the thigh and leg, and on the foot and
 hand.  All the operations  I have described for hematic cysts, are
 applicable to those that are serous. " Leaving aside what relates to
 the employment of topical  applications, compression,  blisters, and
 even caustics, I would  remark that crushing and puncture with the
 needle would not succeed, except in certain cases, and should not be
 had recourse to unless it  should be impracticable to moke use of irri-
 tating injections.   This  last means, in  fact, especially if tincture of
 iodine be employed, is so perfectly simple and of such unfailing c'li-
 cacy, that it should be  preferred in every case where no particular
 operation  would forbid its employment.   Should  the  cyst not be
 very large, we should make use of-a very delicate trochar  and a sv-
 phon-syringe corresponding.   In other cases we should proceed in
 the same manner as  in the  operation for hydrocele, and  should suc-
 ceed equally well.   Supposing, however, whatever the reason may
 be, that we do not wish to make trial of this remedy, an opportunity
 would  then  present for puncture or the simple incision of the  cyst:
 this sometimes, suffices-to bring on inflammation, suppuration and a
 definitive cure. A woman of 45, had in the left groin a tumor with thick
 walls, slightly bosselated  (bosselee*)  on its surface, of the size of the
 head, but without ever having caused  her any pain.   This woman,
 who had been addressed to me at La Charite* had  her tumor punc-
 tured by  M. Vidal, who  took  from  it two  glasses  of  a limpid
 serosity.   Finally, a  purulent  inflammation established itself in the

   * We shall venture on the coining of this word, as bosse and bossel (from whence em-
 bossing in English—i. e.'sort of basso relie.no or fret-work in the ornamental arts) are not
 translateable with'precision, certainly not with elegance, by bumps, lumps bunches
 bumpy, &c, although they may rudely convey the idea of the ineqaulities, or'elevations
 and depressions meant. T. 
CYSTS,  PROPERLY SO CALLED.
79
sac, and the pus opened for itself an outlet through the puncture
which had caused it.   The tumor was reduced little by little, to the
volume of a pullet's egg.  Seeing-that the process of resolution was
suspended, I considered'it to be proper, before having recourse to a
complete  division of the sac, to make trial of a large temporary
blister.  Eight days after, the walls of the  sac were found completely
agglutinated, and the patient soon after demanded her dismissal from
the hospital, being in a state of perfect cure.  If however puncture
or the simple incision  should  seem insufficient, we should come to
the complete division of the tumor, should it not exceed a small egg
in its size, or in the contrary case, insert  through it one  or several
setons, or better still, divide it on several points of its free portion by
means of large incisions.  As to extirpation, it is neither more effica-
cious nor more certain in its effects than the  preceding method ; and
as it  is obviously the  most dangerous and most difficult, and  the
longest of all, it would be advisable in general to reject it.  Up to the
present time I have not used  the iodine injection for curing serous
cysts, except in the boy who had one on the outer side of his breast,
and in the infant  who had so vast a one in the supra-hyoid region;
but these two examples have satisfied me that a remedy like this will
succeed in at least fifteen cases out of twenty, and that it should be
made trial of before all others.   Serous cysts developing themselves
external to the natural organs and cavities, cannot be examined in a
topographical point of view.  The operative process which  relates
to them should consequently be submitted to  simple  general rules,
whether it be crushing, puncture, injection, the seton, incision, or
multiplied divisions, or finally excision of all  its most attenuated por-
tions, or its extirpation, when it is of too large a size  to allow us  to
hope for perfect agglutination of its walls.  Among serous cysts there
are some that are multilocular [i. e. having  several compartments, T.]
or truly hydatid.   In such cases we should have to qualify what I
have said of irritating injections and the different kinds of incisions.
It would  be next to impossible here to look for a  radical cure by
means of the seton, the simple incision, or even the multiplied incis-
ions,  unless the operation, perchance, should include all the vesicles
of the  cyst.   To operate then in such a case with any chance of
success, it would be necessary to lay open the tumor  throughout all
the compartments (locules) of which it is made up, or to extirpate  it
entire.  An  hydatid cyst which existed in the iliac region was suc-
cessfully extirpated by M. McFarlane (Encyclop. des tic. Med., 1836,
p. 54), and M. Colson (Rev. Med.. 1827, t. IV., p. 33) found one of
this description between the bladder and the rectum.   Whether the
tumor in  this respect, in reality contain  hydatids,  or is- composed
purely of serous receptacles (vacuoles), the indication, notwithstand-
ing, will be the same.   It would  only be a loss of time  to attempt
the other  operative methods described farther  back, and  which,
besides their little efficacy, would expose to  real dangers.

       Article IV.—Synovial  Cysts (Nodus-Ganglions).

  Tumors known under the title of synovial  cysts, were formerly
designated by the name of ganglions or nodus, and it is these, which 
80           NEW ELEMENTS OF  OPERATIVE SURGERY.

people in general call thickened, knotted or twisted sinews, [nerfs foules,
noues or tordus—sometimes  "weeping sinews." T.]   Developing
themselves in the neighborhood  of the joints, or upon the track of
the tendons, these tumors rarely exceed the size of a  nut or  egg.
All of them  appear to consist of a sort  of cul-de-sac or  hernia, or
appendix to  the  natural synovial cavities, whose  neck (collet) had
been obliterated from some cause unknown.  They may be divided
into  two classes: 1.  Articular synovial cysts ;  and 2. Tendinous
synovial cysts.   Nothing, however, is  so  variable as the develop-
ment and progress of such tumors.  Moinichen mentions having seen
them  disappear on the approach  of parturition, and afterwards re-
assume  their primitive volume.  M. Champion mentions having seen
one which  shrunk for  several years successively, every two  years,
about spring-time ; but it appears in  this case, that the shrinking of
the cyst was owing to the  accumulation of the liquid  producing a
crevice.   We may conceive  that the disease then acts similarly in
fact to a hydrocele, which has been accidentally ruptured, and is soon
after reproduced.  As synovial cysts do not  ordinarily cause any
pain, many patients will carry them all their lives, without applying
any remedy or paying any attention to them.  I have seen a woman
fifty years  of age, who  had three of them  about the abductor and
extensor tendons of the thumb for more than twenty-five years.  I
have seen others at the dorsal region of the foot, about the  knee, and
on the track of the different tendons of the  hand, which had existed
to full  as great  a length of time, without the  persons who  were
afflicted with them, ever having thought of  applying any remedy to
them.   I should, in fact, add that many of these  cysts ultimately, in
the course of time, disappear spontaneously.  They are  not to be
attacked by surgical means therefore, unless by their volume or rela-
tions, they produce either deformity, inconvenience or pain, or func-
tional disturbance to such extent as to induce the patient to incur the
risk of the operation.

                     § I.—Various  Means.

  Nothing also, is more variable than the treatment  for this descrip-
tion of tumors.   M. Ch. H. (Encyclop. Method.,  t. XIII., p. 617, col.
2, 1832,) had a ganglion of the size  of a small nut,  on the  flexor
tendons of the left ring and middle fingers.  Having, in  vain, con-
sulted most of the distinguished physicians of Paris, the patient, who
put himself upon the use of the muriate of soda, of which he took from
two  to  three ounces a  day, in  this manner effected a radical cure.
Gilibert (Rousset, These de Strasburg,  1812, p. 6,) says he  has seen a
case of this kind in which satchels of plaster, or  leaves of lavender,
succeeded.   Frictions with  aromatic,  mercurial and  camphorated
mixtures, laurel oil, soap and water, saliva, resolvent plasters, hard and
repeated rubbings and baths of sulphur-water, equally appear to have
been followed by some successful results.   Dupuytren, according to
M. Bouboucki,  (These, Paris,  1828,  p. 25,) dispersed a synovial
ganglion in the ham, by  means of the simple douche.   But were it
allowable to make trial of such remedies, it would be puerile to count
on .their efficacy, unless in some very rare exceptions. 
CYSTS,  PROPERLY SO CALLED.
81
                 § II.—The Temporary Blister,
  Or even one that is permanent, would deserve infinitely more con-
fidence.  Jasger,  (Diet, de Chir., t.  I., p. 526,) who made use of
them for cysts at the knee, asserts that he obtained positive advan-
tages from them.  I have elsewhere published (Archiv. Gen. de Med.,
1826,)  the  case  of a  synovial cyst on the posterior region of the
wrist, which disappeared  under the action  of two large  blisters,
though it was of very ancient date, and  of the size of half an egg.
I have often succeeded with the same remedy since, in similar cases.
A lady, who had  one  of the  size of a large nut, on the  dorsum of
the foot, opposite  the calcaneo-cuboidal articulation, and who would
not hear to  an operation, was also cured  by means  of large tempo-
rary blisters and resolvent  frictions, and compression.   Though I
might  cite at least as many as  ten analogous facts, I ought, how-
ever, to remark that most  synovial cysts will not yield to this thera-
peutic.
                         §  III.—Moxa.
  Moxa. which has  already been  made  trial  of for a cyst of the
wrist by M. A. Severin, (Med. Efficace, p. 550, § 1998,) and which
M. Champion also says he has used with success in  a  patient who
would not submit to  any other means, would  not  probably be any
more effectual, and has too many inconveniences  in itself  ever to
become the favorite remedy for this disease.

                       § IV.—Caustics.

  Though the employment of caustics may have succeeded with F.
de Hilden (Centurie 3, obs. 79, or p. 72 ; obs. 44 of the French trans-
lation,) in curing  a synovial cyst of the carpus, and an arsenical ap
plication have been equally successful with Woolam, (Annal Muys-
kezas, t. III., p. 490, 1811,) such remedies, nevertheless, have in  all
epochs inspired the most vivid apprehensions.   Dalechamps (Chir.
Fran aise, p. 158, in-4° ; p.  910, in-8°, 1570,) relates that a patient,
with synovial cysts on the  dorsum of the hand, who  was  treated
for them by caustics, did not recover until after having experienced
very  severe inflammatory accidents.   It is moreover evident that
this kind of operation, would be exposed  to all the  consequences to
be apprehended from  a cutting instrument, without having  its ad-
vantages.    Their uncertainty and the deformed cicatrices which
they would necessarily produce, will  always be  sufficient to pro-
scribe their use with the generality of practitioners.

                      § V.—Compression.

  One of the remedies against synovial cysts which  has  been most
extolled is compression ; the ancient authors  had already  noticed it.
La  Vauguyon (Traite d'Operat., p.  627,) recommends  that it  be
made with a plate of lead, and that frictions be associated  with it.
This plate of lead, adjusted by a pelote and circular bandage, has
been proposed anew by Marigues and Testat. (Malad. Chir., 1786.)
Theden, the great admirer of compression, says that by means of
                              6 
82           NEW ELEMENTS OF  OPERATIVE SURGERY.

this, with lotions of the arquebusade water, he cured a synovial ganglion
in the space of six weeks.  New facts also in favor of this remedy have
been brought forward during the  course of the present century, by
M.  Balme (Dissert, an. X., p. 39,) and M. Godele, {Rev. Med., 1831,
t. I., p. 19.)   It is nevertheless true  that compression alone rarely
succeeds with synovial cysts, and that in order to obtain any cures
from it, it would be necessary to apply it with such force and to con-
tinue it so long a time, that in reality it scarcely deserves to be made
trial of except as an auxiliary to other operative methods.

                 § VI.—Crushing,  (ecrasement.)
  A more efficacious remedy, and one  which surgeons have in their
pride erroneously associated with the practice of vulgar people or
charlatans who itinerate about the country, is  that of crushing the
cyst.   This  remedy, which  at  first  sight appears so rude, had al-
ready been employed in the time of Philagrius, (Peyrilhe, Hist, de
la Chir., p.  702,) Chaumete, (Enchiridion  des  Chirurg., ch. 3, p.
122, 1560,) and Forestus, (Bonet, Corps de Med., t. HI.,  p. 60.)
Muys (Decad. 2, obs. 8, p. 127; Nouv. Obs. de Chir.,) armed with
a leaden palette, cured  in this manner  a cyst at the wrist, and sim-
ilar successes were obtained by Ledran (Consult, de Chir., p. 257,)
and by Godele (Rev. Med.,  1831, t. I., p.  17.)  I have, says M.
Champion, often crushed  ganglions in the palms of the hands, by
means of the thumbs crossed, or  by  a single thumb ;  but there is  a
good number of them that will not yield to this kind of pressure.
This practitioner, who agrees in  this with Heller that crushing is
very uncertain, almost  always uses a  mallet and a piece of paste-
board cut in  the form of a  shovel.   A single  stroke properly ap-
plied ordinarily answers  in such  cases.  This compression  [rather
percussion, T.] astonishes much more than it does harm.'  On the
carpus and the tarsus  it has never,  says  M. Champion, failed.  A
man who swooned away immediately after the stroke, confessed sub-
sequently that it was from fear.   This process, which the rebouteurs
(rebouteurs) and peasants have employed from time immemorial to
untie the tendons, requires that we should place the limb  upon a
solid support while making the stroke with the mallet, and that the
cyst should afterwards be properly compressed during some fifteen
days.  I  have often  in my boyhood, seen peasants in the country
strike the fist  violently upon the wrist, and in this manner cure sy-
novial  cysts  of the  hand.  I have seen others  who  did  the same
thing on the foot, and I should add, that unless there be a very con-
siderable degree of muscular force exerted, we fail in most instances
when we attempt to crush by the  thumbs alone.   This crushing [or
sudden rupturing or  bursting of the  sac, T.] is in short an  opera-
tion to  be made trial of.   It is, however, exposed to  two inconve-
niences ; sometimes there results from it an inflammation sufficiently
acute, and I  have seen three patients  in whom it was  attended with
such accidents, that a vast suppuration was established in the limb,
and their life  for a long time kept  in jeopardy.
  When every thing goes on naturally, the tumor retains a great
tendency to  be reproduced; more than half of the synovial cysts
which I have treated, or caused to be treated  in  this  manner, have 
CYSTS, PROPERLY SO CALLED.
83
returned at the end of some weeks, or  some months.  We should,
however, render success more certain by associating with this remedy
repeated temporary blistering, resolvent frictions, and compression
for a long time continued.
   [We refer the reader for the advocacy we have made of this in-
valuable resource of sudden and powerful percussion, to what we
have said above of these bursal cavities or cysts, when they contain
other than  pure synovial  fluid—to which the  author here  confines
himself.  Also to our remarks  in  Vol.  I., and also infra, on  the
same mode of treatment.   The cases in which we have used it, and
we never employed any other remedy, were of the character of sy-
novial  cysts proper, in their normal state, so far  as they were  un-
changed in structure and containing their normal sero-synovial  fluid,
only accumulated in abnormal quantity, therefore literally, as by the
vulgar name, a  weeping ganglion.  In  every case  the blow made
with great rapidity and force,  by a heavy book held in both my
hands, and at the height of two feet above the tumor as the  limb
lay firmly stretched on the table, I succeeded in perfectly and  radi-
cally curing the  disease, in an  instant.   The tumor entirely disap-
pears under the blow which crushes it, so that the  deformity,  as if
by magic, leaves thus the smooth natural plain surface of the  skin.
In one of the  cases at the  olecranon, where it appeared  somewhat
bosselated,  the  disease  returned partially in  a few weeks, but a
second blow completed  its extinction.   In a very recent case, the
tumor being of the size of a small nut and on  the ulnar side of the
dorsal surface of the radius, about two inches  above  the wrist,
(caused in  a stout young Irish porter from lifting heavy trunks,) and
resting, in fact, partly on the interosseous space, I was enabled, by
proper  pronation, to bring the tumor on to the  edge of the  radius,
and by this means procure a solid osseous point d'appui.  I would
recommend this course of pushing the tumor where it can be done,
on to a bony plane, before the blow is struck.  This I advert to, be-
cause I believe it  practicable, in most instances, on the dorsal surface
of the metacarpus, where the tumor lies on an interosseous space.
In one such case I recommended it to a very bold practitioner, who
nevertheless pursued his own course, opened the sac and caused a
severe, if not dangerous inflammation.  In striking the blow, it  must
be done with a good deal of force and with a heavy  quarto book for
example.   In the cases of our author, whenever the disease returned,
he was perhaps  too sparing in this respect, towards  his patients.
This beautiful illustration of sub-cutaneous or sub-muscular, or  even
sub-aponeurotic surgery, (for I should consider a synovial tumor be-
neath an aponeurosis, provided  the turnor could be made to rest on
bone, equally curable by this mode,) excludes effectually every other
treatment, and for myself, I  never saw the slightest  accident super-
vene from  it.   Nor  have I found the least degree  of  compression
necessary after the ecrasement. T.]

                 § VII. Sub-cutaneous Puncture.
  Some surgeons, having confidence in the rupture  of the sac, and
experiencing some difficulties in effecting it, have proposed to intro-
duce obliquely under the skin a cataract needle, and thus puncture 
84           NEW ELEMENTS OF OPERATIVE  SURGERY.

the little synovial pouch so as to allow of expelling its contents and
forcing them to become infiltrated into the neighboring cellular tissue.
M. Cumin,  (Journ. Univ. des. Sc. Med.;  Journ. Analytique,  t.  I., p.
367, Nov. 1827 ; Bull, de Ferussac, t. XIV., p. 225; Arch. Gen. de
Med., t. XIV., p. 252,) who appears to have been one of the  first to
suggest this operation, recommends with reason, that  we  should
make use of compression also after having emptied the sac.  I  have
attacked  in this manner a synovial cyst  on the dorsum of the  foot,
another which was situated in front of the malleolus externus, and
similar tumors on the back of the hand and wrist, without ever  hav-
ing obtained a single radical cure.  The tumor was emptied and the
sub-cutaneous  layer  of the neighborhood became slightly cedema-
tous;  but the cyst soon filled again and  the  disease  reappeared  as
before, whatever M. Roberts (Journ. des Progres, t. XII., p. 258;
Rev. Med., 1829, t. I., p. 299)  may say on this point.   To  obtain
any favorable results from this means therefore, it would be  neces-
sary to associate with it not only compression, but also  temporary
blistering and resolvent frictions.

                         § VII.—-Seton.
  Puncture, and the* abstraction of the liquid by means of a syringe
or gum-elastic bottle, as recommended by Monro (Ancien Journ. de
Med., t. LXXIX., p.  138,) would be at the same time more difficult
and also still more uncertain.  The seton, wrhich has been employed
by quite  a  great number of practitioners, and  which is  mentioned
by M. Ch.  L. (Encyclop. Meth., t.  XIII., p. 618,)  and also by M.
Cooper, is considered by others  (Journ. de Med., t. V.) as calculated
to induce a  cancerous degenerescence of the ganglion.  At the
present time the seton might  be made  trial of under a  form  less
dangerous.  One, two, three or  four simple threads passed through
the tumor, as  has  been said of Erectile Tumors  and  Varices, and
withdrawn after the  lapse of some days, would probably be suffi-
cient to create a moderate degree of inflammation in the cyst, and
to effect its resolution.  But how could we then avoid one of two in-
conveniences, a purulent inflammation which would not be unattended
with danger, or  too  slight a degree of irritation, which would  pre-
vent our succeeding ?  Without, therefore, absolutely condemning
this remedy, we  ought not to repose too  much confidence in it.

                  § IX.—Irritating Injections.
   Irritating injections, though made use of by some practitioners,
have, however, always excited  some apprehensions  when about to
be employed for synovial cysts.  The inflammation which it  is pro-
posed to excite by them, has been considered  dangerous, in conse-
quence of the neighborhood  of the articulations.   It is  true  that
some accidents have resulted from them; that  a woman on whom
they were used and who came to the hospital of the Faculty in  1824,
was seized with all the symptoms  of  a  phlegmonous erysipelas  on
the dorsum of the hand, where the cyst  was situated, and on a por-
tion of the dorsal region of the fore-arm; but, I do not think that the
subject has been sufficiently examined.   The synovial cysts  are  le-
gitimate serous cavities ;  [see note infra,  where the propriety of thus 
CYSTS,  PROPERLY SO CALLED.
85
giving the name serous rather than mucous to the various  burses, is
well sustained.  T.]  Every thing leads to the conclusion that an
irritating liquid would produce  an adhesive inflammation there, as
in the tunica vaginalis.  Provided  this injection was made  through
a simple puncture, and not pushed to the extent  of tearing (erailler)
the cyst, and of becoming infiltrated into the cellular  tissue of the
neighborhood, we cannot see what evil  consequences  would  result
from it.  The phlegmasia thus  produced under the skin, should it
extend even to the articulations, is not comparable to ordinary in-
flammations, or such a£ are produced by the action of  some internal
cause or external violence.  Perhaps, also, the irritating injections
have sometimes been  followed by unpleasant consequences, because
of the quantity or nature of the liquid made use of.   Certain it is,
that the  tincture of iodine,  which may be introduced in moderate
proportions into every serous cavity, and which seems to bave the
power of infiltrating itself, at least partially, into the cellular  tissue,
without producing gangrene, has hitherto  enabled me to obtain a
number of cures which, by their simplicity, have been moreover of
the most  encouraging description.
   A man aged from 30 to 35 years, had on the dorsal surface  of the
tarsus a synovial cyst of half the bigness of an  egg; I punctured it
and drew out about two  spoonfuls of a serous liquid.  Two  gros of
tincture  of iodine  diluted, were injected in their  place, and  every
thing went on with the same simplicity as in the  operation for hydro-
cele.  The same  operation  performed twice on ganglions of the
wrist, once below the external malleolus, and in another instance on
the dorsum of the hand,  have been followed with the same satisfac-
ry results.  I have seen  it fail, however, in a man who had a syno-
vial ganglion on the dorsal surface of the foot; but here the cyst was
filled with gelatinous  matter, and the injection caused no  appearance
of inflammation  or  reaction.   In  conclusion,  therefore,  it  would
seem, that irritating injections,, and  especially tincture of iodine,
should be employed wherever the cyst is of a certain volume, and is
 found filled with matters purely serous.   I would remark only, that
they should be punctured with a small trochar, and not with the bis-
toury, and that a certain quantity of the tincture of iodine injected
should be left in their interior.

                         § X.—Incision.
   Like all other cysts, synovial  ganglions may be treated by simple
incision.   Fabricius  ab  Aquapendente  had already obtained cures
by this operation, which is also extolled by Portal (Hist. Anat., t.  II.,
p. 227)  and Schmucker (Bibl.  Ch. du Nord, p. 21.)   Nevertheless,
practitioners of the present day do not resort to it but with repugnance.
All the  dangers imputed to irritating injections,  are equally applica-
ble to this.  It produces, in  fact, one of two things : either the small
wound immediately shuts up without causing inflammation, and then
the tumor soon reappears,  or the interior  of the ganglion becomes
inflamed and is transformed into abscesses, and in  this  case we have
reason to fear the  extension of the phlegmasia under the form of
phlegmonous  erysipelas to  the  sub-cutaneous cellular tissue  of the
neighborhood, and even to the articulations that are situated nearest 
86
NEW ELEMENTS OF OPERATIVE SURGERY.
 to the tumor.   The force of these objections cannot  be denied, and
 in this respect the incision is certainly more dangerous, without being
 more efficacious, than irritating injections.  Without inflammation it
 cannot succeed ; with  inflammation  it causes pus, and purulent  in-
 flammation, in the vicinity of the articular synovial cavities, is always
 a  formidable  phenomenon.  I would not,  therefore,  employ  this
 means but for synovial cysts of a small volume, and for those which
 in place of matters  purely serous, are filled with substances  of a
 gelatinous  (gelatiniforme) and semi-concrete character.  I neverthe-
 less admit, that the simple incision sometimes succeeds, and that it is
 far from being always  attended with  the dangers of which I have
 just spoken.   As for the rest, I should prefer, should I decide upon
 it, to divide the tumor through and through, rather than limit myself
 to incising it only on one of its points.

                      § XI.—Extirpation.
   The remedy which has the greatest certainty, and which in every
 epoch has engaged the attention of practitioners, is extirpation.  There
 is no doubt in fact that it is the most positive resource, and which
 precludes all chance of a return of the disease when applied to syno-
 vial ganglions.  Unfortunately it is  a remedy which alarms most
 patients, one also whose employment is not always devoid of diffi-
 culties and which may involve serious dangers.  Thus to  extirpate
 a cyst of this description, it is necessary to lay it bare by a simple,
 a semilunar, a T, or a crucial incision, then to go through a delicate
 dissection in order to isolate it from the organs which surround  it,
 and thus remove it entire.  The operation may in consequence be
 long, painful and sufficiently laborious.  There results from it, more-
 over,  a considerably large wound, whose suppuration it is  often im-
 possible to prevent.  Finally, by operating in.this manner we run the
 risk of opening  into  the  synovial and articular  capsules,  and thus
 paving the way for  the  introduction of purulent  phlegmasia  even
into the interior of the joints.  It is nevertheless true that the dangers
of this extirpation have been greatly exaggerated.  I have performed
it four times on the dorsum of the foot for ganglions which were of
the dimensions of the thumb in diameter, a French chesnut, (marron,)
a large nut or the half of an egg.  The cure in three of my patients
was speedily accomplished.  The fourth, who was a young girl of
nineteen years of age, continued to be threatened with a phlegmonous
erysipelas during the space of a week ; but sanguineous emissions and
topical emollients put a term to the accidents, and the  cure  notwith-
standing was completed at  the  expiration of three weeks.   I  have
removed similar cysts from the inner as well as the outer side of the
knee.   I have extirpated one also which was situated immediately
above the head of the fibula.  I have treated them many times in the
same way on the dorsum of the carpus and metacarpus, and out of
twelve or fifteen operations of this kind which I could euumerate at
the present day, there is not one of them that compromised the life of
the patient.  After the example of Celsus and Paul of Egina, so also
have Warner, Gooch, Eller, Schmucker, (S. Cooper, Dictionary, 1.1.,
p. 526,) and Heister, (Theses de Holier, t. V.,p. 262, French translation,)
related successes obtained by means of extirpation, an operation which 
CYSTS,  PRORERLY SO CALLED.
87
 Chaumete, (Enchiridion, etc., p. 123,) and Friesse, (Theses de Haller,
 t. V., p. 243, French translation,) equally eulogize.  In 1800, says M.
 Champion, when I was studying medicine, I extirpated in a young co-
 quettish woman, a ganglion of the size of an almond, situated on the ex-
 tensor tendon of the middle finger of the left hand.  An inflammation
 supervened and gave rise to three abscesses.  After the cure the young
 lady retained a stiffness in the movements of the hand, and this lesson
 has taught me not to repeat the operation.  Nevertheless, a young phy-
 sician of my acquaintance,  adds the same practitioner, has extirpated
 one of less size, also situated on the metacarpus, and which I refused to
 operate upon, preferring to wait until it should become larger that I
 might burst the cyst;  but no accident followed the  operation.  Sy-
 novial cysts situated on  the thumb, carpus and tarsus, have  also  been
 removed without danger by M. PI. Portal, (Clinica Chir., pp. 298,
 301, 303, 307.)   I would however remark, that I now regard it su-
 perfluous to dissect such tumors with so much care; that I arrive at
 the same result with infinitely less difficulty or pain to the patient by
 confining myself to opening or cutting freely into the whole sac, which
 I immediately fill with balls  of lint to induce it to  suppurate, and af-
• terwards treat it in every respect as an abscess.   The  operation is
 then remarkably simple, and  I  have satisfied  myself that it will
 obtain  a cure as  prompt  and  certain as extirpatiPn of the cyst,  pro-
 perly so called.  As to the ligature, ft is unnecessary to repeat that
 pediculated synovial cysts only would allow of its employment, and
 that it would  expose to more pain and danger than any of the  ope-
 rations which have  been  described, especially the irritating injections.
 without being attended  either with their advantages or simplicity.

                      §  XII.—Recapitulation.
   To sum up, therefore,  synovial ganglions when  it  is deemed advi-
 sable to attack them  seriously, should be treated by topical resol-
 vents when they are still recent; by  temporary blisters when  they
 are already of ancient date; by permanent compression where the
 blister  and dissolving  pomades are without effect; by crushing  with
 the thumb or  mallet where ordinary compression  does  not suffice;
 by  sub-cutaneous puncture  where  crushing is unavailing  or inap-
 plicable;  by iodine  injections, by preference wherever  they are
 practicable ; and by large  openings or the complete incision in cases
 that are most  obstinate or complicated.  So that I reject as useless or
 dangerous,  extirpation,  simple incision,  caustics,  the ligature, and
 even vinous injections.

                   Article  V.—Osseous Cysts.

   We find in  the annals  of science some cases of  tumors composed
 of osseous shells, in other  respects  independent of the bones and
 periosteum, and  containing  matters  sometimes concrete, at other
 times liquid.   I have  met  with these tumors on the  breast, scrotum
 and shoulder, on the  parietes of the  thorax, certain regions of the
 cranium, and  on  the face and limbs.   M. Tassery (Annates du De-
 partment de VEure, pp.  219, 220, 1810,) speaks of a cyst with osse-
 ous  walls, which was situated on  the hand,  and which contained 
88
NEW ELEMENTS OF OPERATIVE SURGERY.
about two pounds of cartilaginous substance, and  the  exsection of
which was effectually accomplished by means of a saw.  The osteo-
fibrous tumor removed from  the cheek of a  young  man  by M.
D.  Lasserve (Cas de  Chir., &c, p. 27), caused  the wounding  of
the canal of Stenon, and appears to have originated in the salivary
duct.   M. D. Lasserve {Ibid., p. 41, fig. 4) has also given the figure
of an osseous tumor which was as large as an egg, and while dis-
connected with  the  osseous system,  occupied the middle  of the
upper lip of a young man aged twenty-five years.  It will be how-
ever when  treating of tumors of the  face  and breast, that  I  shall
speak of the  operations applicable to  this description  of cysts.   I
will remark here only in respect to general rules, that excision and
extirpation  are the only operations applicable to such tumors; and
that we ought consequently to proceed in the same manner for  their
removal as for the extirpation of a lipoma, lymphatic tumor, neuroma
or hematic tumor.  It is moreover obvious^ that topical applications,
the seton, compression, injections, and  excisions, properly so  called,
could  have no chance of success, and that before every other consid-
eration the osseous or osteiform  plates should  be removed in their
totality, if we expect to obtain a radical cure  in patients who have,
these osseous cysts.
  [One of the most  remarkable osseous formations but not  of this
description,  occurred in an old man aged about 75, a sailor, of tall
and robust form, and  a patient at the Seamen's Retreat while I  con-
ducted that  establishment.   He was of intemperate habits, and the
result of his  indulgence in  this  respect  was one of those old  rum
legs or extensive cedematous ulcers on the calf and below, which
served as a drain to his  plethoric  condition.  In a  fit of depression
of mind  he  threw himself  from  the -piazza of the third  story of
the hospital,  and thus caused immediate death.  In the dissection,
besides various extravasations which it caused in the brain, every rib
on one side was fractured, and on examining the diaphragm we found
in its substance near the centre, a  circular osseous plate precisely of
the size and  thickness and  shape of a  dollar, which lay in the same
horizontal plane  with  the diaphragm and in the midst of its  tissue,
as if inserted or  sewn into that  part.  It did not appear during life
that this  formation had  in the  least interfered with the respiratory
functions. T.]

              [CARTILAGINOUS  AND OSSEOUS TUMORS.

  Mediastinal Tumors—Carcinomato-cartilaginous  Tumors.—An
extraordinary case of  this  kind,  and  of which the specimens are
preserved by Mr. Adams, and  were by him laid before the  Patho-
logical Society  of Dublin,  occurred in  the practice  of Dr.  Cullen
of that city, in 1839  (see Dublin  Review, 1840), in a woman aged
40, who  had been married two  years  but was without children.
She had had for some time great difficulty of respiration, with vio-
lent but  dry cough,  and  especially  paroxysms of  suffocation  at
night.  The bruits of the  chest were normal.   The  left hand and
face were cedematous, and the  veins of the  neck and face livid and
distended during the violent paroxysms of coughing.  In three  or 
                   CYSTS, PROPERLY SO CALLED.                89

four weeks  the left arm, and then the right, and finally the lower
limbs also became  cedematous.   Finally, she was obliged to sit up
constantly to get breath, and the neck began to swell enormously
and to become inflamed immediately above the sternum.  Death soon
followed, when  there was found in the situation of the thymus, in
the anterior mediastinum, an oval whitish tumor near three inches
long, of a carcinomatous structure, and in some places cartilaginous
and cerebriform ,which tumor inclined  at its  largest extremity to the
left, and was adherent in part to the trachea and arch of the aorta.
The  inclination  of the tumor to  the  left causing it  to press on the
vessels of the neck and shoulder on that side, explained why the
oedema was greatest  in that region.   The  heart, aorta and  pulmo-
nary artery were sound; also  the  air passages and lungs, except
that the latter were emphysematous, no  doubt  from the continued
violent  paroxysms  of coughing.  This instructive case shows the
importance  of tumors in the thorax as connected with the difficulty
of diagnosing substernal  and thoracic  aneurisms  and pulmonary
disease.
   A still more remarkable case of tumor in the anterior mediastinum
was published the same year as having occurred in the practice of Dr.
J. M. Neligan, (Edinb. Med. and Surg.  Journ., April, 1840,) in a man
aged 21, who in April, 1838, was attacked with  difficulty of respira-
tion, cough  without expectoration, slight pain in the chest, &c, as in
the above case.   Finally, a  tumor showed itself above the sternum,
and the symptoms became aggravated,  with orthopnea, swollen veins
of the face and neck, suffocating paroxysms, and cold extremities, end-
ing in death in less than a month from the attack.  The lungs, bronchi,
and trachea, were, so to speak, perfectly sound, and  also the heart
and its vessels, and  some transparent liquid  was found in  the pleu-
ral cavities.   We perceive the thoracic viscera were sound, notwith-
standing the tumor had the enormous magnitude  of 14 inches in
length and  4j inches  in breadth, and  had filled the  entire anterior
mediastinum, with firm adhesions in front to the posterior  side of
the sternum, and behind to the pleura and pericardium, while above
it crowded the thyroid gland upwards and, had even contracted firm
adhesions also as far down as  with the  diaphragm  below, and had
extended laterally  on each side^to  the  articulations of  the carti-
lages with  the ribs.  This case still more  strongly  points out  the
importance  of close discrimination in diagnosing morbid structures
in the thoracic cavity.
   Cartilaginous Tumors of the Face and Scalp.—But one of the most
singular complications of tumors perhaps on record, is that of an un-
married woman, aged 52, as related by Mr. Ancell (Medico- Chirur-
gical Transactions, vol. XXV., London,  1842, 8vo.   See also Brit-
ish and  Foreign Medical Review, Jan. to April, 1843, vol. XV., p.
153, 154.)   The  disease first appeared when  she was  14 or 15 years
of age, and  the greater part of her face  and scalp was loaded with
solid tumors of different sizes.   Those  on the scalp externally were
of a very florid  color, smooth, glassy, and denuded of hair, and va-
ried in shape from a nearly globular, to an irregular,  flattened sphe-
roidal form;  among them were  a few perfectly round and of a vio-
let  hue.  Some  were  sessile on broad bases, others suspended by 
90
NE1V ELEMENTS OF OPERATIVE SURGERY.
short thick peduncles.   One of these latter was removed, and when
divided showed a smooth shining semi-transparent texture of a very
pale pinkish hue  and of a nearly cartilaginous consistence.   It ap-
peared homogeneous except for a few  vessels ramifying through it.
The investing skin was much more  vascular.   Among those on the
face were interspersed also a number  of lenticular tubercles aris-
ing from  hypertrophy of the dermis, and some  also smaller which
were  follicular  elevations.  The tumors sometimes itched and were
painful when pinched, but were generally free from uneasiness.  At
one time  a  few were extirpated, and  subsequently Mr. Bryant re-
moved sixty at one sitting !  They were then not cartilaginous and
could  easily be  enucleated.  Within  twelve months from the opera-
tion they were  all reproduced.  This most singular disease invaded
finally the viscera, and a large tumor  appeared to have formed in the
abdomen, which was followed by ascites, anasarca  of the  lower ex-
tremities,  and death.  On examining the body the peritoneum was
found opaque, but with a shining surface.  " The parietal portion (says
the account) and the lining of the diaphragm were studded with my-
riads  of tumors of various sizes."   The fat of the great omentum
was almost entirely absorbed, and its  tissue sprinkled over with num-
berless granules.  A large mass weighing almost  two pounds was
suspended from the  anterior edge of the liver; it extended beneath
the right lobe, displacing and depressing the gall bladder.   It was of
ovoid and irregular form, and  of very  firm texture.  On dividing it
the tints of the  cut surface were extremely varied, green and green-
ish yellow predominating, while the centre was nearly white and al-
most  cartilaginous, and exhibited radiating fibres  and lobules of an
indistinct  cystiform aspect.  Blood  oozed on pressure from a good
many red points, but the tumor could not be called highly vascular.
The disease appears to have been hereditary, but was confined to the
females of the family, who were also remarkably prolific.   A pullu-
lating diathesis  and  tendency to  fibro-cartilaginous growths appears
to have pervaded the entire organism.
   Mr. Goodsir  (Cormack's Lond. and Edinb. Monthly Journal, &c.
Feb.  1843, p.   171,)  has  removed from the compact bone  of the
shaft of the humerus on its outer side, an enchondromatous tumor of
the size of a billiard  ball, which was  lobulated and of compact car-
tilaginous texture  externally, and had  internally masses of exceed-
ingly  hard bone, imbedded in soft cartilage.  It bore the appearance
of similar enchondromatous  masses  found in the phalanges of  the
fingers.  T.]

  [GANGLIONIC,  SEROUS,  AND  SYNOVIAL TUMORS AND CYSTS--BURSiB
             MUCOSAE ET  SEROSA--IODINE INJECTIONS.

   Encysted Hydropic Tumors between the duplicatures  of the
Peritoneum cured by Iodine Injections.—Not only has  the success-
ful treatment by iodine injections,  as  established  by M. Velpeau,
been  generally  adopted in Europe   for synovial tumors or  hydro-
cele, but  also,  so  long as six years since,  was boldly applied by
M. G. Pagani,  Surgeon-in-Chief of the Hospital of Novarre in Italy,
(see Annali Universali  di  Medicina,  Fasci  290, An-osto,  1841, 
CYSTS, PROPERLY SO CALLED.
91
also Journ. des  Connaiss., &c, de Paris, Fevrier,  1842,  p. 84,) to
hydropic  encysted collections, which  apparently existed between
the duplicatures of the peritoneum in the hypogastric region.  The
case in question was that of a man from the country, aged about
thirty-two, in whom a rheumatic fever of short duration and  accom-
panied by much dysuria, and  finally a sort of dysentery, was soon
succeeded, in spite of copious bleedings, purgatives, &c, by the rapid
formation of a large encysted tumor in  the hypogastric region.  An
exploration by the  cataract needle and trochar enabled the surgeon
to draw off a small quantity of fluid very similar to that of ganglionic
capsules,  [i. e. bursas mucosas, or more properly bursal  serosa, see
remarks  of M. Petrequin under this head, infra, T.] which with an
examination  per anum, and the introduction of the catheter into the
bladder,  and  evacuation  of  its urine, led to the diagnosis that the
tumor was circumscribed  by the enormously distended layers  of peri-
toneum where it is reflected on the posterior part of  the bladder and
anterior portion  of the rectum.  The surgeon accordingly, keeping in
view the analogy of tissues to the tunica vaginalis, and the cures he
had obtained by injection  of the alcoholic tincture of iodine in hydro-
cele, introduced into the  abdominal cavity in question, by means of
the canula and syringe, through the puncture he had previously made,
two fingers' breadth above the pubis, and two inches  to the left of the
linea alba, a diluted preparation of the same material.   A very mode-
rate degree of  warmth and  reaction was felt by the patient,  and in
five days the tumor had entirely disappeared, followed shortly after by
the cure of the dysenteric affection and perfect restoration of health.
It would  be worth while  to  ascertain how far this  treatment could
be employed with utility in ordinary ascites, ovarian dropsy, &c.  We
have already spoken of it  (see Vol. I. and the present vol.) as success-
fully employed in the mouth of the sac in reducible hernia, after the
taxis.
   M. Petrequin  of  Lyons, in an article on synovial  tumors,  (Journ.
des Connaiss.,  &c,  de Paris, Juillet, 1842,  p. 10, et sequ.) in pass-
ing a compliment  on the labors  of MM. Monro,  Brodie, Ollivier,
Lenoir and Velpeau, disapproves  the phrase bursa  mucosa  as alto-
gether capricious  and erroneous.   These tumors occupy serous, not
mucous capsules, and he has marked their whole progress, from their
inception as simple hydropical collections, through the  several suc-
cessive stages of sub-acute inflammation, hematocele, abscess, ulcera-
tion,  chronic  induration,  &c.  M. Petrequin reverts to a treatise he
had published many years since,  that on exsections  of the lower ex-
tremity,  and again enforces  the  necessity of early exsection of the
great trochanter, and saving of the leg before the exfoliation caused
in that process, by inflammation and improper treatment  or opening
of the sub-cutaneous bursa situated over that prominence, shall have
involved the coxo-femoral articulation;  for lesions of which last there
is reason to believe these  implications of the trochanter from  the dis-
ease in the superposed bursa, are too often mistaken.   The more im-
portant does this advice become, because the affectiqn of the trochan-
ter produced in the manner mentioned, may extend to the joint itself.
  In ante-patellar  bursas, (hygroma prerotulien,)  M. Petrequin has
seen one  of four inches  diameter in the direction of the axis of  the 
92
NEW ELEMENTS OF  OPERATIVE SURGERY.
limb,  and three inches laterally,  which had existed two years,  and
which Dupuytren  himself had in vain endeavored to  cure.  These
bursal tumors often result from traumatic contusions, and then con-
tain bloody, grumous, and sometimes fibrinous matter, which latter
M. Petrequin considers the original cause (or nuclei) of foreign bodies
about the joint, i. e. spontaneous or amphi-articular bodies.
  These tumors, arrived at this condition, communicate, on pressing
them, a sensation  of movement,  (fremissement,)  leading to the idea
of the existence of semi-cartilaginous corpuscles or of hydatids rub-
bing against each other, all which can be explained by the existence
of fibrinous concretions, or the crushing together of sanguineous clots.
(See M. Velpeau's  remarks on these bloody tumors sup. and in Vol. I.)
He places, erroneously, as we think, some reliance  on resolvents,
(such as muriate of ammonia,) and on compression, &c.; but where
these fail, he has  found, like M.  Velpeau,  a cure effected by iodine
injections, and should the contents of the sac be solid, an incision be-
comes necessary.
  M. Petrequin errs also, as  we know from  experience,  both in
olecranian and  ante-patellar bursas, (see in this note below, and also
sup. and Vol. I.) in supposing that bursting them by strong percussion
will not succeed if they have existed over a year.   It is the remedy, as
we conceive, par excellence, and next to that comes iodine injecf ions.
  He remarks, with  great appearance of sound practical reflection,
that such ante-patellar hygromas, when they suppurate and infiltrate
into the neighboring tissues, might well give rise, by the tumefaction
they produce, to the supposition of an inflammation and effusion into
the tibio-femoral articulation.
  These sub-cutaneous, cellulous, serous bursa,  as M.  Petrequin
properly considers synovial bursas, so called,  are found, or may in
fact  be accidentally  produced over all osseous prominences where
there is much traction and friction of the superincumbent tissues, par-
ticularly therefore, it might be added, near the articulations.   He has
seen them at the inner malleolus also, becoming ulcerated and form-
ing there  pseudo-mucous  fistulas, like those which may result from
abscesses.   Such are cases in point for the iodine injections.
  Besides tibial bursa, as those  on the internal malleolus  may be
called, M. Petrequin  has seen also fibular bursas, i. e. on the outer
malleolus.  In cases like one he saw, and which resulted in caries to
the fibular extremity, he properly recommends exsection of this part,
which can readily be done  without implicating the joint.  These
fibular bursas are  not uncommon among tailors,  from their habitual
position while at work making pressure on the outer  ankles.
  M. Sedillot speaks of calcanean bursa (i. e. at the heel.) as new,
or at least as hitherto undescribed by authors.   That they have long
been  familiarly  known, is an undoubted fact, but  in most cases pro-
bably confounded  with corns, to  which  they bear a resemblance at
first.   M. Petrequin has  described them in his usual clear and con-
densed  manner.   The epiderm forms a blister or  phlyctena,  and the
subdermoid tissue  is thickened like a large flat callosity or corn, and
separated from the  parts  below.   From this space oozes a serous
watery discharge, the parts  becoming more and  more inflamed and
exceedingly sore and troublesome.  He says ulcerations and impli- 
CYSTS,  PROPERLY SO CALLED.
93
cations of the os calcis might ensue if such cases were neglected.
Tight boots are the common cause, and the bursa is probably then
an accidental production.
  A very similar affection, which  is not uncommon, (and which  I
have several times seen under the great toe,) explains, M. Petrequin
remarks, the existence of a sub-metatarso-phalangeal bursa in this
part.  This I  treat by poulticing at first, and  after the reduction
of  the inflammation, careful excision  horizontally  of  the  horny
plates down to the sound parts, when a strap or two of adhesive
plaster firmly bound round the toe and foot inclusive, readily com-
pletes the cure.
  M. Petrequin  has seen a bursa similarly situated under the little
toe, and considers also that a  bursa exists under the heel,  also on the
lateral portion of the  metatarsophalangeal articulation of the  great
toe, where  he has  seen them cause much  pain and inflammation,
ending in suppuration, and passing thence  into chronic  induration
of the capsular walls, giving the appearance of an enlargement of the
extremity of the metatarsal bone.  These also, we think, are some-
times mistaken for  corny  callosities; though most probably a  great
number of  corns or callosities so called, about the small joints of the
toes particularly, are in reality enlarged  bursas, from pressure of
tight shoes, and therefore more common in females.  The lateral bursas
at the toe go by the name of ognons in France, (see Vol.  I. and Vol.
II., under Corns, &c.)  Soft Corns, so called in this country, and which
form between the toes near  their commissure, and which from their
position become less frequently indurated, are also probably natural
or  accidental bursas, inflamed by tight shoes.
   M. Petrequin  has seen an inflamed encysted lateral  metatarso-
phalangeal bursa on  the great toe in a man, acquire the size  of an
egg.  It was red and fluctuating, and seemed to involve the natural
bursa which exists  above, and the one  also below the articulation.
On opening it pus and blood were discharged, after which a cure was
effected by iodine injections.   In one case the matter evacuated was
gelatinous.
   We do  not wonder that  M. Malgaigne, (see 4th edition  of his
Manuel de Med. Operat., Paris, 1843, p. 113,) could, not  succeed by
Sabatier's inefficient  mode of rupturing these bursas, by slow pres-
sure of one thumb over another.   Sudden and strong percussion, as
with a bound book, noticed by M. Malgaigne, is the  only sure  mode
of  making this process successful. (See our remarks infra; also on
the same subject in Vol. I. of this work.)   Certainly this mode could
not succeed where there is no point d'appui, as when these tumors,
according to M. Malgaigne,  are found, (though extremely rare,) be-
tween the os hyoides and thyroid cartilage. Where they are met with,
however, on  the dorsal surface of the  hand over the interosseous
space, between the metacarpal bones,  as  we  have  said above,  it
would not even then be difficult, as  it appears to us, to crowd them on
to the adjacent metacarpal bones, and burst them in this  position.
  M. Malgaigne's own process in fact is nothing more than the sub-
cutaneous  principle  of M. Guerin, and  M. Goyrand of Aix, &c. ;
i. e., he draws the bursa forcibly to one direction, makes a small sub-
cutaneous puncture into one  extremity of the sac, evacuates the sy- 
94
NEW ELEMENTS OF OPERATIVE SURGERY.
novia or small cartilaginous bodies if they  exist, and  then with the
blade of the instrument sub-cutaneously breaks down effectually the
walls of the bursa, after which he makes for 10 or 15  days strong
pressure with flat pieces of agaric and thick compressions, (loc. cit.,
p.  113,  114.)  This  process  may undoubtedly answer where per-
cussion  fails.
  In encysted tumors, developed in the cellular tissue, containing
collections of serosity or other liquids of greater consistency, as pus,
&c, M. Recamier is in the practice (op. cit. Malgaigne's Manuel de
Med Operat., 4th edition, Paris, 1843, p. 113) of evacuating a portion
of the pus, &.c, little by little, and replacing this portion by injection
of warm water,  until the walls  collapse  and adhere,  in the same
way as  he does for abscesses  by congestion.
  M. P. J.-Cabaret of Saint Malo, (France,) in a memoir  on bursas
mucosas, (Journal des Connaissances Medico-Chirurg., Paris, Juin,
1844, p. 224—228,) after noticing the almost total neglect which had
been evinced towards them until the time  of Beclard, (Additions a
VAnatomie de Bichat, 1821,) states that these bursas form a roundish
(obronde) cavity, divided by imperfect septa, (coloisons incompletes,)
but without any  opening ; that in their texture they appear to be
membranes, differing  only from cellular tissue by being more  con-
densed  and composed of large laminae  (en grandes lames); their
evident  design  being [like cushions  or  pulleys,  T.] to give greater
ease to the movements of the  bones under the skin.  For which pur-
pose their homogeneous smooth surface is slightly bedewed with an
unctuous mucilaginous liquid.   Most anatomists concur in the opinion
that they are less  numerous in  children  than in  adults, because
their  development depends on muscular movements.   M. Velpeau
has noticed them on both  sides of the spine, on the  malleoli, and on
the outer, posterior, and  middle  part of  the thigh.   I have  seen
them also in one case (the result  of syphilis) directly over or upon
both the great trochanters, easily movable, elastic, somewhat pain-
ful, elliptical in shape, and thus buried deep under the muscles and
aponeuroses, as hard to the touch as a  stone, and of the size  of a
pullet's egg, but totally disappearing spontaneously under the proper
internal  remedies  for the constitutional  disease to which they ap-
peared  to  owe their origin.   They are  most usually found acci-
dentally developed in consequence of unreduced fractures and lux-
ations, and Sir B. Brodie has  seen one of great size in the case of a
girl with Talipes Equinus, and Which formed  upon  the part of the
instep upon  which she walked. (Pathological and Surgical Observa-
tions on Diseases of the Joints, London, 1818.)  The excessive se-
cretion from their internal surface may distend them into elastic tu-
mors, truly hydropical in their character, as our author,  M. Velpeau,
in a recent valuable  memoir, has  very  properly considered them.
(Recherches Analomiques, Physiologiques  et Pathologiques sur les
caviles  closes, naturelles  ou  accidentelies  de  l'economie animale,
1843.)  Others have on that account invented  for them the name  of
Hygroma, which  is adopted by the wriler,  M. Cabaret,  whose  trea-
tise we  have under consideration.   M. Cabaret remarks  that these
serous bursal tumors are found in all parts of the body, but more es-
pecially at the elbow, [see notes on this subject in Vol. I. and inf.,] the 
CYSTS,  PROPERLY SO CALLED.
95
knee, [vide same  notes, T.]  in  front of the patella of individuals
who rest frequently upon this part, such as preachers, religious per-
sons, washerwomen, slaters, tilers, thatchers, &c, &c.   In England,
from the more rigid division of society there for centuries into cer-
tain casts or permanent occupations from one generation to another,
more opportunities of course present for  noting what may be con-
sidered the acci'dental products or results of such professions or oc-
cupations.   Hence we  hear there, and see surgical descriptions  of
these enlarged bursas under the familiar names  of the miner's elbow,
the housemaid's  knee, and the scrivener1 s palm, &c.  Sir B. Brodie
has known this disease to be hereditary.
   These tumors are, as might naturally be  conceived, more or less
dense or elastic, more or less distended, and of greater or less vol-
ume, according to the greater or less pressure, constriction, motion,
&c, of the surrounding parts.   While  not  in  a state of inflamma-
tion, the contained fluid continues to be analogous to synovia;  when
arising from contusions, blood  may be  effused, giving a reddish or
brownish or black color to the synovia.  They then may be said to con-
stitute a natural hamatocele, the same as happens in the cavity of the
tunica  vaginalis testis, or as some now call it peri-testis, in which
case they present the most favorable circumstances for M. Velpeau's
treatment  of bloody tumors by  percussion, [see Vol. I. supra,] or
puncture and iodine injections, more lately advocated by our author.
[See sup.]  Fibrinous clots, says M. Cabaret, or a sort of transparent
bouillie, are  sometimes the result of the alterations which the blood
undergoes in these tumors.  At other times the  liquid they contain is
mingled with a number of movable  bodies  of  a flattened oval form
and deep-brown color, and in appearance resembling melon seeds.
These  small masses, which  are  at  first  albuminous and movable,
progressively acquire a great degree of hardness.
   M.  Cabaret rejects every kind of local  application, of frictions,
 lotions, unguents, &cc, whether iodine, mercurial, saturnine, or other-
 wise,  and also doubts the value of compression and temporary blis-
 ters, wh:ch have succeeded with M. Velpeau.
   Excision of the tumor  in whole  or in  part  is also generally pro-
 scribed.  M. Velpeau has seen two cases of death from this opera-
 tion, (see Archives Gen. de Med., Paris,) and Mr. Keate has seen the
 disease return in a case in which he-believed he had thus extirpated
 it.  Sir B. Brodie recommends it only under certain restrictions or
qualifications, which according to M*. Cabaret  are where the  bursa
has become  fibrous, thick, disorganized and incapable of resuming its
normal condition.
   Simple incision is of no avail, as we all know, against a return,
and the consequences, such as intense inflammation of the surround-
ing tendons, sheaths, and muscular  tissues, abscesses, phlebitis, &c.
are often of the most formidable character, which  are likely, as we
consider, to  be aggravated by the former practice of introduc'ng a
seton into the cavity thus opened.  This mode  of provoking aggluti-
nation  of its walls we deem  too  severe, of which opinion we  find
also M. Cruveilhier.
   Puncture of the hygroma and injection of a moderately stimulating
liquid, as for example, the iodine injections which have proved so 
96
NEW ELEMENTS OF OPERATIVE  SURGERY.
successful in the hands of M. Velpeau, is, according to M. Cabaret,
deserving of adoption as a general method of cure for this disease.
  M. Cabaret, in illustration of the success of this treatment, presents
five cases, four of which were bursal tumors on the patella and one
on the olecranon, and all of which were perfectly cured by puncture
and  injections of wine  and  water,  diluted tincture of iodine, &c,
causing in a few days complete agglutination  of the walls without
any serious degree of inflammation.  We  should suppose that for the
puncture an extremely delicate trochar, not much larger than an
exploring needle, would be most advisable, rather than an ordinary
trochar or bistoury.
  In conclusion, M. Cabaret says:  The three last cases (two of the
patella and one of the olecranon, and in which he injected the iodine)
which I have just given, and many others which I possess, furnish
incontestable evidence of the truth of the law laid down by M. Vel-
peau, in the following terms :  that" we should cause to be produced
in shut cavities containing effused fluid,  an  irritation  wrhich should
be constantly adhesive  and  never purulent."   These cases,  adds
M. Cabaret, will, I trust, help to  make us feel the value to be derived
from the treatment of hydropsy of the sub-cutaneous synovial bursas
by iodine injections, as administered according to the method of the
learned professor of clinical surgery at the Hospital of La Charite.
  Nevertheless, as we  have  before expressed  ourselves upon this
subject in various places in the text of this work, we  must with  all
due deference to the  importance of the facts above adduced, and of
the unquestionable value of the  treatment proposed and so success-
fully pursued by M.  Velpeau, confess that we should in  all  cases
where it is practicable, and where  there  is but little  or no serious
pain  or inconvenience in the tumor, be the tumor of what size it  may,
(provided it  has not, from its long standing, undergone the kind of
fibrous consolidation  spoken of,) prefer sudden and powerful percus-
sion, as we have described it.
  The distended, rolling bursa is then instantly  broken up into  frag-
ments, if the stroke  is made  from a considerable height  and with
great force  and rapidity, as by a heavy, book or something similar,
held  in the operator's hand, while the patient is unaware of your in-
tention  and has his head turned away, and  arm or leg firmly sup-
ported upon a table.   Thus have I perfectly succeeded in a large
olecranal bursa, which  had  been growing for a year or more in
H----, a healthy mulatto (part  Indian and part white) of sound con-
stitution and good habits, and aged about  35.  The patient, who was
confidential porter of a distinguished mercantile firm of this city,
finding the tumor at length had  attained such dimensions, being oval
shaped and  of the size of a small hen's egg and exceedingly tense,
though elastic, as to  give a considerable degree of pain and annoy-
ance  in  the  use of  his arms in hoisting and  carrying boxes and
bales of goods.  He  had imagined his arm would have to be ampu-
tated, and having promised, if it should be found  necessary when 1
should, examine it, (for I had  not yet seen it,) that if  so serious an
operation as amputation was  required  it should  be performed, I
sent  word to him to call upon me, and in that  event  I would give
him a note to an eminent surgeon, who would do it at his clinique at 
CYSTS, PROPERLY SO CALLED.
97
the University.  Immediately on looking at it I perceived it was
nothing more than a bursal tumor, and as there was nothing to pre-
vent proceeding at once to the mode of cure I have mentioned, I
asked him to stretch his arm out in pronation firmly upon the table,
and to turn his head away.   Having at this  time purposely in my
hand  a heavy quarto  volume which I appeared to be engaged in
perusing, I suddenly camedown upon the enlargement with it, hold-
ing ij; in both my hands, with all my force, from an elevation of three
feet, striking such  a blow upon it as dispersed  in an instant  every
vestige of disease.  To the patient it naturally seemed marvellous;
and in fact would have appeared to be such in the eyes of most per-
sons out of the profession. If an operation of this kind, so instantane-
ous, so bloodless and painless too, it may be said, (for the pain is but
momentary,) and yet so radical in its total extirpation of the disease,
was known to the  school of Esculapius, we cannot wonder why the
ignorant,  marvel-loving,  superstitious  multitude, before whom  this
master spirit could have turned such skill to a valuable account, (by
momentarily taking the patient for a few instants out of their pre-
sence,) should have deemed  him more than  mortal,  and built altars
and temples to his honor.
   Far be it  from  the writer of this, however, to glorify himself on
such  an achievement, so  long as its common  utility  and the facility
with  which  any person may perform it, are  so obviously sustained
on the plain principles of common sense.
   The truth  and  efficacy of this  treatment, and  its  total protection
from all return of the disease or any accident whatever, had been
made manifest to me many years since, during my residence at Nas-
sau, in  the Bahama Islands, in effecting the  same results for bursal
enlargements upon the wrist.  Besides the remarkable case of that
on the olecranon just mentioned, I have since performed  the same
operation oh another patient, also a laboring  man, and on whom  the
tumor was situated in precisely the  same locality;  but in this last
patient, from not  having had it in my power to strike a  full  and
perfect blow at first, I was obliged  to  repeat it a few days after,
when the cure was complete, and has  remained so  now in both the
individuals (whom I am frequently in the habit of seeing) for several
years.
   In  another case there was a hemispherical sub-cutaneous bursal
tumor of great size on the patella, full equal in dimensions to the half
of a large orange, and completely, covering  the  patella like a large
inverted cup.  This rnari,  as the porter or  wine-marker of a wine
vault in the  largest hotel in this city, was in the constant necessity
of being upon his knees.  I effected a partial cure and subsidence of
the tumor for a year or more by producing, by means of common
strong ammoniacal liniment, a copious  suppurating drain over its
whole surface for weeks;  but ultimately was obliged,  about three
years since, to come to percussion, which was performed  as men-
tioned, and which  effected, as he informed me within a few months
past, a radical and permanent cure.
   It is unnecessary, perhaps, to say more than we have already said
in the first volume on the new  mode  of curing bursal tumors by
breaking them down (as in couching the lens in cataract) at the point
                                7 
98
NEW ELEMENTS OF OPERATIVE  SURGERY.
  of a narrow tenotome, introduced sub-cutaneously at some  distance
  from the tumor.   The cures  effected  by this process, appear to be
  well substantiated, (vid. Vol.  I.) and we have  had no evidence (at
  least no  published evidence) of its  failure in  any case.  A priori,
  however, it  would be deemed an operation of too great severity,
  but for these successes, and  others  of a more remarkable  kind, by
  the same process, in extracting foreign  bodies from the knee joint,
  and  the  practicability of which M. Velpeau himself has recently
  confirmed (vid. Vol. I.) by the sub-cutaneous extraction of a ball from
  the same articulation.
     The successful treatment of enlarged bursa mucosa, by  injec-
  tions of tincture of iodine, as some years since introduced into prac-
  tice by the learned  author of this  work, M. Velpeau, has, we  are
  gratified in perceiving, been recently verified in a most satisfactory
  manner, .by experiments performed for the same disease  in horses.
  At the sitting of the Academy of Sciences  of Paris, March 24, 1845,
  (see  Gazetie  Medicate de Paris, Mars  29, 1845, tome XIII., p. 204,
  205,) MM. Thierry and Leblanc communicated  the result of their
  experiments upon this  subject, made in presence of MM. Velpeau
  and Rayer.   ^Tt  is  known, say MM.  Thierry and  Leblanc, that
  horses are often\ affected with  dropsy in the articulations and mu-
  cous passages (lev courses muqueuses), and which are described by
  veterinary surgeon.s under the name of wind-galls (molettes) and
  vessigons.  Up to tl.>e present time, one remedy only has been em-
  ployed for this affection, namely, the red hot iron, applied either in
 the shape of the raye^ or the pointed cauteries.  But  whatever
 were the means used, injurious traces of the disease always remained
 behind.   It was with the view of obviating this inconvenience, that
 the authors, guided by the researches of M. Velpeau, made experi-
 ments with iodine and vinouls  injections as  compared with the appli-
 cation of the hot iron.   Fron *  the results they obtained, they believe
 themselves authorized in deck iring that iodine injections in the mu-
 cous bursas and synovial sheath >s> m horses, may advantageously re-
 place  cauterization by the red  * hot  iron, and that in a plurality of
 cases, this  mode of cure ouo-ht to  he first employed.
   We have upon the  strength of \ veil-attested recorded  facts, con-
 sidered the discovery of the mode o ^ effectually curing these ancient
 opprobria, by the new system of sub  -cutaneous puncture, so impor-
 tant and valuable, that we have been t. hereby in some measure com-
 pelled to anticipate our author  in the   position to which  he has as-
 signed this  subject in the French edition o\ e this work.  As the cure of
 these bursal tumors, which have hitherto  so mucn annoyed, as well
 as  baffled,  our art, except where the patiei.  (t an^  surgeon together,
 have had the courage to adopt the ancient   anc^ after all, when the
 case warrants it, the most radical  process  (w  e mean sudden percus-
 sion,) is the most important point to be' con. s'dered  in  relation to
 them ; we have, in consequence, said most of wi iat we had to add on
that subject, under the head of sub-cutaneous t 'urgerv> m our first
volume. Though incisions and setons in these natui   a' bursas, enlarged
morbidly into painful encysted sacs, (the most incoi  ^ve™611* cases of
which are those in working men, as those familiarh   ' kn°wn in Eng-' 
CYSTS,  PROPERLY SO CALLED.
99
land, as the maid-servant's knee, the miner's elbow, and  the scriven-
er's palm,) have  been for the most part abandoned for the teno-
tome, several surgeons, nevertheless, among them our author, M.
Velpeau, continue to  adhere  to his process.   M. Velpeau's mode
consists in a simple  puncture with the trochar, to evacuate  the
hydatid corpuscules, which step is deemed indispensable to the cure,
after which he  makes use of free injections of diluted tincture of
iodine, after  the  present  received mode of treating hydrocele, in
order to stimulate the sides of the sac to agglutination.   M. Velpeau
has met with most signal success by this course, and obtained speedy
cures, free from all accidents.  (Ann. de Therap., Paris, April, 1845—
also Cormack's Lond. and Ed. Month. Journ., June, 1845, p.  460,
&c.)   M. Chassaignac (Ibid.)  in a remarkable case of one of these
tumors  in the wrist, found that  from its great size, twice that of an
egg or orange,  it  was compelled by the annular ligament of the wrist
to assume a bilobate form, about one half being above the ligament,
and the rest in the palm of the hand.  The large  quantity of hydatids
evacuated by the trochar were found by M. Chassaignac to be true spe-
cies of that enzootic class, possessing, as examined by the microscope,
elastic, compressible, vesicular bodies, and  not composed of those
hard,  albuminous concretions which  are  mistaken, he  says,  for
them.
   M. Gherini, surgeon of the great Hospital of Milan,  (Ib. and An-
nali Universali, Jan., 1845,) saw also a bilobate bursal hydatid cyst on
the posterior part of  the elbow, though that  has no annular ligament
to explain this form, and cured it by incision, evacuating 52 barley-
shaped corpuscules.   The sac suppurated,  but the cure was com-
plete.  Neither of the lobes of the bilobular cyst communicated with
the articulation.  We should for ourselves be adverse to the incision
in  any case  except in one  of extreme necessity, as, for example,
where there was  great extent of inflammation in the cyst and neigh-
borhood,  from bruises, injuries, &c, and  then  the knife should be
withheld until  general and  topical depletion had reduced the vio-
lence of the inflammation and attending fever, if any, and that the  dis-
tension of the sac by the contained synovial or hydatid matters had
made it necessary.  But a mere small sub-cutaneous  incision in such
cases, and sufficient to evacuate  the  contents, is a very different
thing from an extensive dilatation of these cavities themselves, while
they are in an uninflamed state.  The  incision  practised in this lat-
ter state, from the exposure  to the air of the peculiarly sensitive tis-
sue of these  bursas, becomes itself, by the operation, the source of
danger, whereas  in the other case, it is to  subdue inflammation, that
we have recourse to it. We think we are warranted by the pathologi-
cal discoveries of sub-cutaneous surgery, and by the reiterated injunc-
tions so studiously enforced  by our author throughout this work on
the subject of the dangerous accidents, such as burrowing, destruc-
tive suppuration,  phlebitis, purulent infections,  tetanus, typhus, &c,
from  wounding synovial  membranes, surfaces, passages (coulisses)
and capsules, to  lay it down as a precept, that these bursal cysts
must not be thus  meddled with by  direct  incisions, except under the
circumstances mentioned. 
100
NEW ELEMENTS OF OPERATIVE SURGERY.
  Irrelevant and improper as would be  the  admission  into a work
eminently didactic and elemental as is this on operative surgery by
M.  Velpeau, of  all matter  purely controversial, unless  as  in  the
academic discussions upon tenotomy (see Vol.  I.) and those on fibrous
tumors, (see this vol. infra,) new and valuable facts are thereby elicited,
we  deem it, nevertheless, an act of impartiality to state in this place,
in reference to  a subject already treated of in the 1st vol., (the sub-
cutaneous puncture for articular  dropsies and foreign bodies, &c.,)
that M. Bonnet, of Lyons, claims the merit, how just we  cannot at
present decide, (see his recent work, Traite des Maladies des Articu-
lations, 2 vols. in-8°  Paris, 1845, also  a  notice of the  same  in the
Gazette Medicate de Paris, Mai 17, 1845,  t. XIII., p. 319,)  of having
been  the first to employ, and  before M. Velpeau, iodine  injections
into the articulations.   By a curious coincidence, however, M. Bonnet
himself, in making this reclamation over the surgeon  of  La Charite,
has in his  work just cited, committed an  act, (Introd.,  p.  xxxvi,
and tome  I., pp. 451, 487,) according to  M. H. Diday, (Gaz. Med.
loc. cit., p. 320,)  of positive injustice  towards M.  Jules Guerin in
another matter appertaining to this subject; viz., in asserting that we
owe to M. Goyrand, of Aix, the  credit of having  first  treated the
evacuation of articular dropsies, and the extraction of foreign  bodies
in the joints, by  the  sub-cutaneous puncture.  M.  Diday contends
(Gaz. Med., loc. cit., p. 320,) that  at least the germ, or original idea
of this treatment, in both these classes of affections, was  so specifi-
cally and formally laid down by M. Guerin, as early as in  the years
1840 and 1841, (see M. Guerin's  Mem. sur les Plaies Sous-cut. des
Artie, lu a l'Acad.  des Sciences de Paris, le  4 Mai, 1840; and the
Essais  sur la  Methode Sous-cut., Paris,  1841, pp.  84 et  113,)  that
there  can remainnot a shadow of doubt as to his (M. Guerin's) claim
of priority.   M. Diday, however, seems  willing to  make a sort of
commutation of this last mentioned difficulty, by admitting that M.
Bonnet may possibly be entitled to the merit of having been the first
to execute, and  with success, the sub-cutaneous operation for the ex-
traction of intra-articular foreign bodies ; but that the same operation
as applied to the evacuation of the liquid of hydarthrosies, by making
this fluid pass  under  the  skin, by a sub-cutaneous incision into the
synovial capsule, as practised by M. Bonnet,  is not  so certain  and
efficacious a cure as the pure and simple evacuation of the liquid, by
means of the syringe, as practised  by M. Guerin ;  the  process of
M.  Bonnet incurring the risk of not procuring a complete evacuation,
and of leaving a portion of the liquid, as an irritating substance, under
the  skin.
  Patellar bursa, or  those between the patella  and integuments,
and familiarly known  in England  as the housemaid's knee, may, Sir
B. Brodie is satisfied, be reproduced  after  their complete  extirpation,
as he  has frequently found to  be  the fact.  (London Med. Gazette,
May, 1846, p. 829, from Sir. B. Brodie's Lectures on Pathology and
Surgery).
  Sanguineous Tumors treated by Ecrasement.—The  process of
crushing, which we have felt it our duty to advocate in such unequi-
vocal terms, as the  one which should always be preferred,  where
practicable, for mucous bursas, has been applied with eminent success, 
CYSTS, PROPERLY SO CALLED.
101
also, in sanguineous hematic tumors that are external, and favorably
situated  for  percussion.   M. Velpeau  reasoned very naturally,
(Traitement des Tumeurs Sanguines par ecrasement; Annates de la
Chirurgie, Aout, 1843 ; Arch. Gen. 4e, ser., t. III., pp. 217, 218, 219,)
that the extravasated blood of such tumors, if once dispersed by their
rupture, so as to become infiltrated into the surrounding cellular tissues,
must  naturally from its assimilation to the  great mass of  the vital
fluid,  be absorbed with yet greater facility than the serous  liquid of
synovial bursas.   He also presents as another striking argument for
the ecrasement of such tumors, the fact, that left to themselves, in their
semi-concrete and confined position, they are rarely absorbed, whereas
every one is familiar with the fact that  every ordinary ecchymosis
or extravasation of blood from a blow or bruise, is rapidly absorbed,
and for the. reason,  that in the latter case it is dispersed by the acci-
dent itself, into the  cellular tissues.   This, probably, is the source of
the correct vulgar practice of applying pressure  and friction imme-
diately, and as soon as such  bruises are received.  The ecrasement
is performed  by M. Velpeau by  sudden pressure  upon the tumor,
with  the palm of the hand or with the thenar eminence,  or with both
hands, or it may be done with a solid body, as a  piece of money or
wood, which is  to  be struck upon with a hammer or the fist.  The
tumor is broken up  immediately, leaving only some lumps (bosselures)
in the tissues.  The tumors best adapted to it should not exceed the
fist  in  size.   He very judiciously adds, that a solid point  d'appui
must of course  exist as  in ordinary serous bursas, and  before the
operation can be thought  of.  In case  of an eschar on the tumor,
the process may still be  applied  if the eschar is superficial, and has
not begun to be detached; in the contrary case we  should abstain.
Ecrasement is  better adapted to  the effusions in accidental, than in
normal close cavities, as the walls of these last are always thicker, and
consequently more  resistant.  M. Velpeau furnishes numerous cases
of cures in favor of this, as it appears to us, most judicious treatment.
Surgery,  it may be said, has at length obtained a tolerable mastery
over  external, synovial  and  hematic tumors, either by means  of
ecrasement or sub-cutaneous injection of iodine, to say nothing of the
value of  this last, or favorite  process of the author in normal close
cavities.
   On Close Cavities in general.—Before this chapter closes it is pro-
per to insert in this place, and more in detail, the new and impor-
tant views of our author, M, Velpeau, as published by him in his work,
entitled Recherches  Anatomiques, PhysiologiquesetPathologiques sur
les  Cavites  Closes,  naturelles  et accidentelles, de I'economie animate.
(Par  A. Velpeau, &c, Paris, 1843, pp.  208, see also an extended
abrege of this in the British and Foreign Med. Review,  vol. XVIII.,
July—Oct., 1844, pp. 79, 90.)  M. Velpeau maintains the new pro-
position, that serous and synovial membranes, as distinct tissues, have
no existence, and consequently that the notion of close cavities formed
by such membranes, is entirely devoid  of foundation.   He bases
this proposition on  the facts obtained from intra-uterine life.  From
ten  embryos examined by him, and which were from fifteen  to thirty
days old, he concludes that even up to the 4th week the free surfaces
present no appearances  of membrane;  the whole body consisting 
102
NEW ELEMENTS OF OPERATIVE SURGERY.
apparently, of a homogeneous, gelatiniform and  fragile substance,
none  of the cavities any where being lined with any distinct mem-
branous tissue, or  laminas capable of being isolated.   The whole is
either surfaces or parenchymata, while there is nothing either in the
head, chest or abdomen, to justify the expressions cutaneous, mucous
and serous membranes, &e.  He contends that what  for example
we call in extra-uterine life  the  peritoneal or serous  membranes
do not always exist, and cannot be detached as a distinct peritoneal or
serous membrane,  properly  so called.  They are in fact only serous
surfaces continuous with, and not separable (except by a traumatic
division) from the subjacent  cellular parenchyma of the organ, as  on
the liver, uterus, ovaries, &c.   So behind the linea alba.   In proof of
this, it is to be considered  that the  serous  membranes, properly so
called, do not exist, and do not become manifest until at a very ad-
vanced period of the embryonic state, that is, prior to the organs in-
vested by them.  Pursuing the same course  of reasoning in respect
to other cavities than  those  of the  abdomen,  and which, however
ably maintained, is  too  strictly pathological  to  be  properly em-
braced  in  the text of our  work, M.  Velpeau  comes  to synovial
cavities, properly so called.  He shows that  there are but few vesti-
ges to be  found of this supposed serous  membrane.   Thus,  in the
knee it is no where to be found, on the free surface of the cartilages,
or on the internal surface of most of the ligaments.
  Accidental close  cavities are divided by  our author  into functional
and  pathological.   The  functional consist  of:  1. Serous cavities
2. Articulations; and 3. Cellular cavities.   The first, or serous, are
formed by an ovary, a noose  of intestine, or a knot of epiploon or other
viscus passing through a fissure of the peritoneum and abdominal mus-
cles, so as to  fix itself under the skin.   The second or articular, are
connected with the articulations, and caused by a luxation or frac-
ture.   They have no lining  membrane, and are nothing more than
the polished surface of the textures which  enter into  their composi-
tion.  The third or cellular cavities, are those  usually denominated
synovial or mucous bursas, and are accidental sub-cutaneous arrange-
ments, which nature interposes over any projecting point or surface
of bone which is exposed to  much pressure from without, and are
evidently designed to protect the soft parts from the hard, in the na-
ture  of pulleys, or rather a sort of distended  sacs or  air cushions.
Thus  on the backs of porters and on the acromion of persons who
carry burdens on the shoulders, on the angle of the scapula in those
who carry scuttles, &c, on the anterior part of the  sternum in join-
ers, &c, on the malleoli, [and tuberosities of the ischium, T.] in tailors,
&c, on the hump of humpbacks, and on  the  salient  points of club
feet.  To  these we may specify those which in certain  occupations
in England are so common as to have acquired, as we have else-
where frequently noted in this work,  a particular designation.  Thus
the bursa over  the patella, called the housemaid's knee, seen also in
the other sex, and in all who have occasion to rest much  on this part;
so also the miner's elbow, meaning the bursa at the acromion, caused
by the position in which the miner works.   To these  add the  scriv-
ener's palm, or bursa in the  palm and  wrist of those who have  to
write a great deal.  Our author also  has seen them on  the body of 
CYSTS, PROPERLY SO  CALLED.
103
the clavicle, on the posterior surface of the fore-arm, on the internal
surface of the tibia, the crest of the ilium, &c, from exposure of those
parts to friction  and pressure.   All these cavities, like normal ones
of the same character, are destitute of investing membrane.
   Pathological  close cavities comprehend every  kind of  abscess,
cyst, and  morbid deposit.  But  it is  to  morbid sub-cutaneous close
cavities, analogous to the normal close cavities of joints and  under
tendons, that he particularly directs attention.   These sub-cutaneous
morbid cavities  are observed: a. In the cellular  tissue, which have
been described particularly  as serous cysts, and which are surround-
ed by the condensed cellular tissue, which is mistaken for a supposed
lining membrane to the cavity ;  b. In glandular bodies,  as in the thy-
roid body, breast, testicle, &c, where it  is also clear that their sur-
face is part of the tissue of the gland.   The pellicle, which may occa-
sionally be separated, has been formed there in the same way as that
which constitutes a part of the cavity of an aneurismal sac, in  which
the blood has continued to  circulate.   In  the  ovaries, M.  Velpeau
says, the truth of his doctrine is  strikingly illustrated by the coexist-
ence of real  cysts like hydatids  and  which can be readily detached
from the tissue of the organ, with close cavities the surface of  which
is inseparable from it, and forms part  of it.   c. In ganglial  cavities,
as under the jaw in the region of the parotid, and in the  carotid ca-
nals, and  in front of the  larynx, in the supra-sternal fossa,  axilla,
 bend of the arm,  groin, and ham, and in the interior  of the pelvis.
 These last may exist in the gland, shut up, as it were, and with their
sides in contact, or if they are towards the surface of the gland, they
then, from having  room, expand into  a pouch, which, however, will
always be found to be attached in some portion of it to the glandular
mass.  The  practical inference  from all the above is that diseases of
close cavities or surfaces are in fact primarily nothing more than dis-
 eases of the  tissue, of which these cavities constitute a part.  From
 whence M. Velpeau  lays it  down as a law, that as the articular car-
 tilages are destitute of arterial and venous circulation, and of a  serous
 membrane, properly so called which is distinct from their tissues, so
 neither inflammation, ulcers, fungous diseases, nor transformations,
 nor degenerations of any kind, exist as a primary malady on the free
 surface of those articular cartilages.   A  deception may arise  in this
way ; that inflammation without the cartilages may lead to a deposi-
tion of lymph between the  cartilages, and  this deposition becoming
organized and vascular, or  even blended with the  surface of one of
the cartilages, may give rise to  the supposition that the free surface
of the cartilage  itself is the seat of the disease.  For this deposition
may constitute  a real vascular  movable membrane in the  articular
cavity.  Hence fungosities  and  vegetations upon this membrane may
be described as those of a synovial membrane.  M. Velpeau admits
that in the progress of the disease, the cartilage itself may now be-
come implicated, and thus vascularized from its ci-rcumferehce to its
central parts.  This  however, he says, is no proof of a real synovial
membrane, as the friends of Bichat maintain, on the diarthrodial car-
tilages, or that inflammation ever originated on an isolated layer of
such cartilages.
   The opinion advanced, that articular cartilages are unorganized, 
104           NEW  ELEMENTS OF OPERATIVE SURGERY.
is, it must  be confessed, contested by  a great number of authors.
M. Velpeau contends  that the synovial fluid is  directly  produced
from  the surface of the articular cartilage.   The salutary organic
process of adhesive inflammation,  deemed peculiar almost to cellular
tissue, and  seen as the precursor or protecting interposition intended
by nature to circumscribe and to  intercept the progress of suppura-
tion, is developed also in close cavities, and with the greater rapidity
in proportion  as their parietes are smooth and  completely serous,
finally soldering them together and obliterating the cavity.   This ad-
hesive inflammation is dangerous in large cavities, as in the perito-
neum and pleura, and may in  its turn give rise to suppuration.   The
excitation therefore, where we wish to  obliterate a cavity, as in hy-
drarthrosis, should, as before observed, be so controlled as to produce
always an adhesive inflammation only, and one  which shall never
become purulent.  The more the  effused fluid resembles serum, the
more  easy  is it to procure adhesive inflammation, and  the more it re-
sembles pus, the less chance is there of escaping purulent inflamma-
tion.   Hence  it is  an  important point to change the  contained  fluid
as much as possible into the condition  of serum, which our author
maintains, can  in certain cases be effected by frequently  emptying
the cavity by puncture.  So  also  with accumulations of blood; and
in this manner  there is finally poured out instead of  blood or pus, a
purely serous, or a sero-sanguineous or sero-purulent fluid.   This re-
sult M. Velpeau has  verified in  most  regions  of the  body.   This
brings our  author naturally to his  favorite injections  with  iodine, as
tested by him with  such eminent success in hydrocele, &c, and the
latest  information in regard  to which will be found at length in our
notes  under that head (infra).  He remarks in this work under  con-
sideration, that additional importance is given to iodine from its well-
known resolvent properties, and the beneficial influence which these
properties  may have  upon the infarcted condition  which is gene-
rally found to exist  in some parenchymatous organ, in those cases in
which there is  a serous.effusion in a close cavity.  This applies di-
rectly to an infarcted or congested testicle accompanying hydrocele,
and where M. Velpeau  has  found  the true  treatment to lie  in a
course which is  the reverse  of the  old practice.  Thus, therefore,
instead of endeavoring to resolve the  congested testicle before treat-
ing the hydrocele, he begins with  both,  and acts  upon both at once
by his iodine  injections into the hydrocele cavity ; that is, provided
the infarction  is not scirrhous, encephaloid, melanotic, or tubercular,
but merely a hypertrophied condition of the testicle.   The most for-
tunate results have  been  obtained  by M. Velpeau by the practice in
question.
   But it is  unnecessary to dilate here on the advantages of these in-
jections, as we have given the latest details from M. Velpeau  him-
self and others, (see  this volume,  supra) and  (infra,) as more  fully
disclosed in the recent animated discussion to which this subject gave
rise in the Paris Academy of Medicine.  It  is proper, however, to
notice the various  kinds of  diseases of close  cavities in  which M.
Velpeau now successfully employs this  treatment:—1. In encysted
collections of serum in the tunica vaginalis.  2. Collections of serum
in the tunica vaginalis, which communicate with the cavity of the 
CYSTS,  PROPERLY SO  CALLED.
105
abdomen, forming what is  called congenital hydrocele.   3.  Serous
collections within a perineal sac, whether the sac be continuous with
the peritoneal cavity or otherwise.   4. Encysted  serous collections
of the spermatic cord.  5.  Serous collections in the external genital
organs of women, contained  in  close cavities, and resembling the
last mentioned.  6.  Serous  collections in the lymphatic ganglia of
the groin and  iliac fossa; and 7. Collections of purely liquid blood
in the interior of the pelvis in women.  We wish we could subjoin
additional successful results to the  few well-authenticated cases we
have alluded to in our first  volume,  in which the neck  of the sac of
several old, large, and reducible inguinal hernias, (not congenital,) has
been completely and permanently obliterated, and the hernia  radi-
cally cured by means of injections of Tincture of  Cloves, (doubtless
suggested by  the  practice  of M. Velpeau,) in the hand of some
young and bold practitioner of this  country.  But  we are not aware
that this  practice has been followed up, though several remarkable
cures to which both Dr. Mott and  myself were both eye-witnesses,
and the happy results of which gave much satisfaction to that sur-
geon, would certainly authorize  new trials with it.   M. Velpeau has
succeeded with iodine injections in the cavity of a  large sanguineous
tumor, which was diagnosed and  proved to be such by this distin-
guished surgeon, and which had formed behind the uterus and  as-
cended towards the right iliac fossa.   He also succeeded in a case of
an accidental close cavity in the thyroid body, which though the first
in which he  found  constitutional  febrile  reaction caused  by the
iodine, ultimately recovered.   Finally, the same success has attended
his iodine injections when thrown  into the cavities of the joints, to
cure  articular effusions, and he had thus already triumphed (when
this book was published, 1843) in six cases out of  seven of pure hy-
drarthrosis.   His experiments on dogs go to show that iodine of more
strength than one-seventh of the water used to dilute it, is fatal when
thrown into the peritoneal cavity; not however by absorption and
poisoning, but by peritonitis and enteritis.   The state of this question
of iodine injections  at  the  present time will be best understood by
our notes elsewhere in this volume, (vid. infra.)
   Treatment of Tumors.—M. Bonnet of Lyons, with all the natural
predilections  which an eminent surgeon like him must possess  for
the chirurgical rather than therapeutical treatment of disease, has
in his late important work (Traite des Maladies des Artie., 2 vols, in
8°, Paris, 1845:  see a short critique on this work, by  M. H. Diday,"
in the Gazette Medicate of Paris, Mai 17, 1845, p. 316 et sequ.) in-
sisted very  judiciously as  we think upon the absolute necessity of
looking to the general diathesis of the whole system as the frequent
if not most common source of all fungoid, serous and other growths
and diseases in the articulations. Some of his views upon this sub-
ject appear  to be presented under  an original aspect.  The cause
of these  diseases lies, M. Bonnet says, most frequently in an arrest
of organic development, dependent on the general condition of the
system.   Thus articular fungosities  (fungous  growths or tumors)
for example, are nothing  else than plastic lymph which  has  been
suspended by an internal influence; the part which is the seat of the
disease being but a type of what is passing in the general economy; 
106          NE*V ELEMENTS  OF OPERATIVE SURGERY.
  but  if the vital energy  in  the  latter, now  temporarily paralyzed,
  should  recover  itself,  these  fungosities  will  be  converted into
  fibrous (i. e. healthy organic) tissue.  As in the  serous membranes,
  so in the articulations, the fibrous transformation is the fortunate or
  salutary maximum or last term of the nisus formativus : and wher-
  ever a fibrous layer  is  found upon the articular surface of bones
  denuded of their cartilage, and that we perceive this t'ssue expanded
  into  membranes, or concentrated  into  fibrous  bundles  (faisceaux)
  going from one articular extremity to the other, we may conclude
  for a certainty that there has been  one step taken towards  a cure,
  a vis medicatrix established  by nature to complete the evolution of
  the coagulable lymph.
    M. Bonnet makes three distinct classes in the products of secre-
  tion which are formed  in diseased articulations: 1.  Those which
  are  systematically (regulierement) organized; 2. Those which are
  arrested in their organization ; and 3. Those which are not at all or-
  ganized.
    Thus the  general diatheses, so clearly established in arthralgias,
  may be characterized  themselves by their tendency to favor one or
  the other of these three  products:  in the less severe, as in acute or
  chronic rheumatismal  diathesis, the tendency is to the first or effiu-
  sions of plastic lymph;  in other cases, as in the  scrofulous diathesis
  (where synovial fungosities  are most frequently met with) a  disposi-
  tion will exist to the secretion of incomplete organic  products;  in
  the diathesis which is still more  aggravated, [i. e. where there is the
  greatest degree of degeneration  in the organism, T.] as in the tuber-
  culous, purulent and gouty, there are no organic products secreted,
  but depositions of tubercles, pus and uric acid, [rather lithate of soda
  either in  a fluid state or in crystals, which depositions constitute
  gout.  T.]
    Fungous  articular tumors are  unconditionally ascribed by  M.
  Bonnet to the scrofulous or  so called strumous diathesis, of which he
  makes  several species, altogether distinct from  the products of the
  tuberculous diathesis, as well by their external appearance as  by their
  peculiar characters.
    He makes two distinct classes  of scrofulous  persons: 1. Those
  who are pale, thin  and without  any trace of tumefaction in the ex-
  ternal glands ; such have also hollow cheeks, the eyelids and lips thin,
  complexion pallid, and frequently cold abscesses (abcesfroids) with-
* out  tubercles.  These are  individuals with  the purulent diathesis.
  2. The other class have the face full, the alas of the nose, the lips and
  the  eyelids tumefied, and the glands of  the neck in  general  volumi-
  nous.   They are disposed to congestions with  mucous secretion,
  ophthalmias, otirrheas, &c,   These  are  what are denominated pre-
  eminently scrofulous temperaments, but  which M. Bonnet proposes
  to  consider  as  laboring  under a fungous  diathesis, (diathese fon-
  gueuse.)   In them we frequently  meet with local lesions,  such  as
  those fleshy soft masses,  whose tendency is to suppuration and which
  are usually designated under the name of fungosities, (fongosites)—
  not only in the articulations, but frequently in the bones themselves,
  under the name of spina ventosa;  also  in the glands, which  thence
  become swollen, and in the nose and cheeks, where they may ulcer- 
CYSTS,  PROPERLY SO CALLED.
107
ate and become the source of phagedenic  eruptions (dartres  ron-
geantes), [as phagedena or cancra oris, T.] &c.
   M. Bonnet has  pointed out with much force, the injury done in
the treatment by the common machines  employed to keep the joint
in a constrained  and vicious position, whereby the  disease, from a
false idea of obtaining repose for the limb, is greatly  aggravated, the
synovial membrane and ligaments on one side kept in a state of ten-
sion, the osseous surfaces compressed on the other, with a permanent
tendency to an alteration in  the natural relations of the bones.   He
had by various experiments  on the dead body, to determine the best
possible position for the articulations, contrived a number of kinds
of ingenious apparatus based upon these objects: 1. To bring the
limb into such a position that no stress is made on the synovial mem-
brane  and ligaments,  that  no danger is incurred of spontaneous
luxation, and that will allow (as in cases of anchylosis) of the easiest
exercise to the limb ; 2. To retain the part in this position during a
greater or less  length of time, as may be required to complete  the
cure.
   Among other  remedies  of a  local character, M.  Bonnet has' de-
rived great  advantage in articular diseases from transcurrent caute-
rization with the red  hot-iron,  frequently  repeated, eight or  ten
times for example, on the same scars—also from the moxa, for which
purpose he prefers the large Egyptian moxa.
   Double Encysted  Tumor.—Dr. W. L. Atlee, of Lancaster (Penn-
sylvania), gives a very interesting account of the successful removal,
by him from a healthy, robust boy aged four years, of an enormous
spherical double  encysted congenital tumor on the right side of  the
trunk, which overlaid* several  of  the lower ribs and the  abdominal
muscles on that side, encroaching even upon the internal  abdominal
ring.    It was closely adherent by a broad base to the tissues men-
tioned. On making a long incision over it in the direction of the fibres
of the external  oblique muscle, he finally succeeded by a tedious dis-
section, rendered the more so by the obliteration of the sub-cutaneous
cellular tissue,  in extracting the  entire mass.   This was found to
consist of two distinct hemispherical cysts, one within the other, and
both filled with serum, the intervening space between the two being
filled up by small oval hydatid-like cysts containing pink-colored
serum and which communicated  with each other by  narrow necks.
Tough fibro^cellular  aponeurotic bands ran over the inner surface of
the two principal cavities and connected the whole structure firmly
together, giving it the  appearance of the interior of the  ventricles
of the  heart.   (Amer. Journ. Med. Sciences, vol. VII., new series,
Philadelphia, 1844, p. 84-88.) T.] 
108          NEW ELEMENTS OF  OPERATIVE SVRGERY.
                        CHAPTER IX.

                       FIBROUS TUMORS.

  Among the concrete tumors  which  remain to be spoken of, I
have a word to say of those which are known under the name of
fibrous tumors ; not that I propose to treat now of polypis under this
name, (de ce nom,) but of tumors which appear to originate  from a
concretion of lymph or effused blood in the tissues, or from a trans-
formation or limited hypertrophy in some circumscribed part of the
natural tissues.   These tumors, which are ordinarily globose, (globu-
leuses,) though  more or less  bosselated, are hard, elastic, indolent.
and of a grayish color and of a  fibrous and mammellated structure.
Some excavate for themselves a species of cyst in the tissues, the
different  layers of which latter they flatten out  (etalent) and com-
press ;  others are blended so intimately with the surrounding  tissues
that it is impossible to separate them from these by enucleation.  I
have seen some tumors of this kind which had acquired the size of
the head  of an adult, and it is rare they are found of much greater
dimensions except in the interior of the pelvis ;  most usually they do
not exceed the volume of a small nut, or that of an egg or the fist.
As they  occasion no  inconvenience  in  themselves, they  may exist
during life without any real  danger to the patient.  As they are,
moreover, wholly incurable by any other mode than  by extirpation,
it is imprudent  to meddle with them, unless by their volume, weight
or position they occasion some actual trouble or disturbance  in the
economy, or too great a degree of deformity.

                              §1-
  To effect their separation by a ligature would not be possible or
at least not  advisable, but for  such as  had  a sufficiently narrow
pedicle or neck at their union with the skin.  In regard to this. I
have only to refer to what I have said of the ligature for  tegumen-
tary tumors, properly so called.

                             §11.
  When  we have decided  upon  extirpating them, we have scarcely
else than to recall the rules for the extirpation of  fatty, rather than
those for  lymphatic tumors.  As they are  generally disconnected with
any kind of constitutional affection, and  constitute  almost always a
disease purely local and separate from  and independent of all the
natural tissues, and represent,  in a word,  a simple foreign body in the
midst of the organs ; a fibrous tumor may be extirpated with every
degree of security, and without the necessity of removing with it a
large portion of the sound parts.   Being rarely liable to return, and
leaving a wound which is pliant (souple) at the/bottom, and destitute
of any dangerous germ, we  are enabled  after effecting their abla-
tion, to undertake immediate reunion  with  every possible  chance of
success.  What I have just said, however, is applicable only to those 
FIBROUS TUMORS.
109
fibrous tumors which have, so to speak, dug out for themselves a cyst
in the midst of the cellular tissue.  In fact, in respect to the others,
it would be impossible to isolate, and preserve the skin which covers
them.  There are in fact some  which,  under this  point  of view,
would lead to unexpected  embarrassments if we attempted to operate
upon them by the ordinary methods.   A  porter who had  upon his
nape a fibrous tumor  of  the size of the  fist, came  in  1831 to the
hospital of La Pitie  to have it  removed.  This  tumor was mova-
ble, with  a  large base, indolent and  devoid of any change of color
upon the skin.  With the  view of laying  it bare, I made  a crucial
incision upon it, but soon discovered that there was no limit between
its tissue and that of the skin.  It consequently became necessary to
cut out the four flaps in their whole extent at the expense of its  ex-
ternal  surface ; and when  I had extirpated it, I was enabled  to ascer-
tain that  it was  continuous  at all its  points with  the  tegumentary
tissue,  of which  it seemed to be nothing more  than  an  inflated
(rarefiee) layer enormeusly  hypertrophied.  The operation was  fol-
lowed  by no serious accident; only that  the  skin  in  the neighbor-
hood continued  hypertrophied after the cure  of the wound, so  that
the patient remained almost as deformed as before the operation.  I
have since seen two instances of similar tumors, one at the nape  and
the other at the  middle of the back.   A third fell  under my obser-
vation in  November, 1838.  A man 45 years of age had on the me-
dian line, or a little to the right of the anterior half of the  cranium,
a tumor which at its point descended down to the forehead, and  was
prolonged upwards to a line with the parietal protuberance.  This
tumor  which had formed  gradually and  without  any appreciable
cause,  and which appeared  to be situated upon an  incipient exos-
tosis, had perhaps like the preceding been  produced by the  repeated
frictions to which the diseased region  had been subjected,  and  was
moreover movable, without any well-defined limit, and  in every
respect indolent.   In whatever manner it was attempted to displace
it, it was  always  possible to  recognize in it a disc or plate of integu-
ments  excessively thickened or distended, with an entire absence of
degeneration or transformation of  tissues.   But for fibrous tumors be-
ing unaccompanied with this last feature, I should in fact deem those
of which I speak a species  of flattened elephantine tumors of very
limited extent.
  It follows from these remarks, that in order to effect a perfect cure,
it is necessary to remove  at the  same time with the tumor, every
portion of the skin which  is  adherent to it  or constitutes a part of it.
In the three last cases threfore I have just mentioned, I refused to ope-
rate, inasmuch as extirpation is not in  my  opinion  justifiable, but for
those tumors which continue to increase, or which become the source
of serious accidents.   Some other fibrous tumors, which also include
the  skin in their composition, are however distinguished from the pre-
ceding in  these particulars, viz: that well-defined limits soon become
established between them and the sound  tissues, that the  elements
of which they are constituted  are no  longer  in a normal state,  and
that they seem susceptible of dangerous  degenerescence and trans-
formation.   A man of  about 50 years of age, and who came to  the
hospital of the faculty in 1825, had in  his right groin a tumor of this 
110
NEW ELEMENTS OF OPERATIVE  SURGERY.
description, which was of half the  size of the head, and extended
obliquely from a line with the vessels as far  as to the posterior  part
of the thigh below the scrotum.  It  was extirpated by M. Roux, and
we found that the entire tumor was  homogeneous, and formed  of a
tissue,  the section of which  presented some analogy  to that of
Gruyere cheese.   The  patient got well, but in  the following year
there returned a similar tumor, which was also extirpated ; without
however preventing him  from succumbing at a later period  to the
effects of a schirrous tumor which formed on  the  front part  of the
pubis.   As to fibrous tumors,  which are independent of the skin,
they may be  developed upon almost all  the regions of the body and
especially  in  the sub-cutaneous tissue.   In a woman  operated upon
successfully by M.  D. Lasserve, (Cas de Chir., etc., p. 17, gg. 1. Per-
igueux,) he was enabled  to extract a fibrous tumor of twice the
size of an egg situated upon the upper lip, in such manner from the
midst of the  tissues as to leave  but very little deformity.  A patient
in whom M.  M'Farlane  (Encyclop. des Sc. Med., 1838, p. 56,)  had
removed a fibrocartilaginous  tumor which  was situated  upon  the
side, between the transverse and oblique muscles, died of peritonitis
in the course  of 31 hours.   A  young lady on the contrary who  had
above the  crural arch, a  fibrous, movable  tumor, of the  size of a
small egg, recovered perfectly from the  operation which I had  re-
commended  to her, and M.  Yvan junior has communicated to me a
similar fact.  A patient who had one of the size of  a large nut on
the dorsum of the metatarsus, came  to have it  extirpated, at  the
hospital of  La Charite in 1836.  Having divided the integuments by
a simple incision, I seized  the  tumor with an erigne and  proceeded
immediately  to its removal.  The  consequences of the operation
were simple,  and the tumor did  not reappear.  Another patient ope-
rated upon in 1837 at the same hospital, for a tumor in every respect
similar, and which was situated two inches above the external malle-
olus, between the  tendo achillis and  the fibula, was cured in  the
same way.   I have removed  from  the  breech of  an adult man a
fibrous  tumor as large  as an egg, which did  not go deeper than  the
aponeurosis and was  never reproduced.  Another patient  whom I
operated upon in 1835, had one of the same nature between  the anus
and tuberosity of the ischium.   The cure of this  also was radical.
But a woman who  had one of  these tumors on  the dorsum  of the
point of the sacrum, and which adhered throughout its deep-seated
surface to  the periosteum, thus rendering its dissection sufficiently
delicate, was  seized with an  ichorous suppuration, caries of the  pel-
vis and  general accidents, which caused her death at  the expiration
of a month.  Tumors of this description which I have met with in
the breast or  the head, will be referred to again in other articles.  I
will merely add that whatever  be  their situation, if  the skin which
covers them shall be found  too much attenuated or actually degene-
rated, it will  be advisable to remove  an ellipse from it or take it
away entire at the  same time as the tumor, rather than  attempt to
dissect it.   A youg girl of eleven years of age had on the radial  and
dorsal side of the root of the middle  finger, a hard, bosselated,  black-
ish-looking tumor of the size  of a large nut.   With this tumor,  which
I  isolated from the hand while respecting the metacarpophalangeal 
CANCEROUS  TUMORS.
Ill
articulations and neighboring extensor tendons, I removed also a flap
of integuments one inch in length and six  lines in width.  A strong
and robust man had, from the age of 20 years, above the outer mal-
leolus,  a globular  and very movable tumor  covered with  attenu-
ated reddish-colored  integuments.   Having seized this  tumor with
an erigne, I circumscribed it in an ellipse of the skin, and removed the
whole of it while dissecting its deep-seated surface.  By this mode,
the operation is prompt and certain, and ought to have the preference
when it does not cause too great a  loss of substance.   With these
exceptions, fibrous  tumors must be submitted in every respect to the
rules of treatment  indicated for lipomatous tumors.
                        CHAPTER  X.

                      CANCEROUS TUMORS.

   All the tumors of which I have  hitherto spoken, come within the
 class of tumors  denominated benignant  by the  English surgeons.
 Those on the contrary designated under the title of cancerous tumors,
 have a character of malignity which has always served to distinguish
 them from the others.   Their tendency to repullulate and to multiply
 without end, has  ever constituted them the opprobrium of surgeons.
 If they are attacked on  one side, they soon reappear on the other.
 Frequently the most simple operation will be sufficient to irritate (ex-
 asperer)  them and aggravate all their  symptoms ; no method of
 treatment, even at their first appearance, can promise any certainty of
 effecting their radical cure.  There are a great many surgeons more-
 over, who advise that we should do nothing with them, or make  use
 only of palliative means.  Nevertheless,  upon  the supposition  that
 these tumors are  primarily a local affection, and admitting also their
 malignant character, I lay it down as a principle to destroy them as
 soon and as effectually as possible.   To me it  appears evident, that
 if there is even room to hope for their cure, it must be  by means of
 their mechanical or chemical destruction, and by attacking  them
 before they have had  time to introduce new morbific germs into the
 rest of the system.  All the varieties of tumors  however, denomina-
 ted  cancerous, do  not  exhibit the same  tendency  to repullulate.
 Those which in this respect should be placed  at the head are  the
 melanotic (melaniques) tumors;  then come the enpephaloid tumors;
 scirrhous tumors would be placed in the third line, and the colloid at the
 bottom of the scale.  These particularities, which I will discuss more
 at length while speaking of the extirpation of the breast, convey an
 idea of the course which the surgeon ought to pursue in regard to the
 prognosis and treatment of cancerous tumors in general.

                            ' §1.
  Should the tumors be purely melanotic, composed of flocculi or clots
of anthracine, we should avoid performing the slightest operation 
112          NEW ELEMENTS OF  OPERATIVE SURGERY.

upon them, provided there existed at the same time with the principal
nucleus some spots or granulations of the same nature, either  in the
neighborhood or in other regions, even  though the patient should in
other respects appear to be in excellent general  health.  A man in
other respects in good health, came in  1834 to  the  hospital  of La
Pitie for  the removal of a melanotic tumor upon the temple,  of the
size of a large, nut.  This  tumor,  which M.  Olivier of Angers had
extirpated a year before, and which had scarcely then the size of a
small nut, had reappeared only since the last three months.  All the
internal organs performed their functions freely.  No other  tumor
existed upon the surface of the body, and the patient, who considered
himself in other respects in perfect health, retained also  all  his nat-
ural  embonpoint.   I  extirpated  the  tumor; the operation presented
no difficulty, and everything went  on  well for about twelve days.
The wound then became sanious, general symptoms made their ap-
pearance, and death took place six day s after.  The opening of the dead
body disclosed the fact that innumerable melanotic  tumors existed in
the interior.  The liver especially was riddled with them ; they were
found  here in hundreds, some having the size of an ordinary pin's
head, others equalling that of a small egg, and all presenting precisely
the appearance of truffles, either in  their crude state or reduced to
pulp.  A patient who for twenty years had had  a  melanotic  tumor
(grumeau) on the dorsum of the foot, without ever having experi-
enced  the slightest symptoms of general disease, desired in the  month
of October, 1838, to have it removed.   The tumor, which was only
of the  size of a small nut, was readily extirpated.  Seeing that the
suture of the  wound threatened to  cause a phlegmonous erysipelas,
I returned to the simple dressing and union by the second intention. Up
to the  present time there is no appearance  of a return of the disease.
But will  this cure remain permanent ?   A woman who had  under-
gone amputation of the great toe  for a similar tumor, wras not yet
cured  of her wound when the ganglions of the groin  and iliac fossa
had  already become  attacked to such an extent  that in less  than a
month she had in those regions enormous  black masses, which soon
caused her death.  However slight therefore may be the grounds, for
believing that there shall  exist any remote engorgement or internal
derangement, the surgeon should  rank melanotic tumors in the cat-
egory of the noli me tangere.

                              § II.
   In the case of cerebroidal (cerebroides)  tumors, we must proceed
nearly in the same way.   Nevertheless, if the disease exists in a sub-
 ject who is still  young and in other respects in good health,  and  if
the lymphatic ganglions situated above remain wholly unaffected, and
the tumor is of recent date and perfectly well defined, the chances
of cure are assuredly greater and more  numerous than in the case of
melanotic tumors.

                             § III.
   In a scirrhous tumor there is less tendency  of reproduction in the
midst of remote  organs ;  but more frequently  than the two varieties
of which we have been speaking, it reappears upon the place only or 
CANCEROUS  TUMORS.
113
in the neighborhood of the part which the first tumor occupied.   It
is because this class of tumors present themselves under the form of
a degenerescence or transformation of the natural tissues, as well as
under that of abnormal productions and simple foreign bodies.   It re-
sults from this that a scirrhus is usually badly defined, and that it often
sends out to the circumference  radiations or roots whose terminations
cannot be traced without difficulty.   Moreover, it is  advisable when
we have decided upon operating, to remove at the same time a suffi-
ciently large  proportion  of sound parts, and we should abandon the
attempt to relieve the  patient, if there existed  in the neighborhood of
the tumor, either beneath the skin or even in the substance  of the
integuments,  the slightest indurated  plate (plaque) or smallest larda-
ceous radicle that could  not be extirpated.   In cases of melanosis and
encephaloid matter, our attention is to be directed towards the con-
dition of the remote organs; while in cases of scirrhus on  the con-
trary, it is the vicinity  of the tumor which is to be specially examined.

                              §IV.
   Colloid tumors, which besides being sufficiently rare, often attack
the bones, have this peculiarity, that they usually remain local, and well
defined like cerebroidal tumors, at the same time that they seem to
be concentrated on the  organ which was their primary seat.  It is
these, consequently, in which the operation presents the most chances
for success.

                              §V.
   The  operations proposed  for cancerous tumors are the same as
those for the  tumors  designated in  the preceding articles.  It is not
my intention at this moment to speak either of internal remedies, or
of the topical applications purely discutient or resolvent that have
been so much lauded by some persons; experience  having proved
that such means are  totally inefficient when legitimate cancerous
tumors are under  treatment.   I would say the same of compression,
if it had not  found among us new advocates.  For myself, I  do not
believe that  compression has ever  radically  cured or  dispersed
tumors belonging  to either of the four kinds which I have just been
treating of.   If it should be  contended that it at least has the advan-
tage of lessening or extinguishing the engorgement,  and thickening
of the neighboring tissues, (l'empatement du voisinage,) and of thus
rendering the other operations more easy, I would reply, that this is
a specious argument which cannot  sustain a  close examination.  In
fact, cancerous tumors  are  not generally  accompanied  but with a
very slight engorgement of the  surrounding parts ; moreover, to have
any real hope of success, it is important to remove with  the tumor a
sufficiently large portion of sound tissue.   But what would compres-
sion do in a case of this kind ?  Suppose it should have shrunk the
tumor and  diminished its volume ; the instrument  might be carried
nearer to its confines,  but we should to the same extent increase the
chances of a return.    Unless, therefore,  inflammation  or chronic
engorgement of the  cellular  tissue should have  been  established
around the principal disease, compression must be rejected from the
curative treatment of  cancerous affections.
                               8 
114
NEW ELEMENTS OF OPERATIVE SURGERY.
  A. Cauterization.—The destruction of cancers by means  of the
hot iron  or chemical caustics has  been eulogized  at every epoch.
In spite, however, of the successes obtained by means of their pow-
ders or pastes, they had been generally renounced by Rousselot, and
Frere Cosme, when their efficacy has been again announced by prac-
titioners in Germany, England and  France.  Arsenical caustics and
nitrate acid of mercury, besides being hardly applicable except to
superficial  cancerous plates,  have,  moreover, the inconvenience of
being partially  susceptible of absorption, and of thus exposing  to
actual poisoning.  The zinc  paste, introduced into practice  by M.
Canquoin, having the property of mortifying the  tissues in the man-
ner of a punch, to such depth as is desirable, would always deserve
the preference if it would adapt  itself to the anfractuosities and ine-
qualities of certain tumors, or did not exact  the previous destruction
of the epidermis.   Whenever  this paste  cannot be  applied with
facility we may make use of  the Vienna caustic or paste, which has
the advantage of being introduced in the manner of a pulp into every
possible chink, and of moreover cauterizing with great energy ; (see
Vol. I.)   Potash so  called, butter of antimony and the concentrated
acids are, therefore, excluded from the  catalogue, in consequence
of their tendency of fusion into  the sound  tissues, and their  uncer-
tainty.   But  caustics, of whatever  description they may be, ought
they to have the preference over .the operation, when the question
under consideration is cancerous tumors ?  On this point it is neces-
sary that we  should understand ourselves;  if the skin is sound and
the tumor movable, and can  be  cut out  by a bistoury so as to leave
a wound whose  lips may be  more  or  less perfectly  approximated,
caustics will not be admissible  except in those  patients who  abso-
lutely refuse extirpation.   If the tumor has  more width  than thick-
ness, includes the integuments, is ulcerated upon  its  surface, is situ-
ated at the bottom  of an ancient wound, and prolonged into  some
cavity to a great depth, and soldered  (plaquee) as it were  against
the bones ; if, in a word, it is not  possible to remove the cancer with-
out causing a loss of substance equal to the  integuments, then caus-
tics, and the zinc paste, especially that of Vienna,  may be made trial
of, and would in  some cases even deserve, I think, the preference.
  B. As to the cutting instrument  and  the  ligature, they should be
employed here according to the rules which I have pointed out under
other tumors, especially for  fungous sanguineous tumors.   I  shall,
however, return to this subject in detail in treating of tumors of the
breast.  This last remark renders it unnecessary for me  to treat of
cancerous tumors according to the regions or organs  they attack.  I
will  only add that for  a tumor  of  the foot, which extended  to the
bones of  the tarsus, I deemed it proper to amputate the  leg; that in
a case of cerebroid tumor of the calf, I amputated the leg at the knee;
that an enormous mass of the same nature which occupied the leg of a
young sailor, induced me to give the preference to amputation of the
thigh; that for a scirrhous tumor of the metacarpus, I amputated the
wrist; that for a colloid mass upon the radius, I amputated the fore-arm;
that analogous tumors have induced MM. Luke, Janson,  Roux, Cas-
tara and others, to amputate the  shoulder; that I have disarticulated
the arm for a disease of the same kind;  and that  as a general rule 
CANCEROUS TUMORS.
115
 we ought to prefer  amputation of the limb  to extirpation  of  the
 tumor, whenever the disease penetrates to the neighborhood of  the
 bones, so as to implicate a portion of the' muscles, nerves, and large
 vessels.   Underneath the skin, on the contrary, and in the substance
 of the tegumentary tissue, it is advisable to treat cancers by simple
 extirpation, or by caustics.  A woman who had a cerebroid plate as
 large as the hand between  the umbilicus  and the epigastrium, was
 cured by  means of  two applications of the  zinc  paste.   Another
 woman,  who had upon the thorax, below the left shoulder, an analo-
 gous  plate which was hard and without  ulceration, was  relieved  by
 the following process: having raised it up a little, I glided the knife
 under it flatwise, and immediately detached its lower half, comple-
 ting its isolation with a second cut by returning the edge of the knife
 from above.  The wound, which did well during fifteen days, having
 taken on a sanious aspect, and become covered with inequalities of a
 bad appearance, the idea suggested itself of covering it with a layer
 of  zinc  paste.  After the fall of the eschar,  thfe  wound went  on
 rapidly to cicatrization.  I have  met with  and  destroyed plates and
 tumors of the same description upon the leg, thigh, around the knee,
 at the breech, upon the side, in front of the chest, on the side  of the
 neck, and upon the  cranium and face in  an infinity .of cases, but
 without  the  operative process having exacted any thing special that
 requires to be related here.   It will also be under  the head of can-
 cerous tumors of the br-east, that I shall  have an opportunity of dis-
 cussing  the advantages and inconveniences of immediate or second-
 ary reunion, and the different kinds of anaplasty that may be em-
 ployed after the removal of cancers in general.

                      [cancerous tumors.]

   In thirty cases of cancerous tumors of the  breast  treated by M.
 Tanchou,  (see  Journ.  des Connaiss., &c, de Paris,  Dec,  1842,
 p. 253,)  he has obtained, he asserts, ameliorating  results, and more
 or  less complete dispersion of the tumors, by means of graduated and
 methodical compression, by  compressors specially adapted to this
 purpose, and also by  external applications of sachels containing iodate
 of potash, pulverized sponge, (eponge en poudre—meaning, probably,
 burnt sponge, a remedy of 2000 years' standing in bronchocele,) chlor-
 hydrate  of ammonia, and chlorhydrate  of soda;   also other com-
 pounds made with  the  powder  of sponge, nitrate of potash, and
 Florentine iris.  He proscribes all surgical operations.
  M. Martinet de la Creuse  has  ingeniously proposed,  and  several
 times succeeded, (see Malgaigne's Manuel de Med.  Operat., 4th edi-
 tion, Paris, 1843, p. 118,) in making for the wound,  after extirpating
 scirrhous and carcinomatous tumors, a healthy flap  of  sound skin
 borrowed by the anaplastic method from  the neighborhood.
  M.  Ollivier, who has otherwise written so well  on these tumors,
 proposes  the daring  expedient (op. cit.)  of inoculating  their centre
 with hospital  gangrene!
  From statistical observations obtained by M. Leroy d'Etiolles, from
every department of France, (see the result of these researches com-
municated  by him to the Academy of Sciences of  Paris, February 
116          NEW ELEMENTS OF OPERATIVE  SURGERY.
20, 1843, in  the Journ. des  Connaiss.,  &c,  of Paris, Mai, 1843,
pp. 214, 215,) on the subject of Cancerous Diathesis and Degenera-
tion, we learn the fact that Out of two thousand seven  hundred and
eighty cases,  communicated from  174 practitioners in those depart-
ments, there were 1192 who were not operated upon, or who died with
the disease upon them.   Of these, 18 lived more than 30 years after
the development of the disease, which, after reaching a certain point,
remained stationary and indolent.   But out  of 801  operated upon,
either by the knife or  caustics, four only lived to the same length
of time.  Of those who lived from 20 to 30 years, we find 34 who
were not operated upon, and 14 in whom an operation was performed.
Of those who lived  from  6 to 20 years, there were  88 who were
operated upon, and 228 in  whom the tumor was not extirpated.  So
that the balance in cancerous tumors, so far as the prolongation of
life is concerned, is clearly not in favor of the operation.
   So far as regards a short term of existence, the difference appears
to be in favor of the operation ; thus counting from the first appear-
ance of the disease, the average prolongation  of life  in those not
operated upon is, for men,  five years, and for women, five years and
six months;  while in those operated upon, the average, for men, is
five years and two months, and for women, six years.   And in these
cases, we find the average of time that expired before the operation
was, three  years  and nine months for men, and the time after the
operation, one year  and  five months only;  while for women  it is
three years  and six  months before, and  two years and six months
after the operation.
   To those who say that the return of the disease is too often owing
to the operation for extirpation having been procrastinated, by which
time was allowed for  degeneration to  be  established, M.  Leroy
d'Etiolles replies, that among the numbers in this table in whom the
disease was reproduced, 61 had the tumor extirpated in less than a
year after the disease made its first appearance ;  and that 30 patients
who were operated upon  five years after its first development, did
not have a return of the disease,  and that the same result occurred
in 22 others who were not  operated upon until more than ten years
after the first appearance of the disease.
   In conclusion, M.  Leroy remarks, that though it may be impossi
ble to determine beforehand, whether a tumor will remain stationary
or become cancerous, it is  worthy of investigation to ascertain if the
cancerous diathesis  does  not produce in the  subjects in whom it
exists,  certain characters (as for example,  a  change in the condition
of the fluids of the  economy,)  by which it may be recognized.

Fibrous  Tumors  (corps fibreux)  in general—Fibrous Tumors of
             the Breast (corps fibreux de la mamelle.)
   The justly distinguished M. Cruveilhier, in a memoir read before
the Paris Academy of Medicine, on Fibrous bodies of the Breast, (des
corps fibreux de la mamelle,)  (read Jan. 9, 1844—see  this memoir in
the Journal des Connaissances Medico-Chirurg., Paris, March 1,
1844, p. 8 to p. 93,)  conceives that they  have not been sufficiently
studied, that they are a very frequent disease, (lesion,) and that they
are constantly confounded  in practice with  scirrhous and indurated 
FIBROUS TUMORS.
117
 cancer of these organs, and  as such, subjected tP extirpation.   He
 believes that  such tumors are incapable of degeneration, that they
 never require extirpation,  that  they are in some  sort functional,
 (facultative,)  that when extirpated they are never reproduced, (ne
 repullulent jamais,) in the proper sense of this word, but are a purely
 local lesion and organic  production, independent of every kind of
 general infection of the economy, whether as a cause or effect.
   Neither Boyer nor Sir  Astley Cooper have mentioned this disease,
 nor is it more than obscurely  alluded to by more modern writers.
   Fibrous Bodies in general.—Such growths were for the first time
 described  by  Bayle as found existing in the uterus.   Like Bichat,
 however, who considered that  each tissue had its own lesions, he
 erroneously thought these bodies were confined to the uterus.  True,
 the conditions in  this organ  are most favorable to their production
 and development,  but they are met with in all organs where fibrous
 tissue is found, and are composed of two orders:  1st. As vegetating
 fibrous bodies, growing  from, or implanted in,  (implantes,) a mem-
 branous surface  in the manner of a  vegetable, like fibrous  polypi
 of the nasal fossas, formed at the expense of the periosteum ; fibrous tu-
 mors of the dura mater ; and fibrous, cartilaginous and osseous tumors,
 which grow from  the periosteum  of  the bones and which may be
 called osteo-chondophyte.   2d. As non-vegetating fibrous bodies, (les
 corps fibreux non-implantes,) which grow in the interior of the or-
 gans, (au milieu des organes,) such as the fibrous bodies of the uterus,
 those of the breasts, ovaria and testicles.
   Their general characters, according to the author, (M. Cruveilhier,)
 are: 1st. That of situation, always in the midst of the fibrous tissues.
 2d. That of form and size.  Their form is generally spheroidal^ some-
 times irregular upon the  surface, sometimes mammellated, at other
 times deeply furrowed, (sillonnee,) giving rise  theh to the lobular ar-
 rangement.   Their size varies from a cherry-stone, or even a millet-
 seed, to that of the'head,of an adult, or even greater, their weight being
 sometimes equal to 45 demi-kilogrammes.  3d. The characters de-
 duced from the mode of adhesion and connection of the fibrous bodies,
 with the tissues, in the midst of which they are  developed.   Vegetal
 fibrous bodies (above) seem to be mere prolongations of the tissue of
 the organ, but all other  fibrous tumors are united  to  the parts in
 which  they are developed, only by means  of an  exceedingly loose
 cellular tissue, so that these bodies may be enucleated with the great-
 est ease by means of the finger, a blunt probe or slight traction, without
 ever requiring the aid of a cutting instrument.   In this respect these
 bodies are, in  their isolation or independence of organization, similai
 to encysted tumors, with which also they are sometimes confounded.
 4th. In their characters of texture, fibrous bodies or tumors are of an
 extreme density, similar to cartilage, or to the unimpregnated uterus
 proper.  If the fibro-cartilaginous tissues of Bichat could be sustained,
 fibrous  bodies would  come under them.   These bodies are, in fact,
composed of parts arranged linearly and  belonging to the albugine-
ous tissue,  strongly pressed against each  other, interlaced togethei
in every possible direction, and  often  divided into many groups of
fibres,  and pelotoned (pelotonnees) in such manner as to constitute
distinct masses or  lobules.  They  are provided with  veins whose 
118
NEW ELEMENTS OF  OPERATIVE SURGERY.
trunks are on the surface, and their minute branches distributed to
their substance.   When these tumors are lobulated, veins of greater
or less size are found in the intervals of the lobes.   These veins com-
municate  directly with the proper tissue of the organ in which the
tumors are.  No arterial vessel can be traced into these tumors—
injections  from the neighboring arteries will not penetrate them, and
no lymphatic vessel or nerve  has yet  been shown to exist in them.
They therefore possess no other organic"element than a fibrous tis-
sue, supported (anime)  by veins, and are reduced down to an obscure
nutrition sustained by a feeble oscillatory movement of venous blood.
5th.  The  evolution of fibrous  bodies presents the same characters
at their first appearance as at their complete development, whether
the tumor be only of the  size of a cherry-pit, or has attained that of
the fist (poing) or head.  Facts have satisfactorily established, in the
mind of M. Cruveilhier, the conclusion that if some of these bodies are
primarily  fibrous, and afterwards  become cartilaginous  or osseous,
a number of them will present one or other of these last mentioned
characters from  the beginning.  6th. The consecutive pathological
characters of fibrous bodies are: a. The consecutive results produced
by fibrous bodies on the surrounding tissues, which  consist  only in
the inconvenience occasioned by their weight, being in truth nothing
more than parasitical foreign  innocuous  growths, having a peculiarly
limited vitality, which  causes no  other change in the tissue in the
midst of which they are developed than  some indispensable modifica-
tion of nutrition and circulation;  b. The consecutive  changes which
are effected in the fibrous bodies themselves, and which are exceed-
ingly limited.  These bodies may indefinitely increase, or they may
remain stationary.  Many facts authorize M. Cruveilhier  to believe
that they  are susceptible of an  actual diminution of volume, or a sort
of atrophy, or may become  encrusted or penetrated with phosphate
of lime, or the seat of an oedema, which dissolves the elements that
enter into  their composition and makes manifest their lobular arrange-
ment.  In this case, the tumor is often impregnated with a liquid which
possesses,  in appearance at  least, much analogy to that of synovia.
Fibrous bodies are  incapable of cancerous degeneration.  " I believe
also,"  says M. Cruveilhier, " that  I am sustained in saying (and this
character is of the highest importance) that there is an incompati-
bility between fibrous production and cancerous degeneration."
   To  ascertain if these general characters  apply to certain  organic
productions observed in the  mammas, he invokes a great number of
clinical facts, and some from pathological anatomy.  Of all other secre-
ting  organs in the animal economy, the mammary gland, says M.
Cruveilhier, presents the  greatest  quantity of fibrous tissue,  and has
besides adipose tissue, two essential elements that  enter into its tex-
ture; viz., 1. A fibrous woof (charpente) or gangue; 2.  Glandular
granulations or grains, which latter cannot be well examined, except
in women who have died during pregnancy, and especially after par-
turition, during any period of lactation ;  that except under these cir-
cumstances, mammary granulations are but very little developed,
which feeble development is then in correspondence with the almost
complete  absence of secretion in this organ; that after the cessation
of the menses, and especially in very old women, the granulations 
FIBROUS TUMORS.
119
seem  to  disappear  entirely, leaving the fibrous woof only remain-
ing.   The mamma, therefore,  possesses in a high degree, the condi-
tions favorable to the development of fibrous bodies.
  In the  mammas, the fibrous bodies or tumors appear as small sphe-
roidal tumors, from  the size of a millet-seed or  cherry-pit  to a pullet's
egg, or larger.  Their surface is sometimes uniform, or mammellated
(mamelonnee), and  their  hardness  is extreme,  or as it were, stony
(pierreuse).   Generally sub-cutaneous, they may  also be developed in
the midst of. the tissues of this organ;  and are for the most part cir-
cumscribed, perfectly distinct from the  tissue of the mammary gland,
adhering to it only  by a  very loose tissue, apparently perfectly inde-
pendent of this gland ; they possess the mobility of a lymphatic gan-
glion, (i.  e. gland,) and like that rpll under the finger, from whence
doubtless the name  of glands, given to them in common  parlance.
   Thus are these characters precisely those that M. Cruveilhier has
given of fibrous bodies in general.
   The absence, hitherto, of all clinical and anatomical descriptions of
fibrous bodies has  caused them to be constantly confounded with
other lesions  of the breast, and especially with scirrhous degenera-
tions of that  organ—giving rise to the same rules of treatment, and
the same prognosis as applicable to both.   In  respect both to fibrous
bodies and to scirrhous degenerations, it has been asserted that such
 fibrous tumors of the breast as are commonly  called glands, may ex-
 ist for a long time without undergoing any perceptible growth,  but
 that after 40, 45 and 50  years of age, they increase with  great rapid-
 ity, and  invading  the surrounding parts, vitiate the whole animal
economy,  and present all the  characters of an incurable cancer.
 Hence, as the consequence of such ideas, was that of the necessity
 of immediate extirpation—and  that the sooner, therefore, this  was
 done after these tumors  appeared,  the less the  danger.  This was the
 sole mode of treatment; not that  practitioners asserted that such de-
 generation must  always ensue, but being  ignorant of any diagnostic
 marks between  cancerous tumors and those incapable of such  de-
 generation, " they preferred ten unnecessary extirpations to the omis-
 sion of one that was absolutely essential."
    Even so little has been known of the pathological  anatomy of
 mammary lesions,  that encysted turnors themselves and  cedematous
 indurations of these organs, are usually confounded with cancerous tu-
 mors, and often submitted like the last, to the  general law of extirpa-
 tion.  " Such also, (says M. Cruveilhier, with  great  candor, while
 advocating,  distinguished anatomist and  surgeon as he is, humane
 doctrines so  honorable to him, and so  plainly  deducible from the im-
 portant  truths he  discloses to the profession,) was  my rule of con-
 duct fifteen  years  since.  I postponed the advice to  extirpate only
 to obtain time to prepare the patient for this  operation,  finding  him
 always  tranquil  and resigned,  when  the terrible word cancer was
 pronounced."  Doubts, however, even then arose in M.- Cruveilhier's
 mind, and especially from seeing  in young  girls, scarcely arrived at
 puberty, and in  young women in rosy  health, numerous cases  of
 movable, rolling,  circumscribed,  indolent, and  isolated tumors;  and
 also  from seeing a number of these  tumors  in the  same breast, or
 simultaneously in  both  breasts.  He  asked  himself the question if 
120
NEW ELEMENTS OF OPERATIVE  SURGERY.
 such little tumors, whose discovery was so often due to chance, ought
 ;n reality to be considered a cancer in its first stage.   This sugges-
 tion was strengthened by finding that many women who had refused
 to be operated upon, or in whom he had deferred it, went on for a
 great number of years  under his observation, without any perceptible
 increase of size or degeneration in such tumors, though many such
 women had vbecome pregnant, and suckled their children, and  many
 of them had passed their critical period of life.
   The  fact of non-reproduction (defaut de repullulation)  after  extir-
 pating  tumors of this kind, may also be adduced  as a clinical  proof
 of the innocence of these tumors, and their totally foreign character
 to that of cancerous degeneration ;  for it is well known how common
 it is for true mammary cancers to grow again  after their  removal.
   Proofs deduced from pathological anatomy, in favor of these posi-
 tions, were soon obtained by M. Cruveilhier.  An examination of a
 great number of mammary tumors extirpated for scirrhus or incipi-
 ent cancer (a 1'etat de  erudite)  convinced  him that several of them
 exhibited the  same character of form,  density, and  texture, as  the
 fibrous  bodies of the uterus, and offered  in no respect any of those
 of cancer.  One important fact was established by this eminent ana-
 tomist, viz: that a number of fibrous  mammary  tumors, which, on
 examination, appeared  at first to be full (pleines, i. e. round, uniform
 and smooth) were found, to be  arranged  after the manner of geodes
 (geodes).  That is, on dividing  them in two equal  halves, each half
 could be turned inside out, upon itself, so as to form a hemispherical
 cavity, whose internal surface was then formed by the external sur-
 face of the tumor, and whose external surface was formed by the sur-
 face of the incision.  But  this  now external surface was thick  set
 (herissee) with globular vegetations or fibrous  granulations, some of
 them isolated,  and  others that were branched  after the manner of  a
 polypus ; these fibrous vegetations or globules, which were  superposed
 on each other (qui se modelaient les unes sur les autres) being some-
 times free, and at other times adherent to each other by means of small
 prolongations.  These adjoining (juxtaposes) fibrous vegetations, knots
 or swellings, in the cases described, constituted a cavity without walls.
 In some cases, there was found in the centre of these fibrous bodies,
 a cavity filled by a viscous fluid, analogous in appearance  to synovia.
  M. Cruveilhier has had occasion to see many cedematous 'fibrous
 bodies  of the  breast, which had rapidly acquired a great size and
 were speedily extirpated, and which bodies corresponded exactly with
 the fibrous bodies of the uterus,  their mass being penetrated by a vis-
 cous humor, similar to synovia, and their centre here and there occupied
 by  numerous geodes, without membrane  or cyst, and filled with  a
 liquid matter.  In conclusion, M. Cruveilheir remarks that he consid-
 ers himself upon the strength of such facts,  obtained  from clinical
 observation and pathological anatomy, justified  in adopting  these
 propositions :—1.  The  mammary gland  is subject to the develop-
 ment of an organic  production known  under the name of fibrous bo-
dies.   2. That the  fibrous bodies (or tumors) of the mamma, which
 constitute one of the most frequent lesions to which this organ is
liable  may be distinguished by  certain signs from that kind of indu-
 ration, which succeeds  to  chronic inflammation, and  also from can- 
FIBROUS TUMORS.
121
cerous tumors ;  the  tumor neither  in chronic inflammation, nor in
cancer, being in any manner distinct from the mammary gland itself,
at the expense of which it is formed, and with which it is continuous
without any line of demarcation ; while the fibrous bodies  are com-
pletely detached from the mammary gland and roll under the finger
in the manner of a cyst or lymphatic gland (ganglion).   3.  That as
these fibrous bodies  are incapable of cancerous  degeneration, extir-
pation is  not necessary, upon the supposition (en tant que) that these
bodies may endanger the life of the patient, by the ulterior changes
which may take place in their interior.   Fibrous bodies constitute a
lesion which is essentially Local; their extirpation is, so to speak, con-
tingent (facultative), and would  not be requisite unless from the in-
convenience caused  by their weight and size.   After fibrous bodies
are  extirpated, they  never grow again, (repullulent)  in  the  proper
sense of  this word ;  though new fibrous bodies may be developed in
a breast  which has been the seat of a previous extirpation.
   At the  sitting of the Paris Academy  of Medicine, (January 16,
 1844,) following that at .which M. Cruveilhier read his memoir, an
 animated  discussion  arose among  the members upon the merits of
 the new doctrines therein advanced.  As this discussion (see Journ.
 des  Coiinaissances, &c, Paris, March 1, 1844, p.  124, &c.,) was one
 of a practical bearing, maintained energetically through a number of
 sittings of the learned body alluded  to, it will not be improper briefly
 to notice the leading points and views of some of the most eminent
 surgeons  of  Paris,  (especially as  our  author,  M. Velpeau's  own
 views are also  given in  the debate,) to show what conclusions also
 their experience in  the  rapid progress of surgery, has led them to
 form, up to the present epoch of the history of our art.
   M. Blandin considered fibrous tumors  of the breast rare as com-
 pared with the ordinary tumors  of that organ, and especially with
 its encysted tumors.  He also believed fibrous tumors capable of de-
 generating, that it was impossible  to distinguish them from cancer,
 and  that  there was no danger in extirpating them.  M. Rochoux
 had found by the microscope scirrhous matters scattered through the
 interstices of these  fibrous tumors.  M. Gerdy did not always con-
 sider their diagnosis easy: as an example he mentioned fibro-carti-
 laginous lobular tumors, making  a  crepitus  under the  scalpel, &c,
 and having the same characters as  M. Cruveilhier's tumors, and also
 as Sir  Astley  Cooper's irritable  tumors  of the breast.   Though
 fibrous  tumors may possess analogies to  fibrous tissue, they differ
 from  it.   He  has found three sorts  of tumors: benign, malignant,
 and  the  doubtful, which may degenerate.  The second  exhibit a
 depression of the skin at the centre, when the tumor is compressed
 between the hands,  and are marked by peculiar lancinating pains.
   M. Velpeau  admitted that there were, in fact, mammary tumors
 which did not degenerate, but he  did not consider them  in reality
 the  same  as  the fibrous tumors of M. Cruveilhier, which latter are
 susceptible of this change.  M. Velpeau considers this peculiarity  to
 belong to tumors which he denominates fibrinous (fibrineuses), caused
 by the extravasation of the fibrine of the blood after a blow or a
 contusion.  M.  Cruveilhier, as M. Velpeau thinks, has included such
 tumors under his fibrous order.  The microscopic characters of fibri- 
122          NET," ELEMENTS OF  OPERATIVE SURGERY.

nous tumors have, according to M. Velpeau, been satisfactorily as-
certained  by M.  Mandl;  in fibrinous tumors,  the microscope dis-
closes nothing but fibres and  fibrilli.   But the characters during life
are not always recognizable, and it is rare that we meet with such
tumors except in young  people ; in other words, we meet  them
more  frequently in that class of persons.   M. Velpeau does not be-
lieve  fibrinous tumors of  the breast: capable of degenerating, any
more  than those  of the uterus, at least such a result must be rare.
He blamed M. Cruveilhier for not having entered more into the sub-
ject of th% treatment, and  for confining  himself to proscribing the
operation  without pointing out some  other therapeutic means.   For
his own part, considering that both fibrous and even indolent tumors,
rarely present characters of a very satisfactory nature, and that they
are a  source of perpetual disquietude  to the patients, he is of opinion
that they should always be removed (les operer), this method having
at least the advantage of giving confidence to the patient as well as
physician, (loc. cit. p.  125.)
  M.  Cruveilhier expressed himself gratified with the  remark of M.
Velpeau, that fibrous or fibrinous tumors were not susceptible of de-
generation ;  with which opinion  also M.  Moreau  coincided.  M.
Roux (loc. cit., p. 125) thought the consequences would be disastrous
if the principles of M. Cruveilhier were admitted.  He apprehended
the latter had taken for his type of fibrous tumors of the breast those
that are called fibrous  bodies (i.  e., tumors or growths) of the uterus,
two things essentially  different.   He  denied also  that one  of  their
characters was that of being encysted, as encysted tumors must en-
close  a  liquid, and  such tumors are  rarely fibrous.   He admitted
that many tumors did  not degenerate ; a prognosis to this effect was
a subject of immense  difficulty, and could  only be made of young
persons^   He himself confessed, (and where was  the  surgeon  who
had not) that he  had extirpated  tumors as cancerous which were
not so.  He would not pretend to declare that fibrous  tumors never
degenerated, but thought they did not do so spontaneously, but might
become degenerate (i.  e., cancerous or malignant)  under certain cir-
cumstances.  He opposed  as dangerous, the principle  (loc. cit., p.
126) of M. Cruveilhier, that the operation should be conditional (fa-
cultative;) M. Roux thinks it better to operate even under this  point
of view. He notes the omission of M. Cruveilhier to give the characters
of benign tumors:  M.  Roux says,  in fact, there are  none  such;
they may  however, in  rare cases, be  absorbed by  some spontaneous
process or by means of local  resolvents.   The  operation is rarely
fatal, and  its moral effect alone is a matter of great importance, see-
ing that the tumors do not return.   M. Cruveilhier, in rebutting the
ideas of M. Roux, also remarked  that what were called strumous
tumors of the breast were also confounded with the fibrous ;  but that
such strumous tumors  were neuromas  and not scrofulous.  He went
so far as to say that the existence of fibrous tumors in the uterus was
an immunity against cancer in that organ.   M. Amussat denied the
frequency of fibrous tumors of the breast; thus  the  Dypuytren mu-
seum, so rich in fibrous tumors of the uterus, is exceedingly  deficient
in those of the breast.   He believed they would degenerate, and was
in favor of operating always for such tumors, and even for  a simple 
FIBROUS TUMORS.
123
lipoma (loupes).  M. Berard also took ground  against the opinions
of M.  Cruveilhier.   M. Lisfranc considered fibrous tumors  of the
breast exceedingly rare, as he had ascertained from having extracted
an  immense number of  tumors of the  breast.   Yet  such  as M.
Cruveilhier describes were not uncommon.  He does not think them
exempt from degeneration:  and  expressed himself diametrically hos-
tile to the doctrines of M.  Cruveilhier.
  M. Castel (loc. cit, p. 164) called attention to  the opinion of Bichat
that the  glanduar tissue is  as widely different  as possible from the
fibrous tissue.  M. Cruveilhier remarked that the chie( difference be-
tween  him and his colleagues arose from their attaching a  different
meaning from him to the phrase  corps fibreux.  M. Blandin thought
(loc. cit., p. 168) the therapeutic  part of this question was overlooked,
and stated that he considered it impossible to diagnose such tumors.
He thought the idea too dominant  on M. Cruveilhier's mind, that cancer
was also constitutional and must  return after  an operation.  M. Blan-
din maintained also, that a cancerous condition and  fibrous tumors
were not incompatible.  These fibrous  tumors of the  breast are so
rare that some practitioners, who have  frequently removed tumors
from the breast, declare they have never met  with  them,  as  MM.
 Laugier and Blandin.   M. Blandin explained the non-degeneration
 of  fibrous  tumors of the  uterus at  SalpCtriere, because they were
 usually old women whose constitutions were  dried up—not young, in
 whom, the natural moisture and fluids of the  parts favored such de-
generation.  He avers that fibrous tumors of the breast may become
the germs of cancer; for,  as M. Andral  says,  why should not the
abnormal fibrous tissue  degenerate into cancer when it is admitted
that the normal does.   M. Blandin alluded to the tumor removed by
him from the vault of the palate  and shown to the Academy, and ad-
mitted by M- Cruveilhier to be cancerous—proved so  in fact, and to
be  both fibrous and cancerous by M.  Mandl, who saw in it the can-
cerous globules scattered upon a groundwork (canevas) of pelotones
of fibres—which proof of degeneration of fibrous tumors into cancer,
is to be added to a  similar one of Dupuytren in respect to  those of
the fibrous polypi of the nose.   M. Blandin cited two  other cases
where this cancerous degeneration became even encephaloidal, and
yet its removal was not followed by a return of the disease.  If it
be  admitted, says he, that we cannot make  a certain diagnosis of
fibrous tumors of the  breast, and at the same time that we deny the
possibility of their degeneration,  then ought we  also to operate  upon
all indurated tumors which are not resolvable.
  M. Cruveilhier maintained (loc. cit., p. 169)  that the tumor from the
vault of the palate mentioned by  M. Blandin, was not  a fibrous body
become cancerous, but an  instance offibrous cancer, a very  different
thing. The various abnormal productions always preserve their pecu-
liar characters ; they do not undergo transformation, since cancer re-
mains ■ cancer, and( tubercle continues tubercle, in  the same way as
fibrous bodies continue to  remain fibrous.  He acknowledges that
encysted cancers are never reproduced, but  unlike M.  Blandin, he
deems them exceedingly rare.
  M. Gerdy (loc. cit p. 212,) thought a difficulty arose  in  this  dis-
cussion from  each one  dwelling  upon the peculiar  characters of 
124
NEW ELEMENTS OF OPERATIVE SURGERY.
tumors  separately, instead of viewing them in their ensemble, when
we should  discover a certain class  of tumors, which may be distin-
guished both from scirrhus and from degenerate tumors.   Thus, in
considering these  characters  as a whole, when we find the simul-
taneous existence in the two breasts, or in one alone, of numerous
small tumors, which are hard, elastic, indolent, rolling and clearly
isolated, and the absence of cutaneous folds or depressions when the
breast is pressed between the fingers, as is so  accurately described
by Sir Astley Cooper, we can no longer doubt that  such are fibrous
tumors.  Difficult as the diagnosis sometimes is, there is this thing
certain, that we should not operate when the tumors are clearly be-
nign ; in the opposite case, or if we are in doubt, we should  operate.
M. Dupuy considered that the only difference between scirrhous
tumors that degenerated and those that did not, lay in hereditary pre-
disposition.   M.  Lisfranc thought  the  less frequency  of uterine
cancer, dated from the discovery of the operation, which disclosed
those ulcerations  that  are the most frequent source of it,  and by
which we are enabled to apply a radical cure in season.  M. Amussat
mentioned  a case  of cancerous tumor of the breast, which he had
just  removed, and which, in  the beginning, had presented all  the
characters  assigned by M. Cruveilhier to fibrous tumors.  He contests
the opinion of this surgeon and that of M. Gerdy,  that it is possible
to establish a differential diagnosis between indurated (dures) tumors
of the breast.  The true plan, he contends, is to operate at an epoch
as little distant as  possible from the commencement of the disease,
which is then in most of the cases circumscribed and susceptible of
being totally  eradicated.
   M. Roux (loc. cit.  pp. 212, 213,) persisted in maintaining the diffi-
culty of diagnosticating the benign tumors of the breast, and urged
with all his zeal the  necessity of operating on tumors  of the breast
in good season ; at the  same time repudiating with equal energy, the
opinion of M. Hervez de Chegoin, that we should defer operating for
cancer to as late a period as  possible.   Here this interesting discus-
sion closed.  (Sitting  of the  Academy,  March 26, 1844—Journal
des Connaissances, &c, Paris, May 1, 1844, p. 213.)
   The animated discussion which has taken place at Paris on fibrous
tumors in general, and especially those of the breast, and the difficulty
of establishing their  true character  and diagnosing  them  from can-
cerous and other tumors, has  not ceased, but promises to  incite to
still farther and most important investigations.   The researches, in
fact, made with the microscope, bid fair to give a still greater value to
that instrument than  it  acquired even in the time of Lewenhoeck, or
than has been accorded to it for years past, which  is not surprising,
when we  consider  the  mechanical  improvements" which  art  has
effected in that powerful means of interrogating the internal structure
of every kind of organization.  (See our note on a certain fungous
growth of the testicle,  infra.)
   M. H. Lebert, of Paris, has communicated to  the public (Gaz.
Med. de Paris, March.8, 1845, tome XIII., p. 156 et seq.,)some ob-
servations upon the results obtained by him in examining a tumor of
the breast,  which appear to us to possess a good deal of importance.
The case which M.  Lebert furnishes in illustration, was that of a 
FIBROUS TUMORS.
125
woman perfectly healthy in every respect, aged 32, in whom a tumor
of the right breast had existed for ten years, but only latterly became
exceedingly painful and enlarged, appearing to be a general hypertro-
phy of the gland, without adhesion of the teguments, or any feeling
of isolated tumors in it, but somewhat painful on pressure.  The pain
caused by it warranted its removal by the surgeon, M. Lenoir.   The
microscope proved it to be a hypertrophied portion of the mammary
gland, its general color white, and consisting of numerous globules, and
these having throughout their interior smaller cellular globules, filled
with a reddish fluid, which oozed out whenever the knife was applied.
It had none of the characters of fibro-plastic, nor of cancerous tumors
of the breast.   The surrounding cellular tissue, by the long continu-
ance of the disease,  had also become so hypertrophied and thickened
as to give it the appearance of a cyst.  A diagnostic point elucidated
by  the  microscope, and which went  to show that  this tumor was
nothing more than hypertrophied mammary tissue, was the fact that
it contained throughout  numerous large-sized nerves, which afforded
an explanation also of the acute pains, (not, therefore, to be confounded
always with cancerous disease,) and proved its true character, for no
accidental tissues of new growth contain these or other evidences of
high organization.   These results, moreover, confirm, as is remarked
by M. A. Berard in his recent work on tumors of the breast, the accu-
rate knowledge which Sir Astley Cooper had of this  kind of tumors.
 Those called cysto-sarcoma, as  well as fibrous and hydatid tumors of
 the breast, all belong, M. Lebert thinks, to this species.  The process of
 the formation of those under consideration he thinks is as follows : a
 portion of the mammary  gland or  of many of its  lobes become
 the seat of a  sanguineous afflux or local congestion, whence a more
 active nutrition and hypertrophy, both of this diseased gland and the
 surrounding  normal cellulo-fibrous tissue.   These lobes,  as Sir A.
 Cooper says, become  more prominent outwardly, and finally, are
 attached to the gland only by  a mere pedicle, so as to appear some-
 times quite distinctly  separate from it.  The natural fibro-cellular
 tissue which  surrounds  the mammary  gland, becoming dense  and
 hypertrophied more  rapidly than the  gland  itself, is  mistaken for
 a fibrous tumor, and when filled with an abundance  of fibro-plastic,
 or gelatinous liquid, may have a colloidal (collpide) appearance.  Or
 when this plastic fluid  is deposited  in the interstices of the fibrous
tissue, it may form  compartments (loges) which are ultimately  trans-
formed into small cysts, the globules of which may be considerably
altered by imbibition.   When these cysts  exist in great numbers in
the middle of the tumor, they take on the form of mammary-hydatid,
which, however, must not be confounded with serous-hydatid tumors
of the breast, or those which  contain ecchynocoques, and  which are
sometimes found in the  breast.
   M. Lebert  says, moreover,  that those under  consideration may
acquire considerable volume;  that they are more especially devel-
oped in young women; that they do not alter the general health;
and especially do not contract adhesions with the skin which  sur-
rounds them, and that they leave the nipple (manielon) intact: in all
of which  particulars  it will be perceived his views differ in many
points from those of M. Cruveilhier. 
126
NEW ELEMENTS OF OPERATIVE  SURGERY.
  M. Mandl, (loc. cit., Gaz. Med., p. 157,158,) the celebrated micro-
graphist of Paris, who also examined the tumor in question with M.
Lebert, accords with him in the existence of mammary tissue in the
portions submitted by them  to the microscope.  Nevertheless, posi-
tive as M. Lebert's opinions appear  to be on its non-cancerous char-
acter,  M. Mandl asserts  that he  satisfied himself  that cancerous
globules were  also present.   He states the important fact  that we
must not be deceived by the usual microscopic form which the ele-
mentary globules of cancerous tumors  are known to have;  for this
is sometimes not present, and he then  has been enabled  by other
physical characters, or by chemical or other means, (which he will in
due time make  public,) to  establish  the fact that  such  tumors were
nevertheless of genuine cancerous  structure.   So of encephaloidal
(so called) tumors of the retina, though sometimes destitute of glob-
ules of the cancerous form, he has notwithstanding found them to be
unquestionably cancerous.
  Mr. Liston speaks of  what he calls fibrous tumors of the mamma,
(Lond. Lancet, Dec. 7, 1844, p. 308, &c.) which form in the cellular
tissue between the mammas, the latter becoming expanded and flat-
tened out in front of the tumor.
  But neither these nor Sir A. Cooper's hydatid or cysted tumors,
the cells of which latter Mr. Liston has seen sometimes filled with a
fluid as black as printer's ink, are as frequent  he  thinks as carcino-
matous malignant disease of the mamma.   These  may occur, but
rarely, in women under thirty in  perfect health, with uninterrupted
catamenia.   Most  generally they occur between  the ages of forty
and fifty, and sometimes later.  They commence between the nipple
and  axilla,  and sometimes in the centre of the gland, and then at-
tack  the middle of the lactiferous tubes.  Sometimes the tumor re-
mains hard and stony, with the nipple retracted, skin puckered, &c.;
but usually it makes rapid  progress  in  size, becomes soft and pulpy,
or pultaceous and medullary, and  throws out a fungus which may
or may not  bleed profusely, depending on the constitution.  A section
of one of these tumors, says  Mr.  Liston, presents a variety of dis-
eased structure: it may be fibrous-looking, that is, with white bands
running to the cellular tissue;  or present the appearance of a gelati-
nous cancer, or it may be pultaceous or  medullary.   Sometimes all
these heterogeneous  or heterologous tissues are found in the. same
tumor; or some portions are hard and others  softened down ; or the
vessels will give way and  extravasation of blood occur.
  In mere hypertrophy  of the gland, support  given to it with mode-
rate  compression may restore it to  its normal size.  Dr. N.  Arnott's
mode of pressure Mr. Liston thinks is very ingenious, i. e.  by a sort
of wooden cup  or bowl,  made  of  the  size of the tumor, and into
which apparatus is placed a  small air-cushion, made of very fine tex-
ture.  The cushion is inflated with  air, so far as not to be hard; this
cushion is then put in the cup and supported by a spring like that of
a common  truss.  This will answer also, Mr. Liston says, in many
cases of simple tumor of the breast.
  There are, he considers, some enlargements of  the mamma where
the structure is altered; not  a simple hypertrophy,—but where there 
FIBROUS TUMORS.
127
are masses of fibrine agglutinated together, and where  the tumor
will go on increasing in spite of all that can be done.
  Cystic tumors cannot be dispersed by simple compression.  Sir B.
Brodie has described certain tumors of the breast that have yielded
to lotions of spirits of camphor with liquor plumbi kept on till the sur-
face is inflamed, then omitted and reapplied.
   The knife  only, says  Mr. Liston, can  remove  the disease when
the gland is  altered in  structure  and contains a great  number  of
cysts; but such tumors are not as he conceives malignant, and if the
whole mass is extirpated  there is every chance that the disease will
not return.   There is no contamination of the lymphatics, and the
removal of the breast in those cases, may be had recourse to with
great propriety.
   If a patient comes, says  Mr. Liston, with a small tubercle in the
breast, with  some puckering and  adhesion  to the integument, if it
feels exceedingly hard and unyielding, and has all the characters of
carcinoma, but is of recent origin, and  you cannot trace disease to
the lymphatic system, you  may be sometimes  justified in taking the
tumor out, but you must take the whole of the mamma with it.  When
the disease is at all advanced, and there is reason to think that the
constitution  is affected  with it,  it is far better to abstain from the
proceeding.  At one time, adds Mr. Liston, this was the  most com-
 mon  operation in surgery.  I recollect  the period  when a week
 seldom passed over  without the operation  being  performed two or
three times in  our hospitals; but now it is seldom haid recourse to,
and properly too, except in cases of non-malignant disease.
   Mr. Liston has seen a case of carcinomatous tumor of the breast
in a  female  under 30, (see his  Lectures, London Lancet, Dec. 21,
 1844, p. 359, &c.) where the skin covering  both  sides  of the  chest
and all around the  back was affected, hard, unyielding and exten-
sively pervaded by tubercles, to such extent that the motions of the
chest and of the upper extremities were much impeded by the indu-
 rated state of the skin.
   Cancers of the mamma may at an early period be disposed to in-
 volve the lymphatics, the same as in those  of  the lip.  Even  in
malignant disease, Mr. Liston has known Dr. Arnott's mode of com-
pression, if early and well applied, to  cause the tumor in  great part
to disappear: but in other cases it causes great suffering ; for it cannot
be expected  to liberate the system of the constitutional taint, which
will then reappear in the neighboring lymphatics and at places far
removed  from the disease.   Thus, though the fatty matter around
the mamma  has been absorbed by  the pressure, and  the tumor
lies flat on the ribs,  yet  the disease goes on as if nothing had been
done.   Dissection in such cases has shown enough cancerous degen-
eration.
   In  cystic  and fibrous tumors however, he thinks the operation
may be Undertaken with a very fair prospect of success;  but some-
times the disease returns, and is sure to do so if the whole of the tu-
mor is not taken away.
   Pseudo-Cancers.—You meet sometimes  with tumors, says Mr.
Liston, (Ibid., p. 359, 360T &c.) which are not described in books, and
which you will scarcely believe malignant, or that they can possibly 
 128          NEW ELEMENTS OF  OPERATIVE  SURGERY.

 return.   He describes one of this kind in a stout healthy woman, only
 a little over 30, and in whom the lymphatics were not in the slightest
 degree affected.   There was found a great deal of fatty matter around
 it, and its interior to his surprise  consisted of a strange soft-looking
 mass, containing a great deal of coagulated blood and a quantity of
 clot without the coloring matter, but  there was also curious pultace-
 ous stuff amongst  it.  After this he was not surprised to find that the
 disease in a few  months returned, showing  itself in three or four
 fungous buds in the  cicatrix.   There being still no  affection of the
 lymphatics nor of the axillary gland,  Mr. Liston removed  these, and
 with them, as the patient was  so stout, an immense quantity of the
 surrounding tissue, skin, fat and even pectoral  muscle, for  the tumor
 adhered firmly to the fascia of this last  and was incorporated with
 its fibres.  The cure was complete, and remains so now, nine years
 sin :e the last operation.
   In non-malignant tumors, Mr. Liston has sometimes cut below the
 mamma  and  left  that  behind,  but if there  is  adhesion  to it the
 whole must be  sacrificed.
   In malignant tumors  when extirpated, not only the diseased mass
 must come out, but you must be  careful, he  says, to cut out also
 a  large portion of the apparently healthy fatty tissue around it, and
 keep the knife also much beyond and outside of  the white bands
 which you will  see spreading out from the central portion of the
 tumor into the fatty matter.- After  taking out the  tumor, it is to
 be washed and  scraped, and if  any indurated portions be found on
 its surface, you  must proceed to  make further excisions from the
 corresponding parts of the  wound.
   It is a good rule, he thinks, to take away the fascia of  the pecto-
 ral muscle; as the disease frequently has  some connexion with it,
 and will recommence in this tissue.
   Mr. Liston thinks it an advantage in the dressing to apply a layer
 of gold beaters' skin to the raw surface of the wound, to prevent this
 adhering to the lint, which is to be placed upon this intervening tissue.
   Again, Mr. Liston  disapproves of closing the edges of the wound
 tight at first with adhesive plaster, and b'y making firm pressure with
 compresses and  rollers around  the chest;  as  this  causes  pain and
 oozing of the blood, and the formation of putrid clots, foetid discharges,
 &c, requiring the  whole to be removed, and perhaps more  vessels to
 be tied.  He prefers merely the lint applied as mentioned above, wet
 for five  or six hours, then one or two sutures, or more,  may be re-
 quired,  and to terminate by bringing the edges together with isin-
glass plaster.  Thus  you will probably obtain union by first intention,
 and without discharge or pain.
   The male breast occasionally will  become affected precisely,  he
 says,  in  the same way as the female,  and require also removal, or it
 will end in internal malignant disease  and death.
   M. Lesauvage of Caen,  (Arch.  Gen., Fevrier, 1844, p. 178,  &c.)
disapproves of the word fibrous, and proposes, in lieu thereof, gelatino-
fibrous,  to such tumors as are described by our author, M. Velpeau,
(Diet, de Med.) as formed of solidified or vitalized  (vivifiee) fibrine
or albumine.   M. Lesauvage says they  are  to be found  in those
regions that are abundantly supplied with cellular tissue, and that he 
FIBROUS TUMORS.
129
has seen them in the breast, scrotum, fold of the groin, posterior part
of the thigh, mesentery, &c.   They are always isolated, and possess
a distinct organization within themselves of numerous cysts and blood-
vessels, and incommode  the  neighboring parts only by their size,
weight  and pressure.   In the breast they are  always developed
at the  posterior part of the  gland, which latter,  when they  are
very  large, is flattened out and  covered by  them  on  its anterior
portion.   M. Lesauvage does not describe these tumors, which he
has seen  return after  extirpation, in seven instances, with sufficient
clearness  to enable us to appreciate  probably at their just value the
fruits of his experience.  A  discussion which  has elicited such pro-
found researches, microscopic, pathological and otherwise, from the
most  learned surgeons and investigators of Paris, cannot  properly be
participated in by others, unless they come duly armed with accurate
and new facts.
   M. S. Tanchou in a more  recent  work of his, (Recherches  sur le
traitement  medical des tumeurs  cancereuses du sein, Paris,  1844,)
boldly reassumes the prevailing popular  doctrine of conservativeism
and the substitution of medical treatment even in that most formidable
of all surgical diseases, cancer.  He  maintains that by a proper medi-
cation the most  clearly established and unequivocal forms of cancer-
ous tumors of the breast, may be effectually arrested in the  economy,
and in their local devastation.  He strongly censures the frequent
resort to extirpation, where not necessary, and  for alleged cancerous
tumors that are not in reality cancerous.' From a comparative table of
deaths by cancer, at Paris and its environs, between 1830 and 1840, but
from  which no doubt there must be a great deduction made for errors
in the true designation of this disease, as is justly remarked by the
editors of the Archives Generates, (4e  serie, t. VII,, April, 1845, p. 523,)
M. Tanchou asserts that this disease has increased in frequency from
1.96 in a  100 in 1830, to 2.40 in a 100 in 1840.  But according to
a more important table by Professor Rigoni Stern of Padua, (Arch.
Gen., loc. cit., p. 524,) embracing an interval of 80 years, viz., from
1760  to 1839, the same increase of mortality from cancer has taken
place at the last mentioned city ;  viz., from 48 in 1000 between 1760
and 1769, it rose to 93 in a 1000 from 1830 to 1839 ;  but this increase
was exclusively confined to cancers of the uterus.  Whereas, M. Tan-
chou  states the  augmentation  in Paris to have taken place in all  the
most important organs and in proportion  respectively to their greater
degree of excitability or impressionability, and this in their physiologi-
cal order.   He however also admits that the increase has  occurred to
a greater extent in women. M. Tanchou imputes this increase of the
disease to the  effects of civilization, and in  support of this,  instances
the less  degree of frequency of deaths by cancer in the environs of
Paris  than in the capital itself: an error in the tables which,  as is
again justly remarked by the editors  of the Archives  Generates,  (ib.
loc. cit., p. 524,) is to  be ascribed to  the fact that the  poorer class of
patients in the suburbs most usually come for relief to the hospitals
within the city proper.
  Fungus  Hcematodes  occupying the entire bladder.—Dr. E. Bis-
sell, of Norwalk, Connecticut, (American  Journ. of the Med.  Sci-
ences, new  series, vol. VII.,  p. 122-124, Philad. 1844,)  relates one
                              9 
130
NEW ELEMENTS OF OPERATIVE  SURGERY.
 of the most extraordinary cases of isolated and sudden formation of
 malignant disease of the bleeding fungoid description on record.  In the
 short space of one year, a man aged 67, who was of temperate  habits
 and  up to April, 1842,  had enjoyed uninterrupted health and a  sound
 constitution, was seized with irritation in the bladder and constant de-
 sire to urinate, followed by discharge of large quantities of blood, and
 distressing pain and exhaustion, which finally ended in death.  The sur-
 geon, previous to this event, diagnosed through the rectum and  above
 the pubis, an enormous tumor occupying the whole bladder, and thus
 dispelled the illusion of gravel and stone, for which supposed diseases
 he had been for some time under treatment by an empiric.  On
 examining the body, the diagnosis was fully  confirmed.   The tumor
 was ovate, and nine inches from above downwards, and about four and
 a half inches transversely.   Its greatest diameter was naturally to-
 wards the abdomen and perineum, from meeting with less resistance
 in those directions.  It was a true fungus hasmatodes, and originated
near the neck of the bladder posteriorly.  Its texture  could  be torn
 by the finger without  much  difficulty.  The bladder was  so  com-
 pletely filled up by it that there wras not room for the smallest  quan-
 tity of urine.   The most remarkable feature is, that  there was  not a
 vestige of disease in the kidneys or other viscera any where!
  A congenital encephaloidal tumor, or encephalocele, of an extraor-
 dinary character, proving on dissection to be a true hernia cerebri, has
 been recently described by Mr. W. Lyon of Glasgow, (Lon. and Edin.
 Month. Journ. of Med. Science, by J.  R. Cormack, M. D., &c,  Nov.,
 1844, p. 983 ; and  the London Medical Gazette, July 12, 1844.)   The
 child, aged nearly one month, at the  time of the description of the
 case, exhibited an oblong tumor, chiefly over the occiput, and extend-
 ing from the vertex to  the nape,  11  inches  in circumference, 9 in
 length, and 7 in its lateral dimensions,  partially livid or marbled in
 color,  fluctuating and  without pulsation; traversed  anteriorly  by
 small tortuous vessels, and the parts not livid covered with  thin soft
 hairs.  No opening could be felt under its attachment to the scalp—
 the head was normal, but the forehead remarkably low, and receding
—the child well formed, but weakly.   The tumor being without pub
 sation and nearly as large as  the head, and the cranium of normal
 size,  were circumstances that masked its true character and led to
the inference that it could not be connected with the brain  or  com-
posed of cerebral matter.  This opinion was strengthened by the fact
that the fontanelles remained flaccid and could not be made  tense by
 pressing on the tumor,  as  if to  effect its retrocession by a hernial
taxis.  Gentle compression was tried, but soon abandoned.  Finally,
the edge of an opening into the cranium could  be felt.   The  child
lived just a month, and the tumor, on dissection, was found to  con-
tain 3 oz. of bloody serum, and its parietes to be formed of the scalp,
pericranium  and dura  mater.  Portions of the posterior lobes of the
cerebrum, about the size of a small apple, covered by the arachnoid
and  pia mater, having a film  of serum between them and the dura
mater, projected through an opening in the inferior and middle part
of the occipital bone into the sac, being of the size of the  point of a
finger, with rounded edges, and situated immediately above the ten-
torium, which was imperfect.  It was bounded above by the termi 
TUMORS OF THE  BONES.
131
nation of the longitudinal  sinus, at the sides by the lateral  sinuses,
and below by the incomplete tentorium.  The portion of brain in the
tumor was compressed where it passed through  this abnormal fora-
men, and bulged out to the size of a small apple in the interior of
the sac.  There was no fluid within the cranium, either beneath the
membranes  or in  the ventricles.  The substance of the brain Was
quite normal.   The impacted state of the parts  about  the occipital
opening, no  doubt prevented pulsation from being felt externally.
  Cases of this description, though possibly beyond  the reach of sur-
gical  aid,  are rendered exceedingly valuable by the difficulties and
delusions  with which a post-mortem may show the diagnosis  to have
been necesssarily embarrassed.
  Even the  brain itself is not exempt from the formation of scirrhous
tumors within its substance. A remarkable case of this kind is related
by M. Frestel, (Gaz. Med., de Paris, April 19, 1845,  p. 253,) of an in-
fantry soldier of young and robust constitution, who was received into
the hospital of Saint-Lo,  and who, after months of acute suffering
from  pain in the occipital region, but what is unaccountable, without,
so to speak, any fever, or  the least deviation of any of the mental or
physical  functions from their normal state, except  perhaps  a slight
defect at times in the articulation of words, ultimately died suddenly
without convulsions.  The organs of the  different  cavities  and the
cerebrum itself was also found  normal, except that there was a con-
siderable quantity of serosity in its venticles; but on examining the
cerebellum, its entire left portion was found disorganized, increased in
volume, and having small but well-marked mammillary eminences
on its superior surface.  The inferior and posterior part contained
a tumor of the size of a large nut, supported on a  distinct  pedicle.
The right portion of the cerebellum was in a measure healthy.  The
tumor was hard and resisting to the touch, and of a tallowy (lardac6)
aspect,  and  when cut into exhibited the characters ascribed by au-
thors to scirrhous tissue.   T.]
                        CHAPTER XI.

              TUMORS OF THE BONES  (EXOSTOSES).

  Under the title of tumors of the bones, my intention here is to speak
only of the class of tumors designated by the name of exostosis. Sur-
gical remedies are not applicable to all the varieties of exostosis.  So
long as the malady is still the seat of an inflammatory process, and
that it presents the slightest character of osteitis, acute or sub-acute,
there would be danger in attacking it with instruments, and the ope-
ration would  be  absolutely without any  result.  It is its cause that
we  must extinguish, and not the exostosis, which we have to treat.
In the acute state or in a state purely chronic, exostoses, developed
under the influence  of syphilis, or any  other general infection, are
equally repugnant to every kind of surgical operation, so long as the 
132
NEW ELEMENTS OF OPERATIVE SURGERY.
germ has not been completely destroyed in the system.  Should the
exostosis be complicated with caries, necrosis, tubercular, sarcoma-
tous or other degenerescence, it is  still to these  last affections  that
we must address  ourselves, and not  to  the  exostosis, properly so
called.   Finally, operative surgery  ought  moreover to exclude from
its  domain diffused, large  or fusiform  exostoses, and  those which
comprise the whole circumference of cylindrical bones, or the entire
thickness of the large bones to  a  great  extent.  I will add, that
limited  exostosis, more or  less completely pediculated, ancient  and
indolent, which is  almost  the only  kind that ought  to  be  attacked,
would not  of itself justify serious operations, unless by its situation
or volume,  it should in reality cause a great disturbance in the exer-
cise of some of the  functions, or unless it should trouble in too serious
a manner the regularity of the features and forms of the part.  Ex-
ostoses being very common, have naturally very early attracted the
attention of surgeons.  Heliodorus (Peyrilhe, Hist, de la  Chir., p.
391,392,) who seems to have been acquainted with eburnoid exosto-
sis (l'exostose eburnee), positively recommends their removal.  The
ancient Greeks, who often employed the  hot iron in place of the cutting
instrument  in such cases, also made use of both these means at the
same  time.  J.  L. Petit  (GEuvres Posthumes, t.  II.,  p. 27,)  who
adopted the same method, adds that exostoses which have not been
dissolved neither by mercury or other internal remedies, ought to be
destroyed by means of the exfoliating trephine, chisel and  mallet,
(Maladies  des  Os.)   About the  same  epoch Duverney (Maladies
des Os, t.  II., p. 500,) a rival of J. L. Petit,  laid down the follow-
ing principles*:  if  the exostosis has not  a large base, it  is to be
removed, he says, by means of the rasp, chisel  or saw; when  the
exostosis, on the contrary, is large, we  ought to give the preference
to the exfoliating  or ordinary trephine,  taking  care  to  place  the
crowns by  the side of each  other, in order afterwards  to drive  out
and to  rerhove  by means of the  strokes  of the  chisel the bridges
that remain between them.  The red hot iron and caustics found, ,
at the  beginning  of the  18th century,  a decided antagonist  in
Kulm  (De  Exostosi,  etc.,  1732;  These de Halter, t.  V., p. 653.)
Extirpation with the knife, says the author, is the  only remedy for
exostoses, all other means  being doubtful  and  uncertain.   Lecat,
wishing to  reconcile the various ancient modes  of practice, recom-
mended in  1755, under the anonym of Labissiere, (Prix de I'Acad.
de Chir., t. VII., p. 157, in-12,) the  excision of exostoses which have a
tendency to imposthumate  or which are limited  to  the interruption
of certain functions;  the hot iron against those  which are compli-
cated with fungosities and deep-seated  caries;  delay for those
which no longer make any progress and which do not cause any
accident.   This  doctrine did not  prevent  Allan (De Exostosi, § 12;
These, 1770) from  proposing the removal  of exostoses in two stages.
Having incised the integuments, scraped the periosteum, and dressed
the wound  dry, Allan recommends that we should, on the following
day, apply a sufficient number of the crowns of the trephine ; that we
should then, by means of the gouge  and mallet, drive out the osseous
bridges, and terminate by rasping the bone which sustained the exos-
tosis.   It is readily conceived  that this  method  could neither  be 
TUMORS OF THE BONES.
133
agreeable to the taste of the patient or the surgeon, and that Nicolas
(Diet,  de Chir. et  de Med. et  de Veter., t. I., p. 521, 522,) who
simply recommended to saw through the base of the exostosis, when
it is narrow, found more sympathy among  practitioners.   Since then
an attempt  has been made to systematize these different  modes.
  B. Bell (Cours de Chir., t. V., p. 314,) and Mamie  (Maladies des
Os, p.  19-33-35) after him, have established, that an exostosis ought
to be attacked with the trephine, if it can  be included in the  crown
of the  instrument, and with the ordinary saw when it is too large—
When  the exostosis surrounds the whole circumference of the bone,
we must, say these authors, exsect or amputate the part, whether it
exists in the small  bones  of the feet and  hands, or even when it is
situated in  the  thigh,  leg,  or arm.  Petit-Radel (Encyclop.  Method.,
partie  Chirurgicale) in such cases also recommends  to exsect the
cylinder of the  bone, rather than confine  ourselves to the excision
of the  exostosis.   Surgeons,  nevertheless, have pursued  a more
simple practice. With Voigt (Plouquet,  Suppl., p. 53, col. 3,) the ex-
tirpation of an  exostosis  succeeded very  well  and enabled him to
preserve the continuity of the part.  M. A. Cooper (OEuvres Chirurg.,
translation of Bertrand, t. L, p. 306) recommends removing them
with a saw, and says that the operation, which under such circum-
stances is accompanied only with a slight  pain, does not in general
involve any danger when  it has been well done.
   The ligature  mentioned by Klein (Sprengel, Hist,  de la Med., t.
VIII.,  p. 341,) does not in reality deserve a refutation,  since it ap-
pears so entirely foreign to  the treatment  of exostoses.   In conclu-
sion, it is  not,  in fact, allowable to undertake the removal of these
tumors, unless it should appear practicable to reduce them by  means
of the saw, or to destroy them by the  chisel or the  trephine.  By
means of the cultellaire saws, the chain  and rowel saws, and the im-
proved osteotomes, which science possesses at the  present time,
there is scarcely an exostosis, with a strangulated or pediculated base,
which cannot be readily  extirpated.  The operative  process being
simple or complicated, much less from the nature or form of the exos-
tosis, than from the  anatomical arrangement of the organs which sur-
round  or sustain it,  cannot be well understood except  when treating
of exostoses in particular.  It is,  moreover, evident that certain of
these tumors, those especially  which are superficial  and  perfectly
pediculated, are  generally easily  removed.   An  empiric  (Guerin,
Essai  de Med., t. IL,  p. 276, an VI.) supposing that he was about to
lay bare a  lipoma, having  perceived his error and recognizing  before
him  an enormous exostosis, isolated it down to the level of the sound
bone, and succeeded in detaching it by means of a common carpen-
ter's saw: the patient got  well

             Article  I.—Exostoses of  the  Trunk.

                              §L

  On the cranium, the extirpation  of exostoses has not always been
unattended  with inconveniences;  it is  moreover easily performed.
Having laid bare their root by means of suitable incisions, nothing 
134          NEW ELEMENTS OF OPERATIVE SURGERY.

prevents our dividing  them either  by the  ordinary saw, the hand-
saw, or the trephine.   Nevertheless, I would recommend  that on
this part of the body we should not have recourse to the gouge and
mallet, unless it were necessary, and that in order to avoid all cere-
bral  concussion, we  should confine ourselves to the employment of
the different kinds of saws  which I have  just spoken of.  Arnaud,
(Mtrcure de France,  Janvier, 1716,)  speaks  of an exostosis four
inches long and two in breadth, which was  situated on the top of the
head of a domestic,  and which was first  attacked with a trephine.
Perceiving that the  tumor  was osseous throughout its  whole sub-
stance, the surgeons deferred the operation until the next day.  Se-
rious accidents  which came on in the night,  obliged further postpone-
ment, and  the patient  succumbed at the  expiration of three days,
without the autopsy throwing any light on  the cause of  so sudden a
death.   We also  find  in Sauvages (Nosologic, t. VI., p. 235,) the
history of a patient who had in the auditory passage a  tumor that
was taken  for a  foreign body, but  proved  an exostosis, which was
attempted to be  extracted, but soon caused death.  M. A. Cooper,
(GEuvr.,  trans,  of Bertrand, t. I., p. 310,)  cites a case  of fungous
exostosis of considerable size, which occupied the two tables of the
frontal bone, and  which was excised, but in such a manner that the
person operated upon died on the sixth day.  We must not, therefore,
undertake the ablation of exostoses of the cranium without  neces-
sity, nor resort to this grave remedy unless  the tumor has excoriated
and ulcerated the tissues, and  that it is entirely external or threat-
ened with some degenerescense.

                              § II.
  The bones of the face  have still more, perhaps, than the bones of
the cranium been the seat of exostoses, and  for which serious opera-
tions have been fearlessly undertaken.   It is to be remarked, in fact,
that  in  this region surgeons have obtained numerous successful re-
sults.   Brutner  (Koenigsberg, 1775, observ. premiere)  speaks of  a
patient who, in consequence of a fall  when  six years  of age, had
on the jaw an exostosis  which was extirpated  eleven years after-
wards, and which then weighed  six ounces.  Reisinger, (Bull, de
Ferussac, t. XL, p. 361,) states that he successfully removed from
the upper jaw, an exostosis  of certain volume by means  of Thaster's
saw, when all other processes had failed.   Should the exostosis oc-
cupy the  lower jaw, it  must  be destroyed in  the  same  manner.
Jourdain, (Maladies de la Bouche, t. II., p.  123,) in order to remove
one which was  situated  on the outside of  the jaw, incised and dis-
sected  the gum around it, to detach it by  means  of a flat slightly
curved chisel with a sharp  edge.  The actual cautery was after-
wards  found necessary,  to  destroy a  purulent exudation from the
traumatic surface, and the patient recovered in 34 days.   This
method,  recommended by Blicke, has  been favorably received by
M. A. Cooper, who, in a case  analogous to  that  of Jourdain, de-
tached the exostosis  by means of the bistoury, and afterwards
deemed it necessary to  apply the cautery  to the bottom of the
wound.  Other cases of exostoses of the jaws destroyed by the in-
strument or by the hot iron, have also been reported by Harrison, 
TUMORS OF THE  BONES.
135
 (Sprengel, t. VIII., p. 366, ] 832,)  Mosque, (Ancion  Jou~n. de Med.,
 t. LXXL,  p. 506,)  and Verduin, (Theses de Holier, t. V., p.  69.)
 One of the most curious  examples of exostosis of the face, success-
 fully removed, is that related by Vigarous (Opuscules sur la regener
 des Os, p.  170.)  The tumor  occupied the  vault of the palate, and
 extended from the  neighborhood of the anterior palatine foramen,
 as far nearly  as  the uvula.   Its  largest diameter was ten lines.
 The  surgeon having assured himself that it was only soldered as
 it were against the bones, attempted to detach it without penetrating
 into the nasal  fossas.  There  remained  around the  cavity where it
 was situated an osseous border,  which afterwards  came away in
 fragments, and did not prevent the cure from being  accomplished in
 the  space of a month.   Should the exostosis be situated in the vi-
 cinity of one  of the alveolar borders,  the  cutting  pliers, which I
 mentioned under the article of exsection of  the jaws, would render
 its excision one of  the easiest things  imaginable ; Liston's scissors
 would be equally applicable to it, should it be dilated, while present-
 ing at the same time a root that was slender  and of sufficient length.
 Wounds  of the face, moreover, reunite with so much facility  that
 incisions  should not be spared in this region, should  it appear  that
 they would render  the  destruction of the exostosis more easy and
 more certain.

                              § III.
   In exostosis of  the sternum, I have  met  with but one instance in
 which its form and  character would admit of extirpation.  The tu-
 mor  was  of the size of a  pullet's egg, and  its root one-half less in
 diameter than in its dilated portion.  It was laid bare by two curved
 incisions, which detached an  ellipse of the skin in front; its section
 was afterwards made by means of  two cuts, of the crested saw, di-
 rected first from right to left, then from left  to' right, and as near as
 possible  to the anterior  plane of  the bone.  The borders of the
 wound were then gently brought together and the operation was un-
 attended with any serious consequences.

                             §  IV.
   I have also, in two instances, met with exostoses on the apex of the
 spinous processes of the vertebral column, and which  1 might have
 extirpated, in one case, on a level  with the projecting  vertebra, and
 in the other, in the lumbar region.   But nothing was done to remedy
 this deformity.

                              § V.
   The bones of the pelvis sufficiently often  present  these kinds of
 exostoses.   A patient had one of very large size on the pubes, which
 caused him a good deal of suffering.  M. A. Cooper (QJuvr., transl.
 of Bertrand, t.  I., p. 320,) effected its  removal, using Machel's  saw
 to begin with, and finishing with  that of Hey.  The  cure was com-
 pleted in a  month.   I have met  with a young man who had on the
outside of the spine of the ilium,  on  the  left side, an  exostosis a half
an inch in thickness,  half a foot  long,  and  near twenty lines in
breadth, which was situated transversely, and caused,  moreover, no 
136          NEW ELEMENTS OF  OPERATIVE SURGERY.

pain, and  had, according to the patient, been  developed in less than
two years.  The young man was not willing to submit to any opera-
tion for his relief.  I have met with exostoses in the same situation in
three other persons ; but  in these  cases they were of such  inconsid-
erable  size that I have not thought it necessary to recur to surgical
means.  Exostoses, in the interior of the pelvis, are among the most
frequent that we  meet with, the proof of which  I have given else-
where, (Traite d'accouchements,  Vices de conformation,  Accouche-
ments  contre nature,  etc., 2d  edition;)  but as  they are beyond the
reach of operative surgery, it is useless at  this time to examine them.
  Plessman, who asserts that he destroyed one on the anterior sur-
face of the sacrum, by means of the actual cautery, has not been re-
lied upon by any one, and has left it to be  inferred, that the tumor he
refers to, was one of an altogether different description.

                    Article II.—The Hand.

                          §  I.—Hand.

  In the limbs  especially, exostoses require all the attention of the
surgeon.   Covillard (Obs. iatro Chirurg.,  p. 97, obs. 36, 1739,) extir-
pated  one  under the name of  a wen, (loupe,) of a cellular texture, of
the size of a pullet's egg, and transparent as a crystal, and which ex-
tended from the phalangeal articulation of  the little finger to the mid-
dle of  the hand.  The incision of the soft parts having been effected,
Covillard made use of a shoemaker's knife  to complete the operation,
and his patient recovered.  An exostosis of considerable size, which
was situated uponthesame finger, and which incommoded only by its
size, was also at a later period successfully removed by Bidloo (Ex-
ercit. Anat. Chir. 9, De Exostosis.)   It must  be that these  exostoses
of the  little finger are quite  common, for M. Champion, also, gives
two examples  of them:  in  the  first case (communicated  by the
author) a bosselated transparent tumor, of  the size of  a goose's egg,
was situated upon the inner side of the first phalanx of this finger.
Having operated  in the manner I have described in speaking of ex-
ostosis of  the  sternum, the surgeon  made use of a solid  scalpel to
force out (faire sauter) the exostosis, and afterwards had recourse to
the gouge, to remove everything from  the  phalanx, that had  the
appearance of  being  expanded (rarefie), fungous (carnifie), or dis-
eased.  In the second case (These No. 11, Paris, 1815, p. 61  ; obs. 10)
the tumor  was situated upon the outer side of  the forefinger, towards
the middle of the first phalanx.  It was of the size of a nut,  and other
practitioners  had proposed  to destroy it by amputating  the finger.
An osseous tumor of three inches and a  half circumference, devel-
oped itself upon  the  second phalanx of  the forefinger;  Vigarous
(QZuvr. Chir., p. 458,) made an incision,  which included the entire
base of the exostosis, and enabled him to detach it in two successive
stages, by means  of a fine saw, by removing  half  the corresponding
metacarpal bone, and then the  forefinger  itself.   The same practi-
tioner, also, had to remove from the outer side of the right  middle
finger, what he called an osseous loupe, and which kept the two fin-
gers six inches apart.  This tumor, which  was seven or eight times 
TUMORS OF THE BONES.
137
larger than the bone which sustained it, and which formed a kind of
shell to it, was filled with matter resembling tallow or honey. Vigarous
(Opusc.  sur la  Regen.,  &c, p. 172,) removed  the first  phalanx
of the diseased finger, together with the second bone of the metacar-
pus, and cured his patient in the space of six weeks.   M. A. Cooper,
also, speaks of an exostosis which occupied the second  phalanx of
one of the fingers.   The first ablation was followed  by a return, but
the second effected a  radical cure.   In another  case, Vigarous en-
countered  an osseoes  loupe*  on the first bone of the metacarpus.
This tumor, which  was thirteen inches and a half in circumference,
at its dilated portion, and  nine inches at  its root, appeared to have
been developed at the  expense of the second and third bones of the
metacarpus, as well as of the first.

                              §11.
   I have seen exostoses on the fore-arm, which were in some instances
globular, and at other  times styloidal.   But the patients experienced
so little inconvenience from them, that they never thought of having
them removed.
                              § HI.
   The humerus occasionally presents on its outer side and near the
 shoulder, an osseous tumor, the extirpation  of which has already been
 several  times  attempted.    The first example of the kind  which
 has been  spoken of among us,  belongs  to Ant.  Dubois.  I  have
heard this surgeon  relate that the exostosis, which was concealed un-
derneath the deltoid muscle, was situated nearly two inches below
the articulation;  that  it was of the  size of  a large pullet's egg, and
that it became necessary to cut through the muscular fibres, in order
to lay it bare,  after which he made use of the  ordinary saw, gouge
and mallet to complete its extirpation.   In  another case which I  have
seen, the tumor  was  situated precisely in the  same region, and
presented  nearly the  same volume.  M. Roux, who  performed the
operation, being  desirous  of saving the deltoid muscle, made a long
incision on each side of it, so as to leave a kind of musculo-cutaneous
bridge between them.   The blade of a common saw, detached and
passed under this bridge, and afterwards re-inserted  into its  handle,
served to make the section below the pedicle of the tumor.  As this
saw could not be worked in a direction parallel with the axis  of the
humerus, it was necessary to make use of it a second time, and then
to have recourse to a sort of file  to equalize the surface of the bone.
An abundant suppuration and accidents of quite a grave character
supervened, but the cure ultimately was completely established.  At
the present time we should have to choose  between three  processes:
One would consist  in  laying bare the tumor by cutting a large tri-
angular or V flap, which  should  be  raised up  upon its base.   After
having applied pieces of pasteboard or  linen to protect and depress
the borders of the wound, the exostosis could  be  readily extirpated
  * The word loupe literally and anciently means a men; and afterwards it became sy-
nonymous with lipoma, from whence it is probably derived.  (See on Lipomatous Tumors,
supra.) Its use in the case mentioned here and farther back, shows that it was applied
to the reverse of wens  and fatty tumors, viz., to those of an osseous, and also transparent
texture.  T. 
138          NEVv ELEMENTS OF OPERATIVE  SURGERY.

by means of the ordinary saw, which it would be more advisable to
work from below upwards  than from above  downwards.   By  a
second process we might confine ourselves to cutting down upon the
tumor  itself, through the  whole thickness of the tissues,  from the
apex of the acromion to the point of the deltoid, and then push back
the lips of the  wound to the right and to the left, to enable us to
apply the saw upon the pedicle  of the exostosis; but this process
would  not be applicable  but to exostoses which make a very con-
siderable projection, and which  are elongated  and have a narrow
pedicle.  The third, which is no other than the process of M. Jeffray,
for the exsection  of the elbow, and which  M. Roux has proposed to
put in practice, should at the  present time be  performed in the follow-
ing manner: the  two lateral incisions being made, we should care-
fully isolate the bridge  and soft parts from  the contour of the tumor.
The  cultellaire saw or one of the other hand-saws somewhat narrow,
or even the osteotome of M.  Charriere, would  readily divide,  either
from one side to the  other  or from above downwards, the pedicle
of the exostosis.  No  doubt  also the articulated saw would answer
the purpose equally well.  All that would  now remain, would be to
thrust out and extract the foreign body through one of the openings
destined for the passage of the instrument.   But  at the present day
when we know how harmless is the division  of muscular fibres, who
would  expose himself  to  the difficulties  of  this process, when that
w7hich I have pointed out above, renders the operation so easy and so
simple ?  Exostoses are sometimes found also upon the shoulder.   I
have already mentioned, in speaking  of exsection, or extirpation of
the clavicle, that the history  of a tumor of this kind which had two
feet in circumference, and which weighed five pounds, and was  a foot
in length, had been given by  Kulm.  The tumor was removed, with-
out, however, his  mentioning very clearly  whether the clavicle had
to come away along with  it at the same time.

                             § IV.
   Lobstein (Compte-Rendu  du Musee  de Strasbourg, 1834,  p. 64,
no. 79,) says that an exostoses which was situated upon  the scapula
of a young' man, was  extirpated, and  that the cure was effected in
two months and a half.  A child thirteen years of age, had upon the
lower angle of the right shoulder blade, an exostosis of the size of a
large egg, one half of which projected  outwardly, and  the other in-
wardly.   The surgeon, M. W. Beaumont, (Gaz. 'Med., 1838, p. 778,)
by excising with the  saw  or Liston's cutting pliers the angle  of the
scapula, which he caused to  project between the  latissimus dorsi and
serratus magnus muscles, while raising  up  the arm of the patient, in
this manner removed the tumor, and succeeded in obtaining a perfect
cure.

                        § Y.—The  Foot.
   Exostoses of the feet are met with especially upon the phalanges
of the  toes.  Andre   (Observations sur  les  Maladies de FUr%L,
p. 410,) speaks  of an exostosis of the size of a large cherry, which
was  situated upon the great  toe, and which he was unable to remove
until after having cauterized it several times with eau  mercurielle. 
TUMORS OF THE BONES.
139
Having elsewhere spoken (see Vol. I.) of sub-ungueal  exostoses of
the different  toes, described in a  particular manner by Dupuytren
and M. Liston, (Bull, de Ferussac, t. XIV., p. 255,) who with myself
prefer  in such  cases amputation  of the last phalanx to excision of
the exostoses, I will refer the reader to those remarks.  There  have
been met with  on some  of the bones  of the metatarsus, exostoses
which require a little further attention.  It was in an instance of this
kind that B. Bell (tome V., pp. 314, 315,) decided  on extirpating
completely one of these bones for  an exostosis, which occupied its
entire circumference.  M. Herpin (Constitution Medicate d' Indre-et-
Loire, p. 15,  ler  trim. 1818,) speaks of an exostosis of three inches
in  circumference, which  was  situated upon the first  bone of the
metatarsus, and which he removed in the spring of 1806, by means
of a small  saw, after  having laid bare  its root by an elliptical inci-
sion.   The bottom of the wound was cauterized with red  hot  iron,
and the patient radically cured.   There is frequently found upon the
dorsal surface  of the great toe, near its anterior extremity, a conical
shaped exostosis, which  it may become  advisable to extirpate.  A
straight incision and one cut with the pliers, are generally all that is
required for it.  As, however, there  is a  mucous bursa there, which
is  sometimes continuous with the neighboring  joint, it is advisable
 not to operate  there without some degree of caution.

                              §  VI.
   In the leg, exostoses are found upon the fibula, tibia, and patella.  M.
 A. Cooper relates that he saw a cartilaginous exostosis  of the size of
 a chesnut, underneath the periosteum, an inch and a half below the
 head of the  fibula.  The extirpation of  this  tumor was performed
 by M. Leving, (A. Cooper, ffiuvr. Chir., transl.  of Bertrand,  t. I.,
 p. 519,)  who had recourse to  the  crucial incision, and divided  the
 fibular nerve before removing the tumor with Hey's saw.  The cure
 was effected in  a month.  A  patient operated upon by V. Moreau,
 (communicated  by M. Champion, who witnessed the fact,) was less
 fortunate.   In  a peasant girl, there was an exostosis of an  ebur-
 noid character (de nature eburnee) and large base, situated upon the
 antero-external side of the body  of the tibia.   This  J*imor was laid
 bare by means of a quadrilateral flap, and then removed by the aid
 of the gouge, chisel and  mallet.   This was in 1794; accidents su-
 pervened, and the patient died.   In another case, a boy of fifteen or
 sixteen years of  age, the  exostosis, which was seated upon the spine
 of the tibia, had acquired the size  of a Saint-Jean pear.   The dis-
 section of a triangular  flap allowed of  rasping the bone  and em-
 bracing the exostosis in the aperture of a piece  of tin plate,  and
 thus exsecting it, without injuring the soft parts.   The wound was
 united by first  intention, and the  cure,  according to Bourqueneau,
 (Annal. de la  Soc. de Med. Prat, de Montpellier, t. VII., p. 424,)
 was  completed in the space of fifteen days.   Finally, M. A. Cooper
 gives  a case of exostosis with narrow base, situated underneath the
 periosteum at  the antero-superior part  of the  tibia, and which, af-
 ter having made an elliptical incision in the  soft parts,  was suc-
 cessfully removed by means of an  amputating saw, directed  from
 above downwards, and then  from below upwards.   A slight exfo- 
 140          NEW  ELEMENTS  OF OPERATIVE  SURGERY.

 liation, which took place subsequently, did not prevent a radical cure
 from being accomplished.
                      § VII.—The  Patella.
   Vigarous,  (CEuvr.  Chir. Prat., obs.  112,  p. 557,) who has gath-
 ered in his work so many extraordinary observations, speaks of an
 exostosis or osseous steatoma, which grew on the anterior surface of
 the patella, and which was 25  inches in its circumference and was
 covered with four ulcers.  Amputation  of the  thigh had  been pro-
 posed, but Vigarous undertook to remove the  tumor without inter-
 fering with the articulation.  He effected  this  by means of several
 incisions and  by sundry cuts of the saw.   Some osseous laminae exfo-
 liated at  a later period, but the operation, which consumed only fif-
 teen minutes, was  followed by complete  success.   As  for the rest,
 it would  appear from the description which  this author gives of it,
 that this  tumor, which was filled with soft matter, and osseous only
 upon its exterior, belonged rather to the class of degenerated hema-
 tic tumors than to that of exostoses properly so called.

                            § VIII.
  The lower  third of the femur is perhaps the region of the osseous
 system where  pediculated exostoses  acquire the  greatest volume,
 and are most frequently met with.  I have seen them sometimes on
 the inner and sometimes on  the outer  condyle of this bone, and
 near the ham, and either acuminated  or globular, and of the dimen-
 sions of half  an inch to an inch in height.  Those which more par-
 ticularly require the attention of the surgeon, are such as have a ten-
 dency to develop themselves above the  inner condyle, sometimes in
 front and  sometimes behind.   This is a kind of exostosis which is
 scarcely mentioned  in authors, and which has this  remarkable char-
 acter, that the tumor is almost  always found with the same features,
 and in the same place.  M. A.  Cooper, (QZuvr. Chir., transl. of Ber-
 trand, t. I., or translation of Chassaignac, p. 608,)  who  relates  two
 examples, says, that in one of his patients the exostosis, which he de-
 nominates cartilaginous, was situated underneath the periosteum, a lit-
 tle above the inner condyle of the femur, and that it occasioned quite a
 considerable degree of pain.  The exsection  was made  without im-
 plicating the muscles, by means of a  saw which it  was found neces-
 sary to fix by hooks, requiring  afterwards the removal  of some os-
 seous asperities by means  of cutting pincers.   In the other case, the
 tumor, which  was situated in  the same place, and occasioned some
 inconvenience in the movements, was laid bare by an incision, which
 had to include some fibres of  the sartorius muscle, through which
 the exostosis  was extracted after Machel's saw, directed by the in-'
 ventor himself, had  divided its neck.   I  have  already met, "in six or
 seven instances, with the species  of exostosis I have just described.
 In the first case it seemed as if the tuberosity of the inner  con-
 dyle had been transformed into a long and strong  coronoid process.
 The patient, who had been in this state for fifteen years, had become
 so habituated to it, that he would not hear anything said  on the  sub-
ject of an operation for his relief.
  In the second case the tumor existed in a young  man  accustomed 
TUMORS OF THE BONES.
141
to make voyages.  It had the form and size of a small melon,  and
was situated underneath  the vastus internus  muscle,  two or three
inches above  the  articulation.   The idea of an  operation, and the
apprehension of danger, have hitherto deterred the patient, who, how-
ever, suffers from it in no respect whatever.
  The third  case is that of a servant, seventeen  years of  age, who
came in April, 1835, to the public consultation of the hospital of La
Charite.   The  exostosis in  him was precisely similar  to that of the
preceding patient, both in situation, form and volume.
  In  a  fourth example, which I saw in 1836, the patient was  forty-
five years of age, and could not indicate the origin  of his  exostosis,
which was also  situated upon the  inner side of the  femur, at some
inches above the knee.
  It was in November,  1838, that I met with the fifth case.  This
last case was a man of about sixty years of age, who states that he has
had it about thirty years,  and that he attributes it to  a badly-treated
fracture  of the thigh.   There is every reason to believe,  however,
that there is nothing  very authentic in this history.   The abdominal
limb in  fact has no shortening, and the bone, in other respects, is per-
fectly regular.   The tumor, which projects two inches  and  a half on
the inside of the femur, which is three inches in diameter at its largest
part, quite strongly bosselated, and situated at the union of the mid-
dle with the lower third of the thigh, exhibits at its root a contraction
(etranglement) sufficiently marked to forbid the idea of imputing it
to a morbid' (vicieux) callus.  A young boy, twelve years of age, had
one of the size of a pullet's egg, a little lower down, which gave him
no  trouble, and for which he did nothing.  The same was the case in
a patient whom M. Macgloghlin took me to see in 1837.
  It is a matter of surprise that we should so often meet with tumors
of this description in such a region.  None of the patients I saw were
in  any other respect annoyed except by the size, weight or defor-
mity of the tumor.  Thus there were no  sufferings, no lancinating
pains, no excoriations nor inflammations, nor adhesions of the skin or
other tissues.  So also did these patients, when I pointed out to them
some of the dangers  they might  incur in undergoing  an operation,
come to the determination to retain their infirmity, and recoil from the
operation, and perhaps they acted wisely.  Ought we, however, on that
account to say that supra-condyloid exostosis of the femur is absolutely
incurable ?  No, certainly ; but to remove it we have to resort to an
operation,  sometimes difficult, and almost always dangerous, whilst
the disease in itself does not usually compromise the functions of the
limb or  the general health of the individual, and may remain station-
ary for an indefinite number of years, when it has once arrived at a
certain period of its growth.   The  conclusion, therefore, in my own
mind is, that I would not decide upon the removal of tumors of this
description, unless, notwithstanding my representations, the patients
should find themselves so much incommoded or annoyed as to  make
an urgent demand for relief, or unless such tumors should threaten to
acquire  too large a volume, or to  undergo degeneration, or  cause, in
fine, actual pain, or serious functional derangement in the part.  As
for  the rest, there is no other treatment for them but excision or ex-
tirpation, in which event many processes may be employed.   Should 
142
NEW ELEMENTS OF OPERATIVE SURGERY.
the exostosis be flattened and of small diameter, we lay it lare by
means of a simple incision, commenced above and terminating below,
and which ought to penetrate down to the  bone.   The cutting pliers,
Liston's scissors, or one of the exsection saws, will then suffice for ex-
cising it from the femur.   When it does not appear practicable to iso-
late the whole contour of the tumor by means of a straight incision,
we may then choose between the  crucial incision, that of the  T, the
double vertical incision  of Jeftray, or the semilunar.  The crucial
incision would have no  other inconvenience than that of  completely
dividing, and in two opposite directions, all the fibres of the vastus
internus  muscle.   Nevertheless this  difficulty ought not,  at the pre-
sent day, to deter us, if by that means we should render the operation
more  easy,  inasmuch as the section of the muscular layers involves
in reality but very slight inconvenience   The T incision  might be
made in such manner that its horizontal  branch could be placed in
front or behind the tumor, almost  indifferently.  I should, however,
prefer  to  place it in front,  in order that its vertical branch might be
made to fall upon the inner border of the ham,  and permit the two
flaps wThich it circumscribed to be  reversed, the one downwards and
the other upwards  and  backwards.   The incision with two parallel
branches, one situated in front and the other behind,  so as to circum-
scribe  a bridge  of soft  parts upon the exostosis, has in this region
still  greater  inconveniences  than for sub-deltoidal  tumors  of the
humerus.   M. Roux, who made trial of it in the young servant whom
I have mentioned  farther back, was obliged to divide the soft parts
transversely through their middle, transforming it in this manner into
two quadrangular flaps.   Besides creating  in this manner  embarrass-
ment  in  the  section of  the tumor, we expose ourselves moreover to
the risk of not being able afterwards  to disengage it from among the
muscles, and effect its complete extraction.   It is therefore more pru-
dent to resort at first to the semilunar incision.  This incision, whose
free border should be turned inwards, would circumscribe a flap, which
should be reversed from  behind  forwards, and would lay bare the
whole of the exostosis.  An assistant drawing  this flap upon its base
and outwards, while another assistant would hold apart the inner lip
of the wound backwards and inwards, and while the limb was held
in semi-flexion, and lying on its outer side, would enable the surgeon
to carry any saw whatever very near the femur, and to divide the
neck of the exostosis.  If there should remain any asperities o;* osse-
ous inequalities at  the bottom of the wound, nothing would be more
easy than to remove them by means of the chisel, gouge  and mallet,
or by the aid of the rasp or the concave rowel saw of  M. Martin.
We might also confine ourselves to a straight incision, placed on one
of the sides  of the tumor,  and which should be sufficiently long to
enable us to separate its borders wide apart.   The osteotome  of
M. Heine, or the saw of M. Charriere, or  even that of Aitken, intro-
duced  by this means upon the pedicle of the tumor, would evidently
enable us to detach it in the greater number of patients ;  and every-
thing shows that by giving the incision a certain extent, it would give
free egress to the foreign body.   It is perceived, moreover, that the
process in these cases ought to vary  according to the size,  form and
actual  seat  of the tumor, or the particular taste and practice of the 
THE LIGATURE IN MASS.
143
surgeon.   I would only remark, however, that in general me semi-
lunar incision  is the one that should be adopted by preference.   Up
to the present time, this operation has not been performed sufficiently
often to  enable  us to appreciate exactly either its dangers or harm-
lessness.   The two patients of M. A. Cooper, did not recover with-
out causing some uneasiness ;  and  that of M. Roux, who, though he
was young, of excellent constitution, and in perfect health, ultimately
perished.   The surgeon, being obliged to penetrate down to the bone,
necessarily arrives beneath  the fascia lata.  Being unable to detach
the exostosis without more or less  contusing the neighboring tissues,
and without making a wound whose bottom is hard and more or less
rugated,  he can  scarcely count on immediate reunion.  But if the
inflammation and  suppuration, which  in such cases would almost in-
evitably  supervene, should take on a diffused character and extend
downwards towards  the  ham, and upwards  into the body of the
thigh, they would soon constitute one of those forms of phlegmonous
erysipelas, or diffused phlegmons, which are the most formidable that
can be imagined.  I would therefore lay it down as a precept, when-
ever immediate reunion, and without suppuration, cannot succeed, that
we  should not attempt the cure of the wound by first intention, but
confine ourselves to keeping it slightly open by means of small balls
of  lint, until it is perfectly cleansed, and that there has been formed
the pyogenic membrane and cellulo-vascular vermilion surface.
                       CHAPTER XII.

                    THE LIGATURE IN MASS.

   We have already seen in the preceding  volumes under how many
forms  the ligature is employed in surgery.  Useful for  uniting cer-
tain wounds, almost indispensable around vessels, to arrest the blood
in amputations, for wounds of arteries, aneurisms, and most bloody
operations, it is, so to speak, called for as often as we take  the bistoury
in our hands.  But in such cases the ligature includes and constricts
only the vascular  canal, whose orifice  or  calibre we wish to close.
But there are a class of operations in which we apply the ligature in
a different way.  In  these we no longer apply it on a distinct vessel
at the bottom of any wound, nor is  it now designed to  repress the
effusion of blood; its object here  is, by strangulating the parts, to
mortify,  sometimes,  quite a considerable  portion  of them left out-
side of it.  It is to this last kind of constriction that the title, in our
times, is given of ligature in mass.   It is thus that polypus has  been
treated at every epoch, whether situated in  the nose, the womb, or
rectum, or even in the ear.  Most pediculated tumors have also  been
treated at every period of science by the ligature in mass.   Even
amputation of the limbs has been sometimes  performed in  this  man-
ner.  I have related  several examples of this kind under the chapter
on Amputations in general. When castration is performed,  it is allow-
able to embrace the whole of the testicular cord in a ligature, and to 
144
NEW ELEMENTS OF OPERATIVE SURGERY.
strangulate it in mass.  The ligature for fistula in ano, so frequently
employed in the last century, was nothing more than the ligature in
mass.  We  see by these examples under what circumstances the
strangulation of the parts ought in reality to receive the name of liga-
ture in mass, and to how many and to what  kind of operations  this
description of remedy is applicable.  To effect it the surgeon may
make use of all the different kinds of ligatures imaginable ; those of
silk, thread, linen packthread, cord, fibres of plants, lead, silver, gold,
platina, and  maillechort,  rendered  flexible by  the  various  means
known in the arts, furnish  the same resources for  the ligature in
mass as for the simple ligature of vessels or for sutures.   Neverthe-
less, we cannot indifferently employ any one  of these substances in
preference to another.   Should we  require a  ligature  somewhat
small in size, and which should be at the same time very supple and
strong, the silk  ought to be preferred.  If it is  required to effect a
firm constriction of a soft tissue with a root somewhat large, a liga-
ture of hemp, made by twisting three, four or five strands of simple
thread, presents the most advantages.   Packthread, which might
be substituted for  it, has the inconvenience of adapting itself with
less  facility to the bottom of the  parts, and of untying itself  too
easily.  It is advisable, moreover, in place  of besmearing them with
soap, as  some  persons  have recommended,  to  rub  the strands of
the thread or packthread with wax, which  prevents, or at  least
diminishes, its tendency to slip.  Tissues  of  plants or  ligatures of
linen ought not to be employed unless none better can be obtained.
As  to  metallic  ligatures, however  pliant some may consider  them,
they never possess the  flexibility of thread, and  cannot obtain  the
same generalization in practice.  They consequently ought not to be
preferred, unless there is  necessity of a very great degree  of con-
striction, or to put ourselves on our guard against the  dissolution,
putrefaction, or physical alterations of the ligature.  There are also
some cases where substances, which wrould  be susceptible of solution
and absorption by the living organs, might have an advantage.  Thus
to strangulate an intestine, either transversely or on its  side, and in
such manner as to  return it immediately afterwards into the belly, it
would be a precious advanfage to have  the use  of ligatures which.
as soon as they were applied, would cease  to act as a foreign  body.
For this purpose there has been used silk in its natural or raw state,
deerskin, chamois  leather, gold beaters' skin, catgut,  &c.  But in
addition to the fact  that ligatures or threads fabricated  out of these
substances, are deficient in solidity, they  have  moreover the inconve-
nience of not being absorbed, except in a few  cases, without exciting
inflammation or suppuration.   The  ligature in mass is not applied in
all cases in the same manner.  If in some cases we limit ourselves to
encircling the part by  placing the  ligature  immediately upon  the
skin without any  previous  incision, we on  other occasions  com-
mence by dividing the integuments  upon the same circle which is to
receive the  ligature.   These  two  modifications  of  the ligature in
mass were known at a very ancient period.  In  the method known
as M.  Mayor's, and which,  since the time of Hippocrates, all sur-
geons occasionally employ, we commence by laying bare and  dis-
secting the parts which it is our intention  to destroy, and it is  not 
THE LIGATURE IN MASS.
145
until after we have isolated them nearly down to their root, that we
surround them with the ligature and strangulate them.  This last
method is daily applied, as it has been for ages past, for *he extirpa-
tion of tumors of  the  axilla after the removal  of cancers of  the
breast, also in the ligature of the spermatic cord, etc.  The various
modifications of the ligature in mass are nevertheless all classified
under two  general  methods, viz: the ligature without previous dis-
section  of the integuments, and  the  ligature  after the dissection of
the tumor.

           Article I.—Ligature without Dissection.

   The ligature in mass, without previous dissection, comprises three
varieties: the thread or ligature is applied on  the integuments with-
out any other precaution, or after a circular incision of the skin, and
sometimes  also after having cut through the tissues behind the root
of the body which is to be destroyed.  The ligature upon the integ-
uments, whether they are cutaneous or mucous, is effected by means
of all   the different kinds mentioned above.  Some surgeons of
former times, and some practitioners of the ancient academy of sur-
gery, had proposed in such cases to saturate the ligature with some
caustic matter, in  order, they said,  that it might more rapidly  cut
through the tissues.  This  precaution, which rendered the operation
obviously more painful, augmented the inflammation, and  did not
sensibly hasten the  fall of the ligature, and which moreover rendered
it more brittle, is  no  longer employed  in  our time.  It  is by a
mechanical action,  and not by its chemical properties that the liga-
ture, thus applied, is to produce its effects.  This description of liga-
ture, which  is applicable  to  cutaneous tumors, whether they  are
fibrous, vascular  or horny, when they have a narrow root  and  are
easily  raised up, is equally  applicable to bodies that are  fibrous,
mucous, or of any  other character, which are found  in the interior
of the  mucous cavities.  To accomplish  it  we  require a  ligature
properly prepared, and  of a strength, breadth and  thickness pro-
portioned to the  volume of the tumor, or the degree of constriction
to be used.  The ligature  being arranged, the surgeon  causes  the
tumor to be raised  up in such manner as to surround  its root a little
behind  it, and upon the sound tissues.  If the pedicle of this tumor is
purely cutaneous, there is no danger in strangulating it.  When it is
rather more cylindrical or conical  than  dilated  (renflee), we may
limit ourselves  to  applying  the  ligature upon its  neck  without
making the least traction upon it; on the contrary it.may be advan-
tageous  to raise it  up with a certain degree  of force while we  are
applying the ligature, if we do not wish to incur  the risk of leaving
behind a certain portion of the degenerated tissues.
   It sometimes happens, that, in order to prevent the ligature from
slipping, from the integuments towards to the tumor, we are obliged
to give it certain points d'appui on the Confines  of the diseased region.
It is in  this manner  that  an erigne, a tenaculum, or a hook forceps
with very convex teeth, sometimes becomes necessary.  The tumor
being drawn upon by an instrument of this description, obliges  the
ligature to glide backwards, in proportion  as it is  tightened.  As it is
                                10 
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NEW ELEMENTS OF  OPERATIVE SURGERY.
sometimes necessary that this last  precaution  should be  rendered
permanent, it  has  been proposed to pass, at first, a simple metallic
stem, or two similar stems crosswise, under the root of the tumor, in
the manner I proceed, and as M.  Davat has done, for the  ligature in
mass, on varices.  These  stems, having transfixed the tissues firmly,
retain the ligature, which  is placed behind them ; in this manner we
strangulate  without any great degree of difficulty,  and  circularly,
non-pediculated  tumors.   I  have  mentioned farther  back, what  has
been  obtained from this description of ligature, in  the treatment of
erectile tumors.   As it is difficult to  strangulate the parts completely,
when they have a  considerable  degree of thickness, it was readily
suggested, that  we should  embrace  a  portion  only of the  base of
large sized tumors with each ligature, to pass two, three or four  lig-
atures in  order  afterwards to  mortify separately each of the parts,
or one of the  four  triangles of the pedicle, when the threads have
perforated it crosswise.   Should it be desired to apply a double liga-
ture, we take  a  long waxed thread, with a needle, pierced near its
point, and having a  handle, or a long  common needle slightly curved,
or a probe, inserted in a canula which a trochar had previously ena-
bled us to plunge through the  tumor.  We  pass the thread behind
the root of this last.  Having immediately cut it near the needle, or
disengaged it from the eye which  conducted it, the thread is instantly
un-doubled; we then seize hold  of  one of its halves which is tied
into a knot on  one side,  and then  do  the same with the other, on  the
opposite side,  taking care to tighten  them in a proper manner.  In
this way, the  ligature strangles only a portion of the mass.  As it
acts, moreover, from within outwards, it  produces as much effect as
if the tumor was only half the  size that it is.  If, as M. Warren (on
Tumors, etc., p.  418)  appears to have often done, we should incline
to divide the tumor into four parts, by means of threads, it would be
advisable  to insert  the four ligatures in  succession, and to  give the
preference to  the needle  of J. L. Petit.   Each  thread would thus
circumscribe a quarter of a circle, and the entire circumference of
the tumor would finally become strangulated.  Finally, it would also
be practicable to imitate  Somme, who, wishing to divide  the bridle
of a pseudarthrosis, plunged in  his ligature, and brought it out by the
same opening,  after having passed it  around the tissues to be divided,
a method, which, as I have elsewhere said, appears to have also been
made trial of for varices.   We should, therefore, insert by puncture,
and  sub-cutaneously,  by means of a needle slightly curved, or any
other instrument, a  ligature upon the contour of one of  the halves
of the mass.   Brought  again, by a second puncture, to the opposite
extremity of the great diameter of the tumor, the ligature would  be
conducted in the same manner  upon  the other side, and brought out
at its point of  departure.  We should, in this way, procure a circular
constriction, which  would  in no  respect  interfere  with  the integu-
ments, and perform an operation entirely under the  skin.   A last
mode of strangulation, without previous  dissection, and  which has
already been  employed by some surgeons, by  M. Manec among
others, consists in introducing as far as the centre of the  tumor, four
metallic stems, each armed with a hook, which, darting through it in
the  manner of a spring, afterwards divides the tissues from the cen- 
THE LIGATURE IN MASS.
147
tre to the circumference by means of a quick screw adjusted to their
free extremity.

       Article II.—Ligature  in Mass, with Dissection.

   The surgeon has often a good deal  of embarrassment when com-
pleting the separation of tumors that are deeply situated, or organs
whose pedicle is nourished by numerous vessels, which cannot be
seized without difficulty, or that are of large  size.   This is seen in
the extirpation of the tongue, the removal of cancerous tonsils, the
thyroid body when degenerated, and  in most of the tumors  of the
neck, axilla, groin, &c. It is easy to be conceived, that the  surgeon,
who has to extirpate  a cancerous  tonsil or tongue, must necessarily
be intimidated with the hemorrhage which may result from such an
operation.   All extirpations of goitre have also been considered  for-
midable from the same danger.  M. Mayor, (Essai sur la Ligature,
etc., Lausanne, 1821  ; Essai sur la Lig. en Masse,  Paris, 1826,) in
giving more importance than any other person to this inconvenience
in bloody operations, has suggested  that a ligature  which would
embrace the root of the tumor, would enable us to penetrate deeper
down than with the bistoury, while offering, at the same time,  to the
operator all  the  security  desirable.   So that  the Jigature in  mass,
with previous dissection, and  which was  formerly but  seldom had
recourse to, is now in sufficiently general use.   It is effected,  more-
over, with the same  substances, and by the same processes, as the
preceding method.  Thus, in order to accomplish this, we may make
use of threads, of silk, hemp or flax, ligatures of linen, packthread,
or cord, wires of lead, silver, or other flexible metal  or the different
kinds obtained from animal tissues.  In the same way as for the  lig-
ature in mass, externally, we might imbue the thread with caustic or
medicated material, or apply it without any other precaution, upon
the root of the tumor, and prevent its slipping by the various means
employed to arrest the knot in the ligature upon an artery.  If the
body to  be strangulated  is voluminous, it is  advisable, at first, to
perforate  it with a double  ligature, the two portions of which  are
afterwards separated, in order to form a distinct circle, applied to
each half of the  pedicle we wish to mortify.  Nothing, moreover,
would prevent our dividing the root of the tumor into four portions,
by means of four  separate ligatures ;  but the ligature in mass, with
metallic wires, would  be applicable after dissection only, to tumors
whose entire contour  and  root passed beyond the level of the integu-
ments.  If, however,  in order to effect its strangulation in a proper
manner, it should be  thought advisable to insert  the metallic  stems
crosswise, through its root, it would still  be practicable to recur to
this, provided we  took care to withdraw them  shortly after, that is
to say, as  soon as the ligature had cut sufficiently deep into the tis-
sues to prevent it from any longer having a disposition to slip.

Article III.—Manner of effecting Strangulation by the Mass.

  The object here is  to interrupt all  kind of circulation and phy-
siological  action in the mass  whose pedicle is constricted-   The 
148
NEW ELEMENTS OF OPERATIVE SURGERY.
better way would then appear to be, to  strangulate the parts at first
as powerfully  as  possible.   Nevertheless, the ligature  in  mass is
sometimes employed in such manner as to cut or strangulate only by
degrees, the organs which it embraces.  If the ligature has but little
volume and acts insensibly, it may happen that the first organic layers
cut by it do not mortify, but even reunite external to it, so as to im-
prison it, before its action has  been brought to bear upon the tissues
which are deeper situated.  M. Mirault noticed this in a  case of
strangulation of the tongue ;  what I myself have also seen, and what
J. L. Petit had already noticed after a ligature  in mass upon the tes-
ticular cord  ; which result I have witnessed also in the  case of a
child who had strangulated  the penis with  a  simple thread.  This
species of constriction, therefore,  is for the most part very uncer-
tain.   Nevertheless, there might be cases where it would be advisa-
ble,  provided  that by thus  cutting  through the  tissues  by degrees
without mortifying them, some  prospect might be obtained of effect-
ing a radical change  (modifier profondement,) in their morbid con-
dition.  We shall find, in  fact,  in speaking of operations  performed
upon the  tongue, that the patient treated in this manner  by M. Mi-
rault, ultimately recovered of his cancer.   If, however, the strangu-
lation at first  is sufficiently  powerful  to arrest the passage  of the
fluids, the tumor, which is immediately deprived of its vitality, first
becomes blue and livid, and then softens, shrinks and loses its volume.
From this it happens that  the ligature  is  no sooner  sufficiently
tightened, than it slips and  is displaced, and no longer makes any
constriction.   In this  point  of  view, practitioners  in my judgment
appear to have examined  but one of the points of the question.  If
the ligature changes place before the entire physiological  circulation
in the tumor has been suspended, it is clear that life may be re-estab-
lished and that our object will be defeated.  If, however, this dis-
placement does not take place until at  the expiration of 24 hours, or
in consequence of the shrinking of the  tissues, our purpose, never-
theless will be attained.   After this first result, however, the conse-
quences will be the same, whether the ligature remains or is removed.
Every thing existing  external to the ligature is effectually mortified,
represents an  eschar, and acts in the same way as a foreign body
which must necessarily come away through  the eliminating powers
of the system.  We see in  these cases a line of demarcation estab-
lished between the living and dead parts, while a process takes place
in every respect analogous  to that which detaches the eschars from
a burn.   For which reasons, my rule  is to remove the ligature at
the end of one or two days,  when it incommodes, or when it is not
my design to  increase its constriction from  day to day.   As to the
manner of performing this strangulation, it presents a certain num-
ber of modifications.

                  §  I.—Simple  Strangulation.
  Whether the ligature to be applied is to be external or deep-seated,
we nevertheless frequently confine ourselves  to strangulating the  pe-
dicle of the tumor by a double or even a single knot, in the same way
as in tying an  artery.  Nevertheless, as it is almost always necessary
to constrict the parts as strongly as possible, the first knot requires to 
THE LIGATURE IN MASS.
149
be firmly secured while we are adjusting the other.  To effect this
we have three resources:   1. An assistant holds the extremity of
one of his fingers accurately placed upon the crossing of the threads,
while the surgeon prepares the second knot of the ligature; 2. should
the finger be found too large for this purpose, we substitute for it the
blunt extremity of any metallic instrument whatever; 3. or what is
still more secure,  we firmly embrace the  first  knot with the  point of
a forceps.  Still another means consists after the first knot  is made,
in carrying the two portions of the ligature again around the tumor,
in order to knot and tighten them  in the  same manner upon the op-
posite side.  Whatever mode is adopted, it is  advisable to cut one
or both of the  free portions of the ligature near the knot.  We cut
both, should nothing prevent our seizing hold of, and dividing the
knot  at its place, when we judge proper.  We leave one, on the
contrary,  when we  consider  it advisable that  we should have a
guide to remove the ligature at a proper time.   If the ligature is in-
tended to be temporary, we might, after having tightened it, adjust
its  first knot by  a simple  rosette  (bow-knot).   By this  means we
may readily withdraw the  ligature at the end of one, two, three, or
four days, and disembarrass the parts without dividing anything.

                              §11.
   In place of this sudden strangulation, we sometimes have recourse
to a graduated constriction, a constriction which, notwithstanding
the shrinking and withering of the divided parts, shall act in  such
manner that the strangulation of those which remain, is  not  at  all
relaxed, but continued up to the time of  their complete separation.
For this purpose, quite a number of different modes have been de-
vised. One of them  is so ingeniously arranged that the  ligature
tightens itself in proportion as the tissues recede.  To accomplish this
M. Pelletan has contrived an instrument more ingenious than those
of Levret, and which is represented  by a stem with a double canal,
having at its free extremity a sufficiently  powerful spring, which  re-
ceives the extremities of the ligature which have  been previously
passed around the tumor, and which  constantly tends  to make trac-
tion upon them,  (les  entrainer).   Others  have invented ligatures
whose constriction may be augmented or diminished at  pleasure.
All the kinds of knot-tighteners (serre-noeuds) nearly, belong to this
description. Whether, in fact, we make  use of the serre-nceud of Lev-
ret, that of Deschamps, Desault, Dubois, or even the simple bow-knot,
we may, nevertheless, renew at pleasure the degree of strangulation
we have at first produced.   When we  have surrounded  the tumor
with a metallic thread, it will be sufficient to twist the  two free por-
tions in a spiral manner around each  other, if we wish  to make daily
increase  of the constriction.   The most  ingenious  instruments we
possess of this kind are those of M. Bouchet, M. Mayor, M. Graefe,
and Dupuytren.
  The knot-tightener of M. Bouchet is a sort of rundlet traversed
by the two threads, and around which  they are attached in order to
be  shortened to the degree desired.   M. Mayor, reviving  an idea
formerly thrown out by Roderic, has proposed to pass the two united
extremities of  the noose of the ligature which surrounds the tumor, 
150          NEW ELEMENTS OF  OPERATIVE SURGERY.
 through a series of beads or small balls of wood, ivory, horn, bone,
 silver or any other substance, in the manner of stringing  the beads
 of the Paternoster.  The first of these beads being pierced with two
 holes, allows  of tightening  the two  halves of the  ligature strongly
 upon the last, and of forcing the other in  a proper manner against
 the tumor.  To do this with still  greater ease, we may replace  the
 outer half of this  chain of beads  by a metallic or ivory tube, and
 make use of a small winch  (treuil) to receive the extremities of  the
 ligature.   We have, by this means, a ligature which terminates in a
 flexible stem, which adapts  itself with facility to the parts, and inter-
 poses no obstacle  to the gradual strangulation of the tissues.  The
 knot-tightener of M. Graefe, as modified by Dupuytren, receives by
 one  of its extremities the double thread of the ligature.  This liga-
 ture is then attached by several turns to a small lateral nut, (ecrou,)
 which'is separated from or  approximated to the wings  or outer ex-
 tremity of the instrument at  pleasure, by  means of a  quick-screw,
 (vis  de rappel.)   (See  article, infra, on  Polypi of the  nose, uterus,
 &c.)

                   Article IV.—Appreciation.

   The ligature in mass, applied exclusively and alone,  and adjusted
 by a common  knot  as near as possible to the root of the tumor, more
 frequently answers the purpose than is generally supposed.   It is in
 fact, in most cases, not at all necessary, as some think, to renew the
 constriction and tighten the ligature  daily.   I have seen enormous
 tumors yield  to this  kind  of constriction  kept up for twenty-four
 hours, or even in  some cases for only twelve hours.   An  immense
 polypus  of the pharynx and  nasal fossae thus strangulated for the
 space  of some days, and divested of its ligature a long time before it
 had been completely cut through, nevertheless separated at its root.
 How often have we not seen  polypi of the uterus, treated by the
 ligature, detach themselves beyond the point which had been touched
 (touche) by the thread, and although the constriction had been actually
 maintained only for the  space of a few hours !  Nevertheless, this
 species of strangulation is  not as suitable as the  others, when we
have to include a great mass of tissue.,  It is in such cases that par-
 tial or progressive strangulation  merits  the preference.    Partial
 strangulation by means of  threads passed through the tumor, acts
 more promptly and with more certainty than the  simple  ligature;
 but it is applicable only to external tumors, and would not be adapted
 to those whose pedicle includes voluminous vascular trunks, or large
 sized  nerves.   Here, therefore, we  should make use of gradual
 strangulation.   Underneath  the skin  this last mode would, at first,
 present great difficulties, and would not probablv succeed until after
having transformed the tumor  into a  vast absce'ss, at  the same time
 without giving assurance that the integuments would be preserved.
 The  process of M. Manec  is, undoubtedly,  the  most  difficult and
most embarrassing, and  the  least certain of all.  By means of knot-
tighteners, should we use that of M. Pelletan. the results we would
produce could only be imperfect and  incomplete.  The instrument
of M.  Graefe, when a straight and inflexible stem, is not  attended 
FOREIGN BODIES.
151
with any serious  inconvenience ;  or on the contrary, the chaplet of
Roderic, as improved by M. Mayor, may enable us to dispense with
the others, and  presents all the requirements of force and simplicity
desirable.   As for the rest, it is not to be forgotten, that the opera-
tion is practicable with all these instruments and by all these pro-
ceses;  which, nevertheless, does not exempt me from  adding that
the ligature in mass never should be the method of election, when it
is  practicable to  employ the  cutting  instrument without manifest
danger.  The ligature in  mass, used in the manner I have described,
causes the separation of  the tissues at the expiration of a period of
time, which  varies  between three or four days and  two or three
weeks.
   During all  this period the tumor passes into a state of putrefac-
tion, is  decomposed, and emits an odor which is usually offensive,
together with discharges which possess a certain degree of acri-
mony.   Hence  the extremely unpleasant  consequences,  both  to
the patient and those who approach him; and hence the real dangers
which may result from this state of things by  means of resorption,
infection or poisoning.   I have, therefore, been in the habit, when
I have  employed this operation, of excising from  a half an  inch to
an inch of all that portion of the ligature which was found outside,
as soon as the circulation appeared to me  to have  been  sufficiently
destroyed in the centre of the tumor.  I remove the ligature itself at
the end of four  or five days, when this first excision convinces me
that there no longer remains any degree of vitality in the circle  of
the constriction.  The patients are thus relieved from an actual pes-
tilential ulcer, (foyer,) and they have nothing more to undergo than
the eliminative process from all the different points, similar  to that
which detaches  the eschars from a burn; contusion,  or gangrene.
It  is nevertheless true, however, that with the exception of a small
number of cases, the ligature in  mass will always be the favorite
operation with surgeons who have but little experience with the
knife, or not  much confidence in their anatomical knowledge, or the
steadiness (surete)  of their hand.  No one, however, as I think,
would undertake  to contend, that an operation finished in a few min-
utes, and which leaves a fresh and living wound, can be where all other
things are equal,  less advantageous than an operation which cannot
be completed in less than from eight to fifteen days, which is  accom-
panied with all the phenomena of gangrene, and the wound made by
which does not begin to become  cleansed, until at a  period wheD
that of the other may be  perfectly cicatrized.
                     CHAPTER  XIII.

                       FOREIGN  BODIES.

  Numerous foreign substances, and of different kinds, may exist in
the human  body, and require the  intervention  of surgery.  Some- 
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NEW ELEMENTS OF OPERATIVE  SURGERY.
    times these substances come from without, and at other times form in
    the midst of the parts themselves.   The  sequestra of bones, eschars
    within the soft parts, certain  accidental productions, different sorts
    of calculous concretions, the  decomposed products of fecundation,
    whether uterine  or extra-uterine, &c. &c, belong to the last-named
    class.  Substances  derived  from   three kingdoms  of nature, and
    which, having once entered  into the living  cavities  or tissues, are
    arrested there as anomalous, and remain there as morbific causes, are
    to be enumerated under the first class.  The organs most  exposed
    to these kinds of accidents,  are the ear, frontal sinus, eye,  nares,
    mouth, maxillary sinus,  the  air passages, oesophagus, urethra  and
    bladder, vagina and womb, and  the rectum and intestines in general.
    It will be  while  examining the  operations required for the diseases
    of these different organs or regions (appareils) that the occasion will
    present of speaking,  also, of the foreign bodies which are found in
    them.  I do not therefore intend, at this moment,  to treat  of other
    foreign bodies than those that are attached to, or formed upon other
    regions of the animal economy.

                          Article I.—Trunk.

                            § 1.—The  Head.
      In this series we shall find  foreign bodies in the head, face, chest
    and abdomen.  Projectiles thrown by powder, as powder itself, lead,
    and especially balls, langridge (mitraille)  discharges from bombs, or
    howitzers, biscayans, and even small  bullets, are frequently found
    there.  Then come  pieces (tiges)  and fragments of metal, wood,
    wadding, clothing, flints, portions of glass, &c.  There are no regions
    where these different foreign bodies have not sometimes been encoun-
    tered.  A ball which was found near  the gullet, (Transact. Phil,
    1738, p. 449, art. 6,) had entered there bypassing through the lower
    jaw and tongue a year before. A dice (de) entered from the pharynx
    of a child into the pterygoid fossa, (Parrish, Encyclogr. des Sc. Med.,
    1836, p. 321.)  I have removed, through the mouth,  a ball  which a
    boy,  aged fifteen years, had driven by  the discharge  of a pistol into
    the body of the fourth cervical vertebra.  Marchettis (Bonet, Corps
    de Medecine, t. III.,  part 2, obs. 25, p.  230,)  speaks of the fragment
    of a fan, which  having been introduced through the orbit into the
    upper maxillary  bone, made its way out, and was extracted in  part
    externally, and partly through the palate, at  the  expiration of three
    months.  A man, fifty years  of age, whose case is given by Mays,
    (Planque,  Bibl.,  t. I., p. 43, in 4°.)  had in an abscess below the ear,
    a portion of pipe which  he had  forced  into his throat six months be-
    fore.  Percy  (Manuel du Chirurgien d'Armee, p.  109,) relates a
    great number of cases where various foreign bodies had in this way
    become lodged in the head.   A patient mentioned by De  La Motte,
    (Tr. CompL,  1.1., p.  718, ob.  205,) received a sword  thrust between
    the gum and nose, and the weapon breaking,  perforated near the ear
    and remained of the thickness of a farthing external to its place of
    of entrance.  The wound cicatrized over it, suppuration  took place
    near the ear,  and no attempt was made to extract the foreign body.
___A man, in despair from being paralyzed,  discharged a pistol into his 
                        FOREIGN BODIES.                     153

mouth.  The following day he told me he had felt the ball descending
into the stomach, and he was no longer paralyzed !  Watching the
symptoms, I noticed, on the eighth day, a slight degree  of emphy-
sema  over the left eye.  I cut down and extracted  the ball, which
had  shattered and  contused the orbitar arch.   This patient  was
cured both of his  wound and paralysis.  In the case of a wound,
related by Donnadieu, (Anc. Journ. de Med., t. VIII-., p. 549,) the
point of a copper spindle remained for thirteen  months fixed in the
cheek and one of the jaws.  At first its presence was not noticed.
A sinuous ulcer finally disclosed it, when the metallic point was ex-
tracted, and the  cure  took place.   Courgeolles  (lb., p. 551,)  makes
mention  of a fragment of wood, which having  become implanted
or imprisoned in the bone near the supra-orbitar notch for the space of
fourteen years, had produced no other result than a warty excrescence,
which successively disappeared and  returned  without the patient
taking any farther notice of it.   In F. de Hilden, (Bonet, Corps de
Med., p. 160,) we find the history of a ball which-had remained for six
months between the cranium and dura mater.  A patient of Morand,
 (Opusc.  de Chir., p. 159, Ire partie,) who died at the expiration of
nine months, presented a similar fact.  Analogous cases have been
related by a great number of surgeons, and especially by M. Larrey,
 who also speaks of ram-rods traversing the cranium without causing
 immediate death.   An example of this kind has  just  been published
 by M. Zedleg, (Gaz. Med.,  1838, p. 379.)   A ball had been retained
 for  eighteen years above the orbit, in the substance of  the  frontal
 bone on  the  right side, and  the patient, who in other respects had
 been in quite good health up to that time, died of  apoplexy.  . Tho-
 massin, (Extraction des Corps etrangers, etc., p. 16,) in the case of
 a child aged twelve years, saw an arrow forced through and through
 the  apex of the cranium, but which, however, was extracted,  with
 a successful result.  A patient who had carried for the space  of four
 months a similar body in the brain, was cured by M. Majault, the
 father, (Mem. de  VAcad, de  la Chir., t. I., p. 316, in 4°.) but Majault,
 the  son,  operating at the expiration of eleven years for a  similar
 lesion,  lost his patient on the third day, (Journ. de Med., t. XLL,
 p. 82.)   Solingius  (V. D. Wiel, cent.  11,) was more fortunate, and
 succeeded in extracting  from the cranium a portion of the blade of
 a sword, which had broken there after having entered by the great
 angle of the eye.  The point of a poignard, which had broken in the
 cranium, and which at first  could not be extracted, became detached
 almost of itself at a later period, (Bartholin, cent. 4.)  A portion of
 the  stock  of a musket, which had been for two months in the brain
 without  causing  any accidents,  after  being extracted, was followed
 by death, (Journ. de Med., t. I., p. 242, obs. 8.)  [See remarkable
 and recent cases of these injuries in our notes under Trephining,
 Vol. II.]

                         § II.—Thorax.
   If we pass from the head to the chest, we shall find that an ear of
wheat,  (A. Pare, liv.  25,  chap. 16,—Bally, Revue Med. Franc, et
etrang.,  etc.) and  needles  and pins swallowed  by  accident, have
made their way through the lungs, and finally, after having produced 
154          NEV. ELEMENTS  OF OPERATIVE  SURGERY.

an abscess there, and sometimes even without  any previous morbid
changes, have finally shown themselves under the skin.  Every body
knows the case related by Gerard of a knife blade which had become
fixed  in  a rib in such manner as to project  into the  interior of the
thorax more than from the outside of the rib.  Bidloo, Bagieu, Des-
port and  M. Terrin, mention  cases- where they had to extract balls
from between the ribs, where  they had either entered or were mak-
ing their egress.  Wherter, (Journ. Gen. de Mid.,t. LX1X., p. 423.)
on the authority of the  military surgeon  Hunter, mentions a bis-
cayan of three ounces which, after  having  fractured the ribs, lost
itself  at  the  depth  of  five inches in  the lungs.  The fragments of
broken  bones were  exsected, the foreign  body extracted,  and the
patient  cured;  but  this  account is  so  problematical  that we may
place it by the side  of that which mentions  a ball of seven pounds'
weight which had travelled into the haunch !  Broussais (Histoire
des Phlegmasies Chroniques,  2e edit.) speaks of a soldier who died
at the expiration of fifteen or twenty years, with a ball in the lungs,
without any person  having suspected it;  and  Thomassin (op. cit.,
p. 96,) relates that  he found  a  ball in the  right lung  of a man who
died at the expiration of three  weeks from wounds disconnected with
this last.  Briot  (Hist, de la Chir. Milit., p.  97,) cites a case where
a ball, after having  passed through the scapula, became wedged in
between two ribs.
  Having dilated the wounds and glided the beak of a spatula be-
hind the foreign body, its extraction was  effected while the patient
made a strong inspiration.   In the memoirs of  M. Larrey, (Ibid., t.
IV., p. 259,) we find the case of a ball, weighing ten drachms (gros),
which had perforated the thorax between the eighth and ninth ribs.
The surgeon  could not effect its extraction until after having notch-
ed out, by means of  a  blunt-pointed  bistoury, the  whole breadth of
the lower rib, down to within  two lines above its arterial border, to
such extent that the  patient, in a sudden flexion of the trunk, frac-
tured  the rest of this bone, wounded the intercostal artery and pro-
duced a hemorrhage, which was finally restrained, but not  without
difficulty, by means of the  process of Desault.   The same surgeon
had, moreover, some time  previously, extracted a ball weighing six
drachms without previous  exsection of the bones.  A girl who re-
ceived the discharge of a pistol  in her back, died  on  the twentieth
day.  The ball which lacerated  (rompu) says F. Plater (Thomassin,
op. cit.) the spinal marrow had implanted itself into the body of the
ninth  vertebra.  M.  Burnes (Archiv. Gen. de  Med., t. XXVIII., p.
411) speaks of a fork which was extracted from  the back of  a pa-
tient without  its being  known how it had  entered there.  Foreign
bodies of another description also, have quite frequently been found
in the body (epaisseur) of the chest.   I will relate here two singular
cases.   A convict died of a visceral affection at the hospital of Roche-
fort (Guillon, Presse  Medicate, t. I., p. 151.)    In this man a foil (fleu-
ret) was found in the chest which had transfixed it completely, one of
the extremities being in the substance of one of the ribs, and the othei
in the body of a vertebra, while the middle portion, covered with sta-
lactites, was  enclosed in the body of the lungs.  It was ascertained
that the wound had been made fifteen years before, and no one sus- 
FOREIGN BODIES.
155
pected that a foreign body of such a character existed in the thorax
of the patient.  A case not less remarkable, but in which the conse-
quences were more disastrous, was presented at La Charite, in 1836.
While on exercise, an officer of the National Guards, of Paris, received
in his back a musket  ram-rod of large calibre.   This rod penetrated
to the depth of fifteen inches, taking an oblique direction from the left
dorsal region to the right breast.  Tractions made  by a  number of
surgeons, and men of great strength, near Sceaux, where the accident
happened, could not in the least  degree move the foreign body.   I
was enabled in the .evening to examine this patient at the hospital,
whither he had been removed.  After  the  facts communicated  to
me, and  after comparative measurements of the remaining portion
of the ram-rod and  the  musket, with another  ram-rod of  similar
calibre;  and after having  struck several times upon the metallic
point, which projected about five inches from the  dorsal region,  I
had no doubt that it had perforated through and through the thorax.
No serious accident  had  yet occurred, and the patient suffered but
little.  What in such a case was to be done 1  The removal of the
rod might  give rise to a  hemorrhage and effusion of blood which
might suddenly prove mortal; there was room for apprehending
that the  aorta, vena cava, or even the heart  might  have been trans-
fixed (embroches)—[this conjecture scarcely  seems  supportable, T.]
—and that in removing from  them the  species of plug which had
shut up  their perforation, the  sources of life would  have been in-
stantly extinguished.   But by leaving it in its place could we, on the
other hand, hope that the wounded man would  survive ?   For how
could we conceive that a rod  like this, traversing organs so impor-
tant,  would  not soon give  birth to accidents that would prove
speedily fatal.  The  case of M. Guillon was  not then known to me,
and  if it had been  it would  have strengthened me in  the  step  I
deemed it proper to take, which was that of delay.
   This course, moreover, was one of necessity.  Our surgical resour-
ces, rich as they already are, have nothing which would enable us to
extract a body of this description.  I hoped  that the process  of sup-
puration taking place around the foreign body, would soon render it
movable, and allow of its being  removed, at the same time  that  it
would obliterate  the vessels,  if  any  had, in reality, been wound-
ed.   At all  events,  I caused to be constructed, by  the ingenious
artist, Charriere, an  instrument which would have carried out my
views, had not the patient, in  spite of the most rigid antiphlogistic
treatment, succumbed at the expiration of four days, almost suddenly,
without having given any positive evidences of pneumonia or effu-
sions in the  chest.   The opening of the  dead body disclosed to us,
that the  rod had traversed one  of the  dorsal vertebras,  at a line in
front  of the  spinal canal; that afterwards, grazing the  vena cava
ascendens, and passing under the base  of the  heart, it had  passed
through the lung to arrive between the ribs  under the right  breast,
where it still remained.  The larger vessels and the heart were intact.
The lung, though slightly engorged, was not  inflamed ; it would ap-
pear that death had  been caused by the effusion of a certain quan-
tity of blood into the  bronchial  tubes, (les  bronches,) laid open in
the track of the rod.   I then made an essay with the instrument of 
156
NEW ELEMENTS OF OPERATIVE SURGERY.
M. Charriere, and we found that it would have perfectly fulfilled the
indication.   This instrument is composed  of  a large metallic plate,
which was intended to have its support upon the back,  after having
allowed the projecting portion of the rod to pass through  it.   This
last being  admitted into a solid tunnel, or sort of socket, itself sus-
tained upon the plate mentioned,  furnished  support to a nut, by
which the action would have been made upon the foreign body with-
out any unsteadiness,  and in a gentle manner,  after -the  manner of a
quick screw from before  backwards, permitting all  the  force requi-
site to be used, and that  without exposing to any kind of concussion.
If this instrument, which could not  be completed until the day the
patient died, had been accessible at the first, perhaps I  should  have
had recourse to it: would the  patient, in that case, have survived ?
This is precisely the  question which will always cause the greater
number of surgeons to hesitate under such circumstances.  I will
nevertheless add, that hereafter, notwithstanding the case published
by M. Guillon,  and  the defence of it  by M. Larrey, I would adopt
the resolution of extracting the  foreign body, rather than abandon its
dislodgement to the resources of the organism.
  [The difficulty in having at our disposal the  ingenious contrivance
mentioned, is that such accidents are too rare  to have these appara-
tus  on hand, already  fabricated.  The principle, however, could be
very readily adapted,  we should think, in a few minutes, to a tempo-
rary construction.   This  case vividly calls  to mind  the  unparalleled
one in our  notes, Vol. II., under Trephining, of a long  sharp chisel,
implanted  deep into  and through the vertebral column, and which,
by herculean efforts, was extracted on the spot, the  proper course
undoubtedly. T.]

                        §  III.—Abdomen.
  Foreign  bodies in  the abdomen, like those of the thorax, arrive
into this cavity sometimes directly from the exterior, sometimes  after
having passed through the mouth and oesophagus.  A boy (Planque,
Bibl. de Med., t. L, p. 46,)  thirteen years of age, having swallowed an
ear of barley,  discharged it three weeks after, by an abscess which
was formed in the left hypochondrium.  The same accident was fol-
lowed by the same result, in a little girl  in Silesia, (Journ. des Sa-
vants, October, 1688.)  When balls, lead or other projectiles strike
the abdomen,  they enter into  the peritoneum,  or  are  arrested  in
the thickness of the soft  parts.  In the last case, the foreign body
should be  extracted without hesitation, by the  ordinary processes.
Should the ball have  dragged in with it in such  manner as to  have
pushed ahead of it, and  become wrapped  up  (de maniere a en its-
ter coiffee) at the bottom of the passage, in a  portion of the clothes
of the patient, nothing more would be required than to make a.--
tion upon this last, in  order to remove  the whole.  It is what  I did
successfully in two of the wounded in 1830, and each of whom had
received a ball, one below and to the right of  the umbilicus, and the
other to the outside and left of the same point.  Supposing, on the
contrary, the projectile had fallen into the peritoneal cavity, and that
there was  no  means  of  ascertaining precisely its exact  situation,
every attempt at extraction would be fruitless, and in fact extreme- 
FOREIGN BODIES.
157
ly imprudent.   It is difficult to conceive, therefore, how the contrary
rule should have been reproduced in a recent treatise upon wounds
from fire-arms, and that a surgeon should not hesitate to advise that
the abdomen should be freely laid open, and that we should perform
a sort of gastrotomy, to  go in search of balls  that have  wandered
among the convolutions of the intestines.  Once in the belly, the ball
may cause there various disorders.  In a man who had received the
discharge of a pistol, and whom  I  saw with Bogros, the ball had
opened the hypogastric vessels, and speedily caused death. A simi-
lar fact has been  published by M. Gibson.   It is known that Carrel
died of a wound of the intestines, and that the ball in him remained
in the belly. Though in such a case we should even succeed in  with-
drawing  the projectile, what would thereby be gained ?  It  is the
wounds it has  caused, and  not its  presence, which is the  source of
the danger.   Who, moreover, does not know,  that  balls, lead, and
buck-shot, left  in the midst of the  tissues, become encysted, and fre-
quently remain there a considerable length of time without materi-
ally disturbing the functions 1  Does not  M. Larrey  (Clin. Chir., t.
II., p. 521,)  inform us that balls which had traversed  the pelvis, rec-
tum and bladder, have nevertheless  not prevented the wounded from
recovery ?   If the projectile was  still in the tissues, we should even
take care, while  trying to  extract  it, that we do not cause it to fall
into the  belly or  pelvis, as happened to that  practitioner  mentioned
by Theden, (Thomassin, op. cit.,  p. 31.)   As to foreign  bodies that
have arrived through the digestive passages, they have given rise to
certain results, exceedingly curious.  Legendre (Biblioth. de Planque,
t. III., p. 560, in-40,)  speaks of an  individual who, after  a  certain
lapse of time, discharged per anum  a fork which he  had  swal-
lowed.   Who is not familiar with the  history given  by Habicot, of
the poor boy who, to protect them from robbers, decided upon  swal-
lowing his  ten pistoles of gold, and  who after being on the point of
being suffocated,  discharged them  piece by piece, through the  anus,
during the  space of fifteen days ?   A  curious history of this kind is
that of Pierre Yvens, related  in  the Journal of Blegny (Nouv. De-
couv., Mai, 1679, p.  188; et Bibl.  de  Planque, t. I., p. 51.)   This
man, who was an extravagant character, swallowed the steel (affilior)
of a hog-killer, and retained it thus during five or six months.   Not
until then did  an abscess form in the right hypochondrium, and  allow
the unfortunate porker to recover his  instrument, which he had be-
lieved lost forever.    Some time after, this foolish sort  of fellow
swallowed  in  the same  way  the leg  of a  porridge-pot,  which he
voided by an abscess in the left hypochondrium.  Attaching  no im-
portance to these abscesses, Pierre Yvens  took  it in his head also to
swallow a pocket-knife with its handle, (gaine,) which  at a subse-
quent period came out above and by the side of the lumbar  verte-
bras.  A. Pare also relates (Traite des Monstres,  liv. 25, chap. 16,
p. 772,) upon the  authority of Cabrolle,the history of a shepherd who
was compelled by some  robbers to swallow a knife half a foot long,
and which remained in his body during the space of six months. An
abscess having formed below the groin, allowed of this foreign body
being extracted from it.   Besides the other analogous facts related by
Pare, there is also mention made of the operation of gastrotomy per- 
158
NEW ELEMENTS OF OPERATIVE SURGERY.
formed  upon A. Grunheide, (Bibl. de Planque, t.  I., p. 54,) for the
purpose of extracting a knife which had entered his stomach through
the mouth.
  Quite a great number of cases of gastrotomy to remove a knife
directly from  the  stomach, have now  been  related.   M.  Larrey
(Clin. Chir., t. II., p. 269-369) says that Grager  had  recourse to
this operation in 1613, and that Frisac also at Toul employed it with
success.  Beckher (Arch. Gen. de Med., t. XV., p. 274,) who, in the
seventeenth  century, makes  mention of a similar operation  and
Bernes,  or Barnes (Ibid.,) who, according to M. Marion (Thes , No.
294,  Paris, 1831,) had occasion for  it,—do they refer  to  the same
fact,  or  did each one have a case of gastrotomy'.'   What prevents
our rejecting such examples as manifestly  apocryphal, is the  fact
that, they are occasionally, in our own time, recurring in such a way
as to dispel every kind of doubt.  Caiyroche (Bull, de la Fac. de
Med., t. VI., p. 451)  gives  a  case of gastrotomy  successfully per-
formed  upon a  lady,  who, for a long time previous, had had a fork
in her stomach, and Valentin (Ibid.,  1807) relates a simila  case of a
silver spoon.  At Paris, in fact, A. Dubois (Ibid., t. VI., p  517) was
seen to take from an  abscess in the iliac fossa, the blade  if a knife
which the patient had swallowed a long time previous.  ;V misan-
thrope made an attempt upon his life and did not succeed  ; he then
swallowed a tea-spoon.  Nine months after, a tumor, which suppu-
rated, appeared at the epigastrium.  M. Otto (Bull, de Th-ropent.,
t. XV., p. 320)  perceived it, and through this exit removed the for-
eign body, which was yet  but little changed.   The cure took place
rapidly.  [See  notes  under Special Operations, infra.   T.]
  [Instances of a similar character  of swallowing jackknives, table
and pocket-knives, bits of broken wine-glasses and tumblers, which
had been first chewed  up in the mouth;  also of brass  buttons, &e,
have  been very frequent  in the United States  for the  last half
century.  These feats have been usually performed by reckless and
intemperate  persons,  in high as well as low life, on  banters, bets,&c.
In some cases they have proved fatal, in others they have passed off,
per anum, harmlessly, or after having caused considerable visceral
disturbance.  The jugglers of Hindostan, some of whom  have ex-
hibited in America, fearlessly insert, and that several times daily, a
smooth  narrow sword of one to two feet in length and  near an inch
broad, through  the mouth  and  oesophagus, as far down  as to the
pyloric orifice, without the slightest injury to the parts.   T.]

                 § IV.—The Urinary Passages.
  The emigrations of foreign bodies, which have been introduced
through the digestive passages, have at every epoch  attracted the
attention of  observers.  A woman,  tormented with attacks of colic,
was  not cured, according to Van der Wiel, until after she had dis-
charged through the urinary passages  a ball she had swallowed.
Among  the examples of calculi of the bladder, which have exhibited
for their nucleus, a pin, needle, point of a spindle, ear of wheat, ball,
&c, it is probable that many of these reached there by this emigra-
ting  process.   These substances  having arrived in the stomach or
intestines, get entangled in some of the folds of the mucous mem- 
FOREIGN BODIES.
159
brane, and gradually escaping outside of them, continue to march
in this or that direction,  according to  the disposition of the parts.
Pins,  needles, and very slender bodies, may in this way course
to long  distances without  giving  rise  to symptoms  of inflamma-
tion.  Thus an infinity of cases are related where needles, which
had previously been swallowed, had finally made their appearance
under the skin.  Should such bodies, in traversing through the cel-
lular partitions and layers, ultimately reach the bladder, they might,
as will be readily conceived, become there the nucleus  of a calculus.
Might it not be possible, also, that in becoming arrested in the ureter,
after having pierced through the intestine, they would descend with-
out difficulty into the reservoir of the urine ?   And could  we not, in
this manner, explain how worms, nuts, kernels of fruit,  and beans,
have been expelled through the urine ?  In the case of the soldier,
mentioned in the Journal of France, (Bibl.de Planque, t. I., p. 48,)
and who  had a pin  in the ureter;  would he not, at a later period,
have been affected with a calculus 1   A man  about 30 years of age
came into the Hospital of La Pitie, for a considerable contraction
of the rectum.  At the opening of  the dead body we  found in  the
pelvis a sub-peritoneal induration, which almost  completely closed
the rectum.  A purulent passage extended beyond this as far nearly
as the liver.   A calculus of the dimensions of an inch, with a pin for
its nucleus, was found between the ureter and ascending colon, at
two inches  below the  kidney.  The  pin was  situated in such way
that its head still projected into the intestine, while  its  point was
directed into the ureter.   Is not this one  of the cases, where nature
leaves herself in some sort, to be guided  by the state of the circum-
stances (prendre sur le fait) ?  Does not all this  show, that but for
the lithic  concretion, the pin, escaped from the intestine, would have
ultimately descended into  the bladder.

                      - § V.—Operation.
   It is  unnecessary to remark, that the presence of such foreign
bodies does not in itself call for any surgical  operation,  so long  as
they do not, by any special  manifestation, show  themselves exter-
nally.   When, therefore, they have been swallowed, we  must con-
fine ourselves to the conservative  treatment  of  the organism, and
wait  until they make  their way out themselves, or  indicate their
presence  upon the exterior of the  body by some particular symp-
toms.  Under these circumstances, whether an abscess is established,
or by the touch we distinguish the projection of the foreign body,
we must no longer hesitate, but extract it as soon as possible.   The
rules  to follow in such instances are subordinate to the  particular
circumstances of each case.   Thus, should there  be an abscess, it is
to be  opened freely, in order to give exit to the pus, after which, by
means of a forceps, we seize hold of the foreign body to be extracted,
and take it away with caution.  Should the skin  be sound, we first
incise it to the proper extent, after  which, the foreign body having
been secured, we should  proceed to the  required dilatation and en-
largement of the track which is to  serve for its  passage.  As  the
outer  surface of the stomach  or of the intestines will almost necessa-
rily have contracted  adhesions with the corresponding portion of the 
160
NEW ELEMENTS OF OPERATIVE SURGERY.
abdominal  wall, we may enlarge the perforation of  these  organs
without necessarily opening into the peritoneal cavity.  Neverthe-
less, these  adhesions being  sometimes  irregular or  very  circum-
scribed, there would be danger in  enlarging too liberally in one
direction, and an indication presented of having recourse to multi-
plied incisions.  It  is, moreover, a remarkable fact,  that after these
operations  the wounds generally close up quite rapidly, even after
the digestive  cavities have been largely laid  open.   Experience
having established that the cure is not so prompt and certain where
ulceration exists as where the organs are merely divided, it is evi-
dently much  better to operate in good season than  to wait for the
tedious processes of nature.

                    Article II.—The  Limbs.

  Foreign bodies when introduced  into  the limbs, are more easily
recognized than in the splanchnic cavities.  They act, however.
nearly in the same  manner, except that they do not  travel there by
the intervention of the natural canals.  It is easy to  conceive, how-
ever, that small  grains of lead  or other bodies of small size, might
possibly after entering a vein be transported to the  heart, and give
rise to the suspicion of a lesion of an  entirely different nature.  This
fact, indeed, might involve legal consequences sufficiently serious to
justify the  mention I have made of it.-  An inhabitant of Vannes
having been engaged in a duel,  received the discharge  of a pistol in
his neck.  Repeated hemorrhage and various accidents  took place,
and death followed on the sixteenth day.   The opening of the dead
body demonstrated that the carotid artery  had been opened, that the
ball had entered into the jugular vein where it still remained, that it
had formed here a varicose aneurism, and that but for a slight contrac-
tion in the vein, the  projectile  wrould evidently have fallen into the
heart.  I have seen the specimen and  can  guarantee that all that
has been said in relation to this case by M. Jorret is perfectly cor-
rect.  Surgery however could  have nothing to do with the extrac-
tion of such bodies, unless they had  become introduced into the su-
perficial vessels.  As to  foreign bodies resulting from  mortification
and necrosis  of the bones  or soft parts, I have treated of them at
sufficient length under  the chapter,  on exsections, to make it unne-
cessary to recur to them now.   There remain then the foreign bodies
which have come directly from without, and those which may have
come from  a  distance through the cellular tracks, (trainees.)

                               §1.
  Under these we  have needles  and pins.   A pin  having  a head,
does not generally go deeper than the level of the skin, and may be
extracted without difficulty in almost all cases.   It is no longer the
same with  pins  without heads  and  with needles.  Frequently we
see these lost in  the  tissues, while they allow the wound by which
they entered  to  be  cicatrized, and  cannot  be found again without
difficulty.   A young man  sat down  upon the point of  a needle and *
pricked himself severely; his master being  alarmed, sent for me
two hours  after.  Finding neither a  puncture nor the  slightest ap- 
FOREIGN BODIES.
161
pearance of a foreign body on the point of the breech indicated by
the patient, I supposed he  had been deceived, and  that the needle
had  been lost in the chamber.   At the expiration  of eight days,
something sharp-pointed was  perceived  underneath the  skin upon
the outer side of the thigh, and which I laid bare with a cut of the
lancet;  it was the point of the needle, which then became easy of
extraction.  A boy eight years  of age broke  a needle in his calf.
He himself insisted that there was nothing left in the leg ; his mother,
on the  contrary, was convinced that  every thing  except  the  eye
of the needle  had become hidden in the flesh of her child.   By dint
of searching, I was enabled to discover  at the distance of two inches
from the puncture  a hard  point, pressure made upon which caused
pain.  Having laid open the  skin at this place, I found the needle
there lying naked, and that it  was an inch in  length.  It would be
difficult for me to say -how  many times  the same thing has happened
to me in respect to the fingers, palms of the  hand, fore-arm, arm,
shoulder, foot, body of the leg, thigh and breech.  Even the face and
cranium are not exempt from  similar occurrences.   When we  are
called therefore  to such wounds, two cases may present themselves :
either by means of a well-conducted  exploration we establish the
presence of the  foreign  body in the tissues, and then it is important
to extract it forthwith ; or in spite of our most minute researches we
find or  recognize nothing, and here prudence suggests that we should
wait and watch the wound, and that  we should be prepared for
any event, without affirming that  there is nothing  there, but also
without having recourse to any expedient or any inconsiderate ope-
ration.  [See notes on Special  Operations, inf.  T.]

                             §11.
   After needles, fragments of glass are those which, having been
introduced under the skin, most frequently remain  there  without
producing inflammatory symptoms, while  at the same time allow-
ing the  external  wound to close over them.  An adult man retained
for the space of fifteen months, under the  integuments of the fore-
head above the eyebrow, a  triangular plate of glass nineteen lines in
length and eight lines in width at  its base.  For a long  time con-
cealed by a cicatrix, this foreign body  ultimately showed itself  ex-
ternally  and projected  at  two or three lines  above  the eye, but
without ever having produced the least degree of inflammation, or
any other result  than a slight degree of inconvenience in the move-
ments of the eyebrow and forehead.  After having  moderately  en-
larged the wound, I extracted  the body, which proved to be a frag-
ment of a pane of glass. In the thigh  I have  seen  fragments infi-
nitely larger.  A laborer, aged  25 years, was thrown from the base-
ment story through a window, and  by this means received a wound
in the left thigh,  for  which he was taken to the hospital of La Pitie.
I  found the wound an inch  and a half long, and upon the outer side
and near the middle of  the  limb.  I removed from  it three pieces
of glass, respectively of an inch, half an inch, and  some  lines in
length.  Every thing went on  well  until the eighteenth day, when,
in pressing slightly upon the thigh of the patient, I perceived that he
felt, in the neighborhood of the femoral vessels, a considerable deal
                               11 
162
NEW ELEMENTS OF OPERATIVE  SURGERY.
of pain, which was augmented on the least  movement of the mus-
cles.   An incision there enabled me to extract from it a portion of
glass five inches in length by about fifteen lines in breadth, together
with some other small fragments of the same substance. Some dilata-
tions  afterwards  became  necessary,  and the  patient recovered.
Another young man had retained in this way, for  the  space of
seventeen days, an irregular portion of glass of an inch in diameter,
and without experiencing any other inconvenience than some prick-
ing when he was obliged to walk.  The wound being cicatrized, I
made an incision of two inches externally, and where this fragment had
arrived, and  this  slight operation was followed by nothing unpleas-
ant.   The palmar surface of the fingers and the plantar surface of
the foot, are frequently the seat of similar wounds. I have removed
a fragment  of glass more than  an  inch long,  and three lines in
breadth, which had existed  in the fold of the arm for the space of
seven months.  A young distiller who had broken a liquor phial in
his hand fifteen  months before, though  cured of his wounds,  had
never ceased to be entirely without pain.  An incision of an inch in
length  upon  the point originally wounded, enabled me, after some
researches, to reach  and extract a triangular fragment of glass of
from five to six lines in length.  I was obliged to perform the same
operation, occurring from a  similar  accident, on a young chemist
then  employed at the hospital of La Pitie.
  A  man had, for the  space of thirteen  months, at the  root of the
thenar eminence, an imperfect cicatrix resulting from a wound caused
by a piece of broken bottle.   As this man scarcely suffered any and
did not mistrust that  any thing remained in the  hand, he continued
at his labors, only occasionally asking  some  surgical  advice of the
surgeons of the three or four towns where he had beon.   Suspect-
ing that there was some foreign  body there, I made an incision in
the track of the ancient wound.   The probe  having confirmed me
in my first idea, I  enlarged the incision and succeeded in extracting
a fragment of glass fourteen lines in length by two  in diameter in
its smallest dimensions.   To explain how fragments of glass, though
ungular, irregular and cutting in their edges, should thus be enabled
to remain in  so many instances in the midst of the  living tissues,
without producing any reaction, is a matter of very great difficulty.
All that we can say is that they are insusceptible of chemical action,
or enlargement or diminution, and that being  devoid of inequalities,
(rugosites,) the glass is restricted in its action to the mechanical or
physical disturbance of the parts, without irritating them or altering
them in any manner whatever.   As for the rest, whether it admits
of explanation or not, the fact is nevertheless as stated, and as expe-
rience  has a thousand  times  demonstrated, which makes it proper
that it should be so received in practical surgery.

                             § III.

  Glass, moreover, is  not the only substance which sometimes  acts
in this way in the midst of the organs..  I have seen in the midst of
delicate tissues large sized and long  pieces of wood,  which caused
no more disturbance  than  bits  of glass.  An adult  man had been 
FOREIGN BODIES.
163
wounded in breaking a box of black wood eighteen  months before.
The w »und, which was between the thumb and forefinger of the left
hand,  soon healed.   Nevertheless it reopened  from time  to time,
and the patient  suffered a little  at  the thenar eminence.   I  re-
moved from it a piece of wood  of eleven lines in length  and two
lines in its other diameters, resembling a nail or peg, and which had
been driven in from before backwards, from  the commissure  of the
thumb to the root of the  first bone of the metacarpus, between the
muscles in that region."  A man employed in the service of Count
Demidoff,  came to the hospital of La Charite, in consequence, he
said, of an abrasion which he  had received from the point  of a nail
in breaking open the cover of a box.
  The injury had occurred fifteen days before, and there was  no
longer any wound;  but  a phlegmonous erysipelas had appeared
upon  the fingers and almost  the entire hand.  Having made some
incisions to give greater freedom for the  escape of the pus,  the parts
were  speedily disgorged, and the patient believed that he would
soon  recover.  Having returned  to his  labors the inflammation re-
appeared, and he Came back  to the hospital  at the expiration of a
month and a half.   Finding a spot on the anterior surface  of the
metacarpal bone of the middle finger more sensitive than the others,
I made there a deep  incision.  Surprised  to find the point  of my
bistoury arrested as if it had struck into wood, I examined the bottom
of the wound, and found  there a  foreign  body, which I immediately
extracted with a strong artery forceps.   What was not our  astonish-
ment  in finding that this was a pliant fragment of wood fifteen lines
in length !  This patient,  who had still some other particles  of wood
remaining in the hand, was ultimately cured of his wounds and  in-
flammation ; but the adhesion which took place  among the different
tissues and the tendons, and especially their  synovial sheaths, left a
stiffness and numbness in the  fingers, which  he will probably never
get rid of.  Bagieu (Examen  de plus part, de la  Chir., etc., p. 103,)
speaks of a splinter of wood  26  lines long and 8 in breadth, which
had remained for two years underneath  the skin below and outside
of the knee, without any body having ever suspected it.   A dragoon
treated  by Thomassin, (Extract,  des corps etrang., &c, p. 10,) had
for the  space of three weeks, without knowing it, a piece  of  wood
in the skin 24  lines  long.   In  the year  1838, I saw at the hospital
of La Charite a man who had under the skin upon his legs a great
number of indolent  tubercles, which had been  there twenty-five
years, and which had  been produced there in  consequence of the ex-
plosion of a mine.   Desirous of ascertaining  if they were in reality
foreign substances, I removed  one of them which had caused consid-
erable pain, and which was of the size of a small nut, and was situa-
ted above the internal malleolus of the left leg.   This foreign body
I  found to be an irregular fragment of iron,  which had  become in-
corporated (combine) as it were with the surrounding cellular tissue.
A few days later, having removed a second  fragment, I found that
this was a portion  of brownish earth, dried very hard,  and also
combined with the living tissues; while  other portions were of the
melted metal (la fonte) or silex.   Quite  a long  fragment  of bone
driven in by the powder, was  also found in the tissues. 
164           NEW ELEMENTS OF OPERATIVE  SURGERY.


                         § IV.—Balls,
  More perhaps than any other foreign body, may form for them-
selves a lodgment, and thus establish themselves in the living organs,
and remain there for an indefinite period of time, without the patient's
being aware of it.   There are in fact some cases of this kind, where
they are found at a great distance from their place  of entrance.  In
the case of the Prince of Rohan they had ascended along the course
of the tibia, and in that of Saint Mars (Dionis-, Operat., p. 818,) along
the femur ; in a child which recovered, two balls which had  entered
at the thigh ascended  as high up as into the belly, (Blegny, Jour, de
Med., t. IV., p. 78.)   M. Dujaric Lasserve (Cas de  Chir., etc., p. 23,
1830,) in extirpating a tumor which a patient had  had for a long
time upon the sternum, was greatly astonished to  find two balls in
its centre.  In the bones balls have often been found which had re-
mained there from ten to fifteen and twenty  years, without giving
rise to any particular  symptom.   An ancient  soldier who, in conse-
quence of a gun-shot wound received twenty-five years  before, had a
necrosis at the lower third of the femur, with an ulcer, which from that
date had opened and closed  a great number of times, ultimately died
of pulmonary phthisis at the hospital  of La Charite in 1836.  The
examination of the limb in the dead body of this patient, enabled us
to ascertain that he had a ball in  his ham, which had worked itself a
perfectly smooth and regular cavity upon the posterior border of the
articular interstice.  It has been laid  down,  therefore, as a precept
from these facts, to make no dilatation (debridement) or any serious
operation whatever, for the purpose  of discovering  either balls, shot,
or any other foreign body whatever, so long  as we have not ascer-
tained to a degree amounting  almost to  certainty, the place where
they have been  arrested.  When, however, we have ascertained in
addition, that they are retained in the midst of the tissues, we may
proceed in opposition to this  precept, if there is no  important organ
that  might be wounded,  or if  the operations deemed  necessary,
should in  themselves  present  no difficulty or  danger.   A fragment
from a grenade, as large as the hand, was extracted from the breech
of an officer by Dionis, (Op., D. X., p. 812.)  Ravaton (Chir. d'Armee,
p. 210,)  and Bagieu (Examen, &c, p. 78,) have removed biscayans
of from nine to twelve ounces in weight,  and which had remained a
long time in  the  tissues, causing there all sorts  of  disturbance.  A
ball imbedded in the instep, at  the bottom  of an  abscess, was left
there at the desire of the patient, and did not, it  is  true, prevent the
wound from consolidating; but a fistula in the thigh did not close up
until after Deschamps (Thomassin, p. 28,) had effected the extraction
of a ball  which rested  upon  the femur; a ball which had passed
through the knee, and which was left in the ham, made it necessary
to amputate, and  caused the  death of the patient,  (Journ. de Med.
Milit., t.  XIV., p. 535.)  Another ball  on  the contrary, retained
between the patella and femur, after having traversed theknee from
behind  forwards, was extracted  with entire success  by  Desport,
(Plaies  d'Armes a feu, p.  242.)   Morand  (Opusc.  de  Chir., 2e
partie, p. 252,)  and Thomassin (op.  cit., p. 100,) have obtained
similar successes in making use of the seton. 
FOREIGN BODIES.
165
              Article III.—Operative  Process.

  Operations required for the extraction of foreign bodies must ne-
cessarily vary from an infinity of circumstances.   In most cases, the
fingers, the dressing  or the  artery forceps, or the end of a spatula,
or extremity of a probe, or the polypus forceps properly managed,
will  answer the  purpose.   But it is proper  to add, that in certain
cases we require instruments and operations  that  are more compli-
cated.

            §  I.—Foreign Bodies retained in the Skin.

   It is rare to find any other matters implanted in the dermis except
grains of powder, small shot, sand, pieces  of earth or mortar.   Sup-
posing that it should be desirable to extract thern, we should proceed
best in doing so with the point of a pin, an ordinary needle,  or a lan-
cet,  or cataract needle.  It would be  then necessary to scrape care-
fully, and as perfectly as possible, each little cup or spot on  the skin
with the instrument, if we desire to prevent all subsequent abnormal
discoloration.

                              § II.

   Rugose or irregular bodies concealed underneath the skin  or in the
depths of the parts, require that we  should first lay them  bare  by
means of incisions of sufficient length.  After that, it is advisable to
seize hold of them with an erigne the same as for a tumor, and to re-
move by excision the cellular tissue, which it seems in most instances
has  become incorporated with  them.  Pieces of wood, scales  of
bone, portions of clothing, and inert concretions that have come from
without, especially belong to this  category.   Fragments of glass,
pins, needles, and all metallic bodies somewhat regular in shape, also
require for their extraction an enlargement of the wound by which
they entered,  or that we  should cut down  to them  in a proper
manner by new incisions.  As they, contract  no adhesions with the
natural tissues, these foreign bodies  should then be seized and ex-
tracted either by means of the  fingers or the forceps.  Being also
sometimes very brittle, they moreover exact that the tractions made
upon them should be managed skilfully and prudently.

                             §  III.

   The enumeration which I have made farther back, shows that cer-
tain  foreign bodies partially show themselves  outside in the  form of
stems or plates.   Thus a needle, pin,  splinter of wood, or fragment
of glass, the blade of a knife or sword, or  a foil  or ramrod, may be
plunged to a greater or less depth into the tissues, while at the same
projecting outside to the extent of some lines or inches.  In such
cases, the hand or fingers are the first instruments to be had recourse
to, and they almost always suffice when the  foreign body has trav-
ersed only the  soft parts, and  offers  a sufficient  purchase outside.
Next to  the fingers  come the  dressing or the  artery forceps, and 
166
NEW ELEMENTS OF OPERATIVE SURGERY.
lastly the blacksmith's nippers.  [See under Trephining, Vol. II., the
fortunate application of this last power in the case I have above al-
luded to. T.]   If the foreign body has been implanted in bone, it is
possible that the tractions  made  in this way may not be sufficient.
It is in such cases that the  nippers called tricoises  in veterinary sur-
gery, may become of  great  utility.  Seizing  the projecting por-
tion of the foreign body, near the tissues, in the manner  of a cut-
ting pliers and without incurring the risk of too readily breaking it,
they furnish the operator  with an extreme  degree of  force.  If a
solid plate of wood or metal were placed  on the skin around the pro-
jecting stem, the nippers  would  thus be  furnished  with  a point
d'appui, by which we wrould be enabled to succeed with them much
better, and without  causing so much concussion upon the organs of
the patient.  If by chance the surrounding body should  project into
some natural cavity, as in the  pleura, as was seen in the case  of Ge-
rard, or the mouth, nose, vagina or rectum, it might be advantageous
while making traction outside, to  apply on its  point a finger, armed
with a thimble,  so as to push it forward at  the same time.   This is
what Gerard states that he did,  and what M.  Champion  has also
sometimes had recourse to,  with the precaution of placing  upon  his
thumb only a few transverse grooves.  It is readily perceived, how-
ever, that for the mouth, vagina and rectum, the cavity of a small scoop,
or small spoon, would answer full as well, and be more convenient than
a thimble.  The instrument  of M. Charriere  would become important
and should be preferred where the resistance to be overcome ap-
peared to  be -very considerable, and where it would be  requisite to
avoid all concussion in withdrawing the blade or metallic rod which
had passed through the bones.

                             § IV.

  Another circumstance still may present itself; it  is when the for-
eign body implanted in the  bones does not furnish a purchase either
without or within the part.  Then  it becomes necessary to apply the
trephine by embracing the projectile  in the  crown  of the  instru-
ment, or we may employ the  chisel, gouge, and mallet, in  order to
chip out at the same time the portions of bone which confine it, or at
.east to liberate its periphery, and enable  us to seize hold of  it with
some kind of instrument. If the bone were not large or important, it
might then be allowable to  divide  it on the  two sides of  the wound,
and exsect it entire  by means of any description of osteotome.

                          §  V.—Ball.

  No foreign body, in  relation to the means to  be employed  for
their extraction, has more particularly occupied the  attention  of sur-
geons, than balls.  Every body knows the  species of forceps called
the ball-extractor  (tire-balle) of Alphonse  Ferri, and from whence
have been derived almost all the litholabes of our days.   The spoon-
bill, the elevator, formerly  so much used, and the tribulcon devised
by Percy, have been introduced into surgery  almost exclusively for
thia purpose ; but the noose, (anserine,) concave and toothed forceps,
the crow's-beak of Maggi,  the cane-beak and  stork's-bill, the instru- 
FOREIGN BODIES.
167
ment of Ravaton, a mere improvement of that of Alphonse, the sheath-
forceps of J. L. Petit, erroneously called Hunter's forceps, (Thomas-
sin, p. 55.) the lizard's-beak, parrot-billed and claw-forceps, and the
auger-forceps  (tarieres)  mentioned by Guy de Chauliac, Pare and
Fabricius ab Aquapendente, the crotchet, and an infinity  of other in-
struments, which are  figured or described in the authors I have
named, are generally abandoned at the present time.   We still find
in Thomassin, (Extract,  des  corps etrang., Strasbourg,  1788, pi. 1,
fig. 3, 4,  5, 6, 7, 8,)  the figures of three descriptions  of  forceps, of
which  one only, viz. that of the  figure G, deserves to be retained.
This is an instrument analogous to that of Ravaton,  composed of
two pieces, which are intended to glide upon each other in the man-
ner of the pelvimeter.  When opened it represents a lithotomy scoop.
An effort is made to introduce it below the ball, which is then secured
by forcing against it the other half of the instrument, which is straight
and slightly pointed.   It is rare, however, that  extraction of balls
cannot be effected by means  of ordinary instruments or the polypus
forceps.   To  favor the operation it is  unnecessary to replace  the
patient in the position he had at the time of receiving the injury, un-
less the  foreign body  should appear to be less easily accessible by
any other mode.   Most  usually it  is advantageous to enlarge  the
opening  by which  the ball has entered, and  consequently to make
some incisions.  If there should be but one opening, this is the one to
be dilated.   If,  however, the ball should  be found at a great dis-
tance, and that in order to fall directly upon it, it would only be ne-
cessary  to  divide  a  few layers that were neither  very thick  or
important, we should  not meddle with the first wound, but proceed
to make  a counter-opening.  When once  laid bare, we endeavor to
force it out by enucleation, or by means of the finger, or a spatula,
scoop, or spoon-bill.   Supposing it should have existed a long time
in the  tissues, and had  become enveloped in them, it would be better
to remove its cyst with it than attempt to disengage it from that.   I
have stated, in speaking of balls introduced  between the ribs, how we
should, under such  circumstances, proceed in removing them.   It is
scarcely but for balls that have become actually encrusted or impri-
soned  in  the body of bones, that there can be a call for the trephine,
or for  some  of the forms of exsection.  Thus in the cranium, os cal-
cis, olecranon, body of the tibia, condyles of the femur, and great
trochanter, the extraction of the ball might require the  division of the
bone itself, and consequently become the occasion for the use of the
trephine  or for exsection.   The most simple mode then is to include
the ball within the crown of the trephine, so as to  remove it with the
osseous disc.   If this process  were not applicable, it would be neces-
sary to apply the instrument to the neighborhood of the ball, in order
that a chisel inserted in the hole might reach underneath  the foreign
body,  and thus cause its  expulsion.   It is readily Understood that by
means  of the  chisel, gouge  and  mallet, we should succeed equally
well in bones of a certain size, those of the limbs, for  example,  but
that there would be some danger in making use of those instruments
to the cranium.  If the  trephine should not appear  to be very suitable,
it would still be practicable to have recourse to the concave rowels of
M.  Martin, or the  osteotome  of M. Heine  or  M.  Charriere, after 
168
NEW ELEMENTS OF OPERATIVE  SURGERY.
the rules laid  down in  the chapter on Exsections.  It is moreover
well understood, that during these operations we ought, by all the
means known, put ourselves on our guard against wounding the ves-
sels, nerves, tendons, articulations,  and in  fact  all the important
organs ;  and that, whether at the moment of the operation or after-
wards, we should prepare ourselves against every kind of danger or
accident that might  occur, the same as we would for any other ope-
ration of a somewhat serious character.

      Ariicle IV.—Foreign Bodies  in the Articulations.

  Among the  foreign bodies which become established  in the centre
itself of the organs, I design to  say one word only of those of the
articulations.  It is  not of fragments of fungosities, fractured bones,
diseased  cartilages,  or particles detached from the neighboring sur-
faces and become free in the joint, in  consequence of a malady still
existing, that 1 wish to speak upon the present occasion, but of those
bodies known under the name of free cartilages, [loose]  in the articu-
lations ; bodies of which I have pointed  out the origin, symptoms
and danger in another work; (Diet, des Sc. Med., 2e edit., t. IV., p.
179.) It is in  the ginglymoid articulations that they have been most
frequently encountered.  Morgagni, according to Boyer, had seen
many of them in the tibio-tarsal articulation.   Haller states that he
found twenty in the  temporo-maxillary articulation.  An elbow ex-
amined  by M. Robert, contained eighteen or twenty;  and M. Mal-
gaigne states  that he found nearly sixty in another humero-cubital
articulation.  It  is  in the knee,  nevertheless, that they are almost
exclusively found.   Pare, Pechlin, Henkel, Simson, Hewitt, Ford,
Bromfield, Theden and Desault are the authors who have more par-
ticularly  drawn public attention to this subject.   The  size of these
bodies is exceedingly variable.   The one mentioned in the case of
Pechlin was of the  size, of the finger, while that in  the  patient of
Pare  had the  volume of an almond.   I saw one removed from the
knee, in 1822,  which might have  been  taken for a flattened chestnut,
[meaning the marron or large chestnuts of France, which are treble
the size of  our American chestnut.  T.]  A man admitted into the
hospital of Saint Antoine in 1829, had one which was  yet  larger
than that by one half.  Sometimes, however, they scarcely exceed
the size of  a barley seed.  When there is but one only, it is gene-
rally of large size ;  when numerous, on the contrary, they are almost
always diminutive.   Some are hard and, as  it were, stony;  others
bear  so  strong a resemblance to  fragments  of  cartilage that it  is
difficult at first  to  distinguish them from this last.  M. Bourse, a
physician in the environs of Paris, sent me one in 1834 for the Royal
Academy of Medicine, which, to  all appearance, was only a fragment
of  the external condyle of the tibia still invested with  its cartilage.
They have ordinarily less consistence, and may almost  always be
crushed  under a certain degree  of pressure.   They contain neither
vessels nor laminae,  and present no appearance of texture.  Whether
lopse or  not they have  an unctuous aspect, which has made  some
suppose they had a  synovial envelope.   Their centre is  usually the
part that has least  consistence, and desiccation  considerably dimin- 
FOREIGN BODIES.
169
ishes their dimensions.  Being truly foreign bodies they are, in my
opinion, simple concretions, whether fibrinous or lymphatic, or mor-
bid sanguineous productions.   These cartilages when they have
once become smooth and unctuous, do not seem to be of a nature to
disappear spontaneously.  We can  conceive  only that they  may
become attached, engrafted  or concealed in  some region  or some
recess of the articulation, where they are sheltered from every kind
of pressure and displacement for the future.  It is thus that certain
patients, after having been more  or less tormented by them, have
suffered no more and believed themselves cured.  Other  persons,
again, are so  little incommoded by them, that they scarcely  think of
them.  A young lady of Arras, who consulted me in 1832, had had one
in the knee for ten years, and  suffered only when through accident she
hit it against some other  body.  I saw in 1830, at the hospital of Saint
Antoine, a man of from  fifty to sixty years of age who had never
been troubled by one that he had  had in the knee for more  than
twenty years.   But the great majority of patients unfortunately
have not the  same good luck.  Besides the pain  that the least  un-
steady movement may re-excite, they have, moreover, to fear in the
sequel that  the joint may become altered, as in the patient of M.
Knox, or that it  may become attacked by either acute or  chronic
inflammation ; whence comes the necessity of considering the  ope-
rations that  possess the power of effecting a cure.  Various means
have been proposed for  this  purpose.  Extirpation is the first which
has  presented itself to  the minds of practitioners; but experience
having soon demonstrated its dangers, it has been necessary to de-
vise others.   Compression in fact is the only resource  that can be
advantageously substituted  for it in certain  cases.  Whether by
fixing  the body at  a determinate point external to the articulating
surfaces,  it  places  it  out of the possibility of  being injured, or
whether it acts by promoting  its solution and  absorption, certain it
is that many patients have experienced great relief from it.   Middle-
ton obtained  undoubted  successes from  it.  Gooch also says he has
had  much reason to be satisfied  with  it.  The  same is  remarked
by Hey, who gives many examples, and who made use of a laced
knee-cap  (genouillere).   Boyer in two  or  three cases was equally
fortunate.  When we have decided  upon making use of it,  it is im-
portant above all, to compel the  cartilage to recede  into  a pouch
(cul de  sac) of the capsule, on the sides of or above the patella, for
example, if it is in the knee,  in order that by fixing it there  we may
maintain it there firmly, without having need of any very great de-
gree of constriction.  The bandage  or  knee-cap, moreover, should
be disposed in such manner,  that the patient may not be impeded in
walking.  We would not have recourse to absolute rest, nor an ap-
paratus for preventing  any  movement in the joint, unless  thVfirst
method had been  used for a long time and failed.   Its use, moreover,
is very inconvenient; the more so inasmuch  as  it acts at first only
as a palliative, and that it is  often  necessary to continue, it for  a
number of years  before a  radical  cure is effected.   Also, it  fre-
quently fails entirely.  Raymarus had seen its inefficacy in  the hos-
pitals of London.
   M. Averill has  given  the case of  a patient in whom M. Ballingall 
170
NEW ELEMENTS OF OPERATIVE SURGERY.
had used it without any advantage, and a great number of practition-
ers have related similar failures.  Their extraction is an operation so
simple and easy in appearance, and  so prompt, that it seems astonish-
ing at first that  compression  should be preferred to it;  but the sur-
prise ceases the  moment we  reflect that it exposes to the same dan-
gers as wounds penetrating into the  articulations.  A patient operated
upon by  Hewitt, and whose case is  given by Raymarus, died in con-
sequence of it.  That of Simpson  created the greatest degree of
anxiety  for several  months.    M. S. Cooper cites two other  cases
that perished from this cause.    An example also is given in the cases
of M. Kirby, which is calculated to inspire serious apprehensions.
A young girl, wThom I  saw operated upon  in 1822, was  seized with
symptoms so formidable,  that her recovery attended  with an anchy-
losis seemed in some degree to  be miraculous.   M. Richerand  states
that out of twelve operated upon by him, four died ;  two mentioned
by M. Decaisne (Encyclogr.  des Sc. Med.—Bulletin Beige, 1836, p.
102) also succumbed.  Bell,  on the strength of facts of this kind to
which he had   been  witness, goes so  far in such  instances  as to
express a preference for  amputation of the leg, unless the cartilage
should appear to be  very superficial.   David, cited by  M. Ledo,
confines  himself to an anchylosis which he recommends should be
artificially produced.   Bromfield,  Cruikshank  and  Boyer  express
nearly the same apprehensions.   It nevertheless  appears to me that
the danger of this operation  has  been exaggerated.   Ford, Hunter
and  Desault  have performed  it  sufficiently often without its  being
followed by any unpleasant results.
   Numerous cases of  a successful issue have been  collected in the
theses of M.  Champigny and M.  Ledo.  M. Larrey, J. Clarck, M.
J. Coley, M. Brodie,  M. Allan, MM. Muller, Soender  and a multi-
tude of  others  have  also furnished  similar examples.   Aumont
(Archiv. Gen. de Med., t. II.,  pp. 412, 472.) removed four of these
bodies at two different occasions, with an interval of forty days, with-
out causing the least accident. Most frequently, in  fact, the cure is ex-
ceedingly prompt; and many patients have had it in their power to
walk and resume their usual occupations at the expiration of six or eight
days.  So great a difference  in the results is however readily ex-
plained.   If it is possible to obtain  immediate reunion of the wound
and no inflammation take place  under it, the whole matter is reduced
to one of the most simple solutions of continuity.   On the contrary,
as soon as inflammation attacks the synovial and the interior of the
joint, there is every thing to apprehend, and the danger of the dis-
ease  cannot be dissembled.   We should not therefore operate until
after  having  duly weighed  all these  different circumstances, and
forewarned  the patient or some of his  friends of  the risks to which
he will be exposed.  The following is  the  rule which  prudence, in
my opinion, prescribes in such  cases.  So long as the cartilage pro-
duces but slight  inconvenience  we should endeavor to persuade the
patient to support it;  if it really causes disturbance in  the functions
of the joint, compression is then indicated.   When it does not yield
to the bandaging, or that the  dressings used cause too  much incon-
venience, it  is then  time to think  of its extraction.   We should not
however decide  upon  this step when the cartilage is concealed deep 
FOREIGN BODIES.
171
within the joint or too difficult to be reached from without, unless it
shall have produced unpleasant accidents, and after  having in vain
made trial of the  other means.  In such cases then  when the carti-
lage, on the other hand, is very much diseased, and that it may be
easily fixed without the articular interline and near the skin, the ope-
ration has every prospect of success.  Many surgeons apprehend-
ing the introduction of air into the capsule, have suggested that we
cannot take too much precaution on this point.  Also to prevent the
parallelism of the  wound of the synovial and that of the integuments,
they have carefully endeavored to draw the skin sometimes upwards,
after  Bell, at other times downwards, according to  Bromfield, and
in some instances  to the side, as recommended by Desault and Aber-
nethy.
  What  I have said of the action of the air, in speaking of articu-
lar wounds, (Diet, de Med., art. Articulation—see also  M. Velpeau's
opinions  and  those of other surgeons on this matter in our abridged
account  of the Discussion on Tenotomy, at Paris, in  our  notes of
Vol. I. of this work,) renders  it unnecessary for me  to discuss  here
the value of these precautions. The only precaution which really de-
serves to be retained, is that which consists in conducting the body
to be extracted as far as possible from the centre of the  articula-
tion, and to a point where there is the least amount  of important
parts to be  divided.  Being once brought there, it is firmly held
between two of the fingers, or better still, as recommended hy M.
Averill, by means of a metallic ring, so as to  stretch the  skin Uni-
formly, as advised by Simson, Theden, Vielle, &c, and in order that
it may not escape under the action  of the instrument  and re-enter
the capsule we have just opened.   As for the rest,  the most rapid
and neat incision is evidently the best.  For example, it is advisa-
ble to make  it fall  perpendicularly upon  the  foreign  body, and to
give to it at once an extent proportioned to the size of the morbid
concretion.   If the cartilage does not emerge by pressure  in the
manner of a  kernel out  of its fruit, we immediately seize it  with a
forceps, hook or erigne, and with one cut of the scissors divide the
pedicle if it  has  any.    The wound being brought together  with
adhesive plaster, the most perfect repose is recommended up to the
time of its complete cicatrization.   We might also, for  greater secu-
rity, apply to the whole of the joint exact but moderate compres-
sion, and keep the dressings wet with cold water during four or five
days.  As the accidents, after all, which may supervene, belong to
arthritis  complicated  with wounds, we have no .need  of occupying
ourselves with  them any further.  I will only call to mir d that the
disease is very liable to return, and that we must  take care not to
pronounce too sanguinely on this point. 
172
NEW ELEMENTS OF OPERATIVE SURGERY.
TITLE  FOURTH.

 SPECIAL OPERATIONS.
                   PART  FIRST.

OPERATIONS WHICH ARE PERFORMED ON THE HEAD.
                        CHAPTER  I.

                      THE  CRANIUM.

                 Article I.—Fungous Tumors.

  Degenerescences of the dura mater almost always exhibit them-
selves under the form  of tumors.  These tumors, united under the
title of fungous tumors since the time of Louis, are nevertheless suffi-
ciently varied in their nature ;  there have, moreover, been associated
with them  a  certain number  of bodies which  are  altogether in-
dependent  of the dura mater.  The case mentioned by Hebreard
(Bull, de la Fac, t. V.) was a species of cyst, filled with pultaceous
matter, and lodged in the left middle lobe of the brain, and which had
only subsequently invaded the  dura mater.  In the same way, also,
certain cases related  by Abernethy (Surg. Obs., vol. II., p. 51, 54.)
seem to belong to degenerations of the brain, rather than to those of
the dura mater.  The confusion in this  respect is so great, that we
find comprised under the same title, fibrous, scirrhous, and hematic
tumors,  encephaloid masses, and various vegetations  and fungosities
which  project from  underneath the integuments of the cranium,
whether they have had their  primitive seat in the dura mater, the
substance of the bones, or in the brain itself.

                     § I.—Fibrous Tumors.

  Though rarely found there, masses of a purely fibrous character
are, nevertheless, sometimes encountered  in the  cranium.   M. Senn
(Espinosa,  These, No.  129, Paris, 1825)  appears to  have met with
an example.  In that which was exhibited to the Academy of Medi-
cine in 1825, (Archie.  Gen. de Med., t. XIII., p. 121,) the tumor was
of the size of an egg, occupied the base of the  cranium posteriorly
and to the right, had depressed the corresponding lobes  of the brain,
and had not been revealed by any symptom during life.  As these
tumors do not appear to have  been yet seen except on the outer sur-
face  of  the dura mater, it would  have been interesting to know  if
the fibrous productions noticed by  M.  Del Greco  (Arch. Gen., t.
XXIII., p. 432) in the pterygo-maxillary fissure, or the  nasal fossa), 
FUNGOUS  TUMORS.
173
and by M. Rayer in the zygomatic  fossa, in a woman who died at
La Charite, in December, 1834, might not be classed in this category.

                    § II.—Hematic Tumors.

   The blood which has been effused into the diploe, or between the
dura mater and the bones, between the dura mater and brain, or into
the most superficial layers  of  the brain itself, may undergo various
kinds of degeneration, and assume the form of tumors  that might
be denominated hematic.   Some facts related by Abernethy come to
the support of  this supposition.  In the case of a man 40 years of
age, who had been struck violently by a stone, and who had in con-
sequence thereof a species of cerebral hernia, the tumor  was found
to be similar to coagulated blood. (Abernethy, Op. cit., vol. II., p. 51.)
The same author speaks of a carpenter who was trephined for a de-
pression of the parietal bone, and who, on the twelfth day from the
operation, had a sort of cerebral hernia, the tumor in which case also
appeared  to  have  been  formed from  blood extravasated  into the
substance of the brain.   From these facts, Abernethy  moreover con-
cludes, that what has been described under the name of cerebral
hernia, is  sometimes formed by blood,  and that it is the same  with
certain fungous tumors of the dura  mater.  A  fungus developed in
the head  of the tibia, and  which he also compares to coagulated
blood, also what I have said of contusions, and what I  have often
since remarked, (These sur les  Contusions,  1833,)  serve but to cor-
roborate this view of the subject.   We  could  thus explain  the ap-
pearance of tumors, which it seems difficult  to range under cancers,
and whose origin in reality appears to be ascribable to some external
violence.

         § III.—Phlegmasian  (phlegmasiques) vegetations.

   Wounds of the head, fractures of the cranium  and trephining have
been  frequently followed  by fungosities  and vegetations upon the
dura mater, in such a way that Louis especially  was led to confound
these productions with true fungus.  When they have been preceded
by a  protracted suppuration, and that  the  surface which supports
them has become exposed to the air, it is difficult to say in  what such
fungosities differ from those which are so frequently found at  the bot-
tom of external wounds.   In other cases, on the contrary, they proba-
bly result from some extravasation of concretible lymph, or from fibrine,
and sometimes also from sanguineous morbid layers which have ulti-
mately become organized. I have elsewhere (Plaies de Tete,  1834) pub-
lished some facts of this kind.   Perhaps also, the following case which
I find in Abernethy, (Op. cit., p.  106,) belongs to  the same description.
A man from thirty to forty years of age was. afflicted with violent
pains in the head, in consequence of a severe salivation; he was tre-
phined and pus was found under  the bones, and  the dura mater,
which was greatly  thickened,  was covered with a soft and reddish
substance.
                        § IV.—Fungus.

  All, or nearly  all the other tumors of the dura  mater are cancers. 
174          NEW ELEMENTS OF  OPERATIVE SURGERY.

Almost all those that have been described, were evidently composed
of encephaloid  matter.  The one which Pare (liv. XII,, chap.  2.'{)
mistook for an aneurism, was formed from the brain.   The patient
mentioned  by Rey (Acad, de Chir., t. V., p. 22)  had at the  same
time, a cancer in the thigh, or the femur vegetated (carnifie.) In that
of Philippe, (ib., p. 36,) the bones  of the cranium were also vegetated
(carnifies.)   In a case cited by M. Chelius, (Arch. Gen.  de M d., t.
XXVIII., p. 422,)  the substance  of the tumor resembled marrow;
and how is it possible not to recognize  a cerebriform fungus in  the
encephaloid (venteuse)  tumor, described  at such  length by Lecat,
(Soc. de  Sante de Lyon, 1798, p. 31) ?   The production was also of
an encephaloid  character in the two lunatics, noticed  by M. Blandin,
(Espinosa,  These, No. 129, Paris. 1825,) also in  the  case mentioned
by M. Deneux, (ib., p. 9,) the child  eight years of age, spoken of by M.
Marjolin, (Diet, de Med.,  le edit., t. IX., p. 305,) and in the case referred
to by M. Bouvier, (Bibl.  Med., 1825 ; or Espinosa, Op. cit. p. 10.) Tin-
tumor removed by M. A. Berard (Gaz. Med., 1833, p. 735)  was also an
encephaloid mass; and  in the patient of Siebold,  (Journ. Comph, t.
XXXIV., p. 304.) and who died under the operation, it was a cavern-
ous substance.   Schindler  also says (ib. p. 325) that cerebroid matter
was found  in a tumor of this kind in an aged woman, and M. Eber-
mayer (Arch. Gen. de Med., t. XXII., p. 229) states the same thing of
a young girl aged four years.  I could  say the same thing of a lady
seventy-one years of age, whom I  saw with M. Durand, and also
of a case communicated to me  by A. Lauth.  M. Cruveilhier also.
who describes and has given the figures,  (Anat. Path., 8e livr.)  six
cases of fungous tumors  of the dura mater, speaks  only of encepha-
loid tissue.   Scirrhous tissue, however, may also form its base.  A
woman, whose case I published in 1825, had two tumors  of this last
description, which I showed at the time  to  the  Professors of  the
Faculty of  medicine, and which I  have  for a long  time  preserved in
alcohol.  Whether  encephaloidal  or scirrhous, these tumors never-
theless differ in a remarkable manner, in respect  to the parts of  the
membrane  upon which they are situated.  Out of fifty-one examples
where this  location was  given, I found thirteen in the parietal regions,
eight in the temporal, seven in the frontal,  seven in the orbito-nasal,
seven in the occiput, five  in the vertex, three on the petrous  bone,
and one in  the substance of the falx  of the brain.   [ have, in two
cases,  seen them  protrude from the  ear,  and  once through  the
pharynx.   All ages are  liable to it.   The following is the proportion
in this respect, which was found in forty cases:   From  birth  to  ten
years, six cases ; from twenty to  thirty, seven ; from thirty to  forty,
ten; from  forty to fifty, nine; from fifty to sixty,  five ; and from
sixty to eighty, three cases: from whence it follows, as had been re-
marked by Boyer, (Malad. Chir., t. V., p. 186,)  that they are, not-
withstanding, more frequent between  the ages of thirty  and fifty
years, than at any other period of life.  As  to the  sexes, I notice
that in forty-four cases,  twenty-three were men and twenty-one wo-
men.   The legitimate fungi of the cranium are in  their  nature incu-
rable.  Those tumors which seemed to  be formed by effused  blood,
like those  examples given  by  Camerarius  and Abernethy,  (Eber-
mayer, Journ. Compl, t. XXXIV., p. 301,) those  which  result from 
TUMORS OF THE DURA MATER.                175
syphilitic disease, and whose character  is not decidedly cancerous,
may alone leave some hope of cure. The prognosis for all the others,
as has been remarked by Delpech, ought to be the  same as for can-
cers of the most serious  description.  Moreover, these tumors some-
times are exceedingly slow in their progress.  The patient of M.
Graefe (Arch. Gen., t. XVIII., p. 421) suffered for thirty-seven years
and then died.  The child mentioned by Schindler in the same way,
lived over five years, (Journ. Compl, t. XXXIV., p. 320.)   Death
did not take place until at the expiration of forty-five years, in the wo-
man whom Robin (Louis, p. 18) caused to  be exhumated five years sub-
sequently ; not until after thirty years in one of the patients of Voisin ;
(Thibault, These, No. 133, Paris,  1816;) aften ten years in another,
and after fifteen years in a case extracted from the English Journals.
(Journ. Gen., Avril, 1814.) Also, it is less by hemorrhages, destruction
of the tissues or extension of the degenerescence, that these tumors
cause death, than by cerebral accidents  which ultimately supervene.
   In at  least twenty cases out of fifty these accidents have been
brought about by attempts at operations.  These  accidents consist
of convulsions, delirium, symptoms of compression of  the  brain in
fine, or of inflammation of the meninges.  Sometimes also, as I have
seen in the case of a woman, they are reduced to symptoms of de-
 bility, soon followed by hebetude, afterwards partial  or general, or
 incomplete or complete paralysis, and a continual  desire for repose
 or even for sleep.   This state may be maintained for many  months,
gradually becoming aggravated.   The  patients then ordinarily ex-
 pire without  spasms, and so to speak, imperceptibly. In  this last case
death almost always happens by compression.  Upon the opening of
the dead body it is seen that  the tumor has augmented in growth
within, either in  breadth or depth (epaisseur) so as to react  with
more or less degree of force upon the mass of the brain. If on  the con-
trary the patients sink rapidly, we find the dura mater, or the surface
of the brain inflamed and covered ^with  pus, as though it were ulcer-
ated or had undergone ramollissement, or been reduced  to a state of
 putrilage (putrilage.) Small apoplectic  cells (epanchements apoplec-
 tiques) are also sometimes remarked in the substance of the hemispheres
 themselves, and it is not unfrequent to find the purulent infiltration of
the arachnoid  extending  itself as far  as the  occipital  foramen and
around the spinal marrow.
   A. Treatment.—The disappearance of a fungus of the dura mater
by resolution or suppuration has never been noticed ; therefore, the
plasters, pomades, unguents, and other  topical applications proposed
or made trial of, with a view of obtaining one or the other  of these
terminations, must be absolutely proscribed.  Nor does the compres-
sion of the tumor appear to possess any more curative  power ; it is
allowable only in the character of a palliative, and even then cannot
be made use of but in a very small number of cases.   The  destruc-
tion of  the fungus, whether by caustics, the ligature, or the knife, is
in reality the only medication which merits consideration.   Extirpa-
tion itself, the only remedy which reason sanctions the  employment
of, appears to  have been  but very rarely followed by  success.  In
fact the external tumor is often only the smallest portion of  the evil.
After having removed it, we soon see it reproduced, if in fact new tu- 
176          NEW  ELEMENTS  OF OPERATIVE  SURGERY.

mors do not also appear.  In this respect they have that feature in
common with cancerous tumors in all other parts of the body.   But
not being  enabled to make their way outwards, except  through an
osseous opening, it is not possible, as in the  last, to designate  their
limits beforehand.   I cannot perceive, however, why we should not
attempt to extract them, wrhen there is every reason to believe  that
they are  clearly circumscribed, and that the  disease is altogether
local.  In a woman who had been cured of cancer of the breast and
who died  of a pleurisy at the hospital of the School of Medicine in
1824, a scirrhus of the size  of a  small  pullet's egg, commencing at
the dura mater, had traversed  the bottom of  the right inferior occi-
pital fossa, made a slight projection  under the  splenius muscle, and
was found to be so regularly circumscribed, that it certainly would
have been possible  to  have removed it entire, if its existence had
been suspected during the life of the patient.   The operation might
be made trial of, at least for the fungous tumors of new-born infants,
to which M. Nasgele has been one of the first to endeavor to draw
the attention of practitioners, and also upon those  which Abernethy
derives from certain  degenerated  sanguineous or lymphatic concre-
tions.  Five out of the  six cases in which caustics were employed
perished.  The individual mentioned by Cattier,  (Obs.  de Med., p.
48, obs. 15,) and who was treated by caustics against the advice of
Pimpernelle, who advised the trephine, also died; it is also probable
that that of M. Eck,  (Ebermayer, Jour. Compl., t. XXXIV., p. 323,)
the only one which was cured, had only a simple hematic tumor.  It
is  equally doubtful if M. Ficker, (lb., p.  320,) had  to  do with  can-
cer, in the case of partial success, which he relates, with the liga-
ture.   As to extirpation, it has not, up to the  present time, produced
but very uncertain results.   Franco  says, (Tr.  des Hernies, p. 485,
An 1561,) "I saw a child who had a fungus  tumor which two of us
wished to extract, (tirer.)   Nevertheless  I was somewhat  deterred,
[je fus aucunement  refrody—ancient French, T.] perceiving that
the cure appeared to be difficult and not what it seemed to be (non tant
qu'elle l'estoit); at the expiration of some days, my companion alone
undertook it, when he found it within the brain  itself, which was follow-
ed by the  death of the patient.   It is therefore very necessary to re-
flect and to ascertain (taster) if the brain is or is not  entire."  A patient
mentioned by Camerarius (Ephem., c. n. dec. 2, obs. 99, an. 8) also died
from this cause. Amatus, (Cent. 5, obs. 8,) Schmucker (Bibl. Chir. du
Nord,p. 10,)„and Rossi, (Med. Op.,t. II., p. 261,) relate similar instances.
It is necessary also to concede that it has scarcely ever been successful.
In one of  the cases  of M. Walther, (torn. XXXIV, p. 314.) he  was
prevented from finishing the operation by a hemorrhage which made
it necessary to apply the ligature to ten arteries ; in a case mentioned
by Klein, puncture was had recourse to, and then an incision. M. Eber-
mayer, (Archiv. Gen. de Med., t, XXII., p. 229,) in  the case of a child
of four years, whose history he gives, mentions only a single cut of
the lancet.  Nor was there any  other treatment than incisions made
use of in the patient of Sivert, who nevertheless died two days after.
   In the  case of Rey, (Louis, p. 22,) the tumor was only laid bare
without removing it.  The patient of Courtavoz and Chopart, (Mem.
de I'Acad., t.  V., p. 28,)  died on the following day,  though here 
TUMORS  OF THE DURA MATER.
177
also incisions  only were  made use of.   A similar  attempt was
followed by the same  results  in the case of Philippe, (Ibid, p. 36.)
Nor was the excision complete in the case of Saltzmann, (Ibid, p. 30,
or Mem. de Saint Petersburg, t. III., p. 275.)   The  same was the
case in the patient of M. Graefe, (Arch. Gen. de Med., t. XVIIL, p.
421 ;) which however did not prevent the wound from cicatrizing,
nor life from being prolonged  to the period of seven months.  The
same should be said of the new-born infant, mentioned by Schneider,
(Ebermayer,  Journ.  Compl.  t. XXXIV., p.  320,) since  it became
necessary to repeat the operation at  the expiration of five years, at
which time it proved fatal. Nor could Siebold  in his case complete
the extirpation  of the tumor,  for the patient died under his hands.
In  remarking that he  removed all  that he could, M. Orioli, (Gaz.
Med., 1834, p. 410,) leaves it quite apparent that the disease had not
been effectually destroyed in his patient, when gangrene came, so to
speak, to complete his operation.  Reasoning moreover, would have
sufficed to demonstrate what experience has now placed beyond all
doubt, to wit: that such attempts were calculated but to augment
the  danger of an evil,  already so formidable and insidious in itself.
Such facts, therefore, are not  to be taken into the account, when we
undertake to determine the value of  the operation of extirpation for
fungus of the cranium.   The  small number of cases where the ^ope-
ration has been effectually accomplished, furnish results somewhat
less alarming.  The Spaniard that M. A. Severin (Journ.  Compl., t.
XXXIV., p. 300,)  states that  he cured, could have been so only by
the trephine.   The same  must be said  of the patient of. Grosmann,
(Stoltz,  Theses de  Holler, 1708, presid. de Sand.)  M. Eck says he
succeeded without trephining ;  but he employed caustics after extir-
pation.   I have already remarked that  the success of M. Orioli was
as much owing to the gangrene as  to extirpation.  M. Klein twice
cured the same patient with an interval of a year, by means of the
trephine and  extirpation ;  but  he believes the  glands of Pacchioni
were the seat of the fungus.  In another patient the same operation
was followed  by death, (Arch. Gen.  de Med.,X.  XXIL, p. 225.)  In
the case related  by Volprecht, (Louis, p. 31,) the trephine was ap-
plied around the tumor; but this last was not removed, and the au-
topsy showed  that other fungi existed in the cranium.   A meningitis
caused the death of the  patient that  Dupuytren had operated upon,
(Denonvilliers,  These, 1789, p.  76,)  by  embracing the whole tumor
in a large crown  of a trephine.  The  patient operated upon by M.
Berard,  also it is true died, but it had  been rendered necessary to ap-
ply sixteen crowns of the trephine, and to remove a portion of the lon-
gitudinal sinus.  M. Pecchioli, in operating upon a  man 46 years of age,
(Gaz. Med., 1838, p. 414,) who had a fungous tumor to the right of the
sinciput, succeeded perfectly by means of three crowns of the tre-
phine, and by removing a portion of the dura  mater.  I perceive
that  M.  Syme, (Edinb. Med.  and Surg. Journal, vol. CXXXVIL,
p. 384,) goiifg  as  far down as to the  dura mater for a large fungous
tumor of  the cranium,  cured  his patient also.   If it were proved
that  the tumor attacked was almost  never  solitary, these  few suc-
cesses perhaps  would not  be sufficient to justify the operation of
which we are now speaking ;  but  it is to-day demonstrated by the
                              12 
178           NEW ELEMENTS OF OPERATIVE SURGERY.

patient of Pohlius, by that of M. Berard and by many others, that
fungus of the  dura mater, like cancer of the breast, is  at  first quite
frequently uncomplicated (unique) ;  nor do I hesitate to say that ex-
tirpation is indicated at the cranium  as in any other region, and that
there it  presents the same counter-indications  as for other cancers.
It must, however, be admitted, that in itself the ablation of deep-seated
cancers of the  cranium is infinitely more dangerous than in  any other
region of the body, and that these dangers, taken in connection with
the unfortunate prognosis which naturally belongs to the disease, are
calculated to make us exceedingly circumspect  in such cases.
  B.  Operative Process.—If however it should be decided upon, it
would be necessary, while taking care to cut the flaps in the sound
parts, to preserve  as much of the  cranial teguments as possible.
Crowns of the trephine should then be applied all around the tumor,
and  the  intermediate osseous angles forthwith destroyed by a saw
made expressly for this purpose (ad hoc), or by  means of the chisel
and  leaden  mallet.  If the tumor should  be  situated in the bones
only, the surgeon  would  remove it immediately without incising
the dura mater.   In the  contrary case we should not hesitate to cut
round the entire  morbid, growth, including moreover in the circle a
sound margin of the dura mater. Having arrived at this stage of the
operation, we ought even to penetrate still deeper if the tumor should
be found to have  its origin between the pia mater and the brain.
  In cases of very  large  fungus, perhaps it would be advisable to
perform the operation at two periods, at an interval of from twenty-
four  to forty-eight hours, to  apply  but half the  crowns of the  tre-
phine on the first day, for example, as  M. A. Berard did, and  not to
complete the perforation of the bones until the day after, or the day
after that, and immediately previous  to the extirpation of the tumor.
A woman recovered in this way after  having  sustained the applica-
tion  of fifty-two crowns of the trephine, for a large necrosis of the
cranium, accompanied with caries, (Mehee  de la Touche, Plaies de
la Tete.)   As it is not possible in such cases to unite  the wound by
first intention,  a  piece of  linen spread  with cerate, and perforated
with holes,  should be extended over the entire solution of continuity.
Balls and then gateaux of lint  should be applied over this,  and kept
in place by means of a  suitable bandage, so as  to fill up the void
which has been made in the cranium, and  make  moderate pressure
upon the brain.  This last  precaution  is of the highest importance
when we have been forced to excise the dura mater.  The patient of
M. Berard, who during the  operation had  experienced no inconve-
nience in this respect, swooned away as soon as the tumor with its flap
of membrane  had been  entirely extirpated, and did not  come to
until after the  compression which they had the  presence of mind
immediately to make, at  the place where the parts  had just been
detached.  It cannot be denied also that the sudden abstraction of an
abnormal pressure which  may have been considerable in its amount,
and existed in  many cases for several years, must necessarily expose
to serious accident in regard to the brain.  Extirpation, therefore, of
cancers of the  cranium, in my opinion, presents but few chances  of a
favorable issue when the disease proceeds from the  pia mater, or
where we have to destroy only a somewhat extensive portion of the 
ENCEPHALOCELE.
179
dura mater.   Consequently then it is for the tumors only with a nar-
row base, and for such as do not render it necessary to remove any-
thing but the bones, that this operation is in reality admissible.   The
rest of the manual and its consequences, moreover, are too analogous
to those of the trephine, to require that I should say any more on this
subject in the present article.

                  Article II.—Encephalocele.

  There is no resource for hernias of the cerebrum and cerebellum
but that of  making  the  patient wear a bandage furnished with an
elastic pelote properly adjusted.  Every kind of bloody  operation
would be dangerous  and probably cause death, as in the case that
Lallement has published, and in that of M. Baffos.   Many surgeons,
however, have ventured upon its excision.  These excrescences from
the brain, so frequent in traumatic phlegmasias, and those that follow
openings into the cranium, and which M. Champion denominates hy-
 percephalose, which Gall considers as the unfoldings of the convo-
 lutions, and upon which Langius has written very learnedly, (Epist.
 6, liv. I.—Bonet, Corps de Med.,t. III., p. 173,) are attributed by Arne-
 mann (Gaz. Sal., 1787, No. 50, p. 2,) to the expansion of the anterior
 ventricle of the brain.  .It succeeded to a fracture in the case of Tul-
 pius (Bonet, Corps de Med., t. IV., p. 37, obs. 54,) and in that of Las-
 sus (Med. Op., t. II., p. 273.)   Diemerbroeck  (Anat.,  t. II.,  p.  235,
 liv. III., ch. 5,)  speaks of one which detached itself several times,
 and which  resulted in death.  In the case of  Tudecius (Planque, t.
 XXVII., p. 87,) the cause was  the presence of a foreign body, viz.,
 the blunt point of a halberd.   In a case where the hypercephalose
 protruded  through the opening made by the trephine, F. de Hilden
 (Bonet, t. II., p. 374,) states that Bourg had exsected it with success.
 According to Henry Pastrus  (Bonet, Corps de Med., t.  IV., p. 49, obs.
 73,) extirpation was also performed by Rhodius.  The excision of a tu-
 mor of this  kind, put a stop to the serious accidents it had occasioned
 in a case related by Trioen and Ravaton, (Prat. Mod. de la Chir., t. I.,
 p. 222,225,) who advises that they should be extirpated as far forward
 as possible, (le plus avant possible,) and has often performed this opera-
 tion without accidents: the pulse after it rose and the head became more
 free, [i. e. less or rather not at all oppressed any longer by the tumor,
 T.]  Tetu (Mem. de Med. Chir. et Pharm. MiUt., t.  XIV., p. 33. et
 39,) after having  performed excision, had recourse to  compression
 with success.  Deidier (Encyclop. Meth. Med., p. 252, col. 2,) in  a
 case excised many excrescences from an encephalocele without caus-
ing pain. It is nevertheless true, that apart from some rare exceptions,
I should prefer with Rossi (Elem. de Med. Oper., t. II., p. 240,) to
restrain these tumors by means of plates, or by any kind of compres-
sion whatever, rather than attack  them with the cutting instrument.

             Article III.—Meliceroma,*  (Meliecris.)

  Many persons will carry during their whole life, under the hairy
  * [The Greek coinage of this word is we deem perfectly justifiable, to harmonize with
steatoma, atheroma, lipoma, &c. T ] 
180
NEW ELEMENTS OF  OPERATIVE SURGERY.
scalp, steatomatous. atheromatous, or mehceromatous tumors, without
being sensibly inconvenienced by them or even attempting to do any
thing to get rid of them.  Others suffer more or less from them and
for some reason or another desire at any hazard to be disembarrassed
of them.
  The nature and formation of these loupes, still imperfectly under-
stood, appear, in my opinion, to require further researches.  There
are some of them which, at their beginning, exhibit themselves under
the aspect of a small,  hard,  yellowish, friable,  unorganized mass,
similar to collections of fibrine, or blood deprived of its coloring mat-
ter and serous portion.  Increasing in growth, they begin by becom-
ing soft at the centre, and are thus transformed into a cyst, which is
so much the thicker in proportion as the tumor is less ancient or of
less volume ;  a cyst which is  filled with grumulous substances, in a
greater or less state of fluidity, and which  resemble neither pus nor
fat.   Should we not ascribe their  origin to some of the elements of
effused blood ?  It is at least certain that they are not  distended cu-
taneous follicles, as is asserted  by Beclard and M. A. Cooper.  Their
cyst, which is thicker in proportion to their  less degree of develop-
ment, is always independent of the skin.   A  tumor twice the size of
the head, and which perhaps was only an atheromatous cyst, though
the author describes it under  the title of lipoma, was removed with
perfect success by M. PI. Portal, from the forehead of a child of four
years of age, (Clin. Chir., p. 279.)  Sebaceous, serous and other
kinds of cysts, lipomas and fibrous tumors, are to be treated at the
cranium as in any other part of the body.  I have seen sub-cutaneous
encephaloid cancers in  many individuals,  an erectile conical tumor
of an inch in length, with a thick pedicle, in a  young Moldavian of
twenty-four years of age, and melanotic plates of sufficient size in
three or four cases.  There might  be cases where the ligature would
suffice to  detach them, as in a case related by Boyer, but it is rare
they are  strangulated at their base.  M. Bertram!, (Arch.  Gen.  de
Med., t. XX., p. 285,) states that he cured  one by passing through it
a long needle, which he kept there in the manner of a seton.  De-
mours, who placed two needles crosswise instead of one,  asserts that
he thereby obtained successful results.   But the cutting  instrument
here is infinitely better, and ought always to be preferred.
  Operative Process.—When  the tumor  is  of great size, and the skin
much attenuated, an elliptical flap  of integuments should be removed
with  the cyst.  Two semilunar incisions  are  then  first made.  A
transverse incision is then made from each lip of the wound, and pro-
longed outwardly, so as to circumscribe four flaps, which being raised
up with care, enable us to remove  the loupe entire and without diffi-
culty.  In most cases these two last incisions may be dispensed with.
While the surgeon, with an erigne or good pair of forceps, draws on
the cyst with one hand, he dissects with the  other, by  means of the
point.of the bistoury, its external surface,  and thus readily succeeds
in separating it from the surrounding tissues.  In the ordinary pro-
cess, and where it is unnecessary to sacrifice any part of the skin, it
is recommended to make a simple  crucial or T incision,  and to take
every possible precaution not to open into the  cyst while dissecting
the flaps of the wound, which latter is to be united by first intention, 
MELICEROMA.
181
after having  extirpated the tumor.  M. A. Cooper adopts another
course.  He  first opens freely into the tumor, empties it by com-
pressing it with the thumb and  forefinger;  then seizes the cyst on
one side by the hook or forceps, and dissects and removes it.  The
incision being made in  such manner as to leave intact the posterior
wall of the mehceromatous pouch, M. J. Cloquet immediately seizes
with a forceps its anterior wall under the right lip of the wound,
draws  upon it in proportion  as  he divides the adhesions, which are
ordinarily  very feeble,  and thus  effects, to some extent, by a single
stroke, the enucleation of the whole cyst.  I have, on more than one
occasion, confined myself to dividing the integuments only, and then
seizing the tumor at the bottom of the wound with a strong  erigne,
after which it becomes easy to dissect and remove it.   By these three
variations  of the process of simple incision,  the operation is much
more prompt and less intricate than by the ordinary  process.   After
the removal of the sac, the borders of the wound, so to speak, replace
themselves in contact, and reunion is generally accomplished in the
space  of a few days.   M. Tealier, (Transact.  Med., t. II., p. 430,)
who,  after a simple incision, confines himself to making traction on
the sac in  order to extract it; M. Brachet, (lb., p. 371,) who removes
this cyst  after having slit  it open and emptied it;  and M. Chailly,
(lb., p. 431,) who  lays it  open and empties it,  and then besmears it
with red oxyde of mercury;  and all which surgeons supposed they
had imagined something new, were doubtless ignorant of what I have
said above.   The process which I now adopt  by preference, is ex-
ceedingly  simple; the youngest pupil may perform it with impunity.
Having opened into the tumor by puncture with a bistoury or lancet,
the same  as for an abscess, I seize, with a  good pair of artery for-
ceps,  one  of the commissures of the cyst, which latter I remove  by
enucleation, separating it  by means of the beak of a spatula,  as M.
Champion does,  or by the myrtle-leaf,  cataract scoop, the handle of
a  scalpel,  or  merely the nail  of the  little  finger.  The operation,
therefore,  is  so easy and prompt, that I cannot see what would be
the advantage in substituting for it the employment either of potassa,
as proposed by M. Brachet, (lb., t. II., p. 371,) Guerin, or M. Canihac,
(Rey,  These,  No. 79, Paris, 1834, p. 91,) or the  Vienna caustic,  as
eulogized  by M. Hennau, (Transact. Med., t. II.,  p. 385,) and  by
M. R. Gerardin,  (Journal des Conn. Med. Chir., 1837.)  It is never-
theless true that, like every other operation, it sometimes gives rise
to serious  accidents.   In a case cited by M. Merat, (Transact. Med.,
t. XL,  p. 432,) it was  followed  by tetanus.   A female patient, who
was operated upon for it in 1825 at the hospital of the Faculty, was
seized  with  an extremely dangerous erysipelas ; and in another wo-
man it caused her death.   But these are very rare exceptions, wlfch
do  not take place in  one case  out  of fifty.  The  wound  almost
always heals  in  less  than eight days.  Left to itself, moreover,
the tumor  increases  in  size, and maybe transformed into cancer.
This is what took place in an old man I operated upon.in 1836, and
in  a woman aged seventy years, whom  I operated upon  on  the
12th of January, 1839.  I have removed as many as eleven of these
tumors at  one sitting.   Some patients also have their  cranium as
it were covered with them. 
182
NEW ELEMENTS OF OPERATIVE SURGERY.
                  Article  IV.—Hydrocephalus.

   The principal operation which has been proposed for hydrocephalus
 is puncture  of the cranium.   Holbrock and Vose (Duges, Manuel
 d'Obstetrique, &c.,) profess to  have performed it, or  to have seen it
 performed with success.  Rossi (Medecine OpSratoire, t. II., p. 16,)
 has drawn in this  manner, at  several times, six pounds of serosity
 from the cranium of a child eleven to twelve years of age,  and who
 got well.   M. Syme, in 1826, had  recourse  to it five times on the
 same child, in the space of  a few months, and each time with  some
 apparent  advantage,  though the little  patient ultimately perished.
 M. Greatwood (The Lancet, 1829,  vol.  II., p. 238,) succeeded with
 it in one  case, and  M. A. Cooper appears once to  have  obtained
 partial success from  it.  M. Bedor, (Gaz.  Med., 1830, p. 188,) who
 has also made trial  of it, likewise believes that it may answer.  But
 the  injury done  to the  brain  by  hydrocephalus, is  ordinarily too
 deep-seated for a simple puncture in such cases to restore the health.
 Nevertheless, should it be decided upon, nothing is easier to do than
 this, either with the lancet, bistoury,  or a small trochar.   There would
 be no other precaution to take than to avoid with care the track of the
 venous sinuses.   Upon the supposition that we did not wish to draw
 off at once the entire amount of the liquid, I would much prefer re-
 peating the  operation from time to  time,  rather than  to  leave a
 canula resting  in the wound, as has  been  proposed by Lecat.  As
 to the rest, it is an operation which  now counts  a great number  of
 trials. Theodoric (Portal, Hist, de VAnat., etc., 1.1., p. 185,) had already
 made the remark, that hydrocephalous children treated by the appli-
 cstion of the red  hot  iron to the forehead  or the occiput,  had ulti-
 mately recovered.  It appears  also that S.  Chabbi  (Hevin, Path.
 Chir., t. I., p. 232,) had performed  it with success.   Also  in  cases
 of this disease  where it would seem to  be required,  other  surgical
 means have been resorted to.  Warner (Obs. de Chir., obs. 11., p. 69,)
 says that in a case in which  extirpation for  a hydr encephalocele  was
 performed against his advice, it Caused death ; and Thiebaut (Journ.
 de Dssault, t. III., p. 327,) gives the history of two similar attempts,
 which were followed by the  same  result.  A case also  operated upon
 in Scotland, and in  which a  hydrencephalocele that projected above
 the nose  was excised,  terminated  fatally.    Leveille  (Nouv. Doct.
 Chir., t. III., pp. 47, 48,) who relates  this fact, says the same  thing
 took place at Gottinguen.  In the case of an infant aged seven months,
 in which the tumor, projecting through  the  parietal  bone,  was cut
 into by Rambaud, (Journ. de Dehorne* t. IV., p. 212.) death in fact
 followed on  the  day after  the operation.    The case of an infant
 mentioned  by Sulpius, (Bonet,  Corps ds Med., t. IV., p.  6, obs. 7,)
 was no less unfortunate.   I have seen, says M. Champion, two infants
 die, who were operated  upon for  this disease in spite  of my advice
 to the contrary, one at the forehead, and the  other near the  occipital
hole.   The first died the day after the  application of the  ligature,
which had been placed around  the  tumor;  the other  survived only
some hours after the ligature had  been applied, followed by excision
of a hydrencephalous sac of considerable size. 
HYDROCEPHALUS.
183
   Puncture of the cranium also for hydrocephalus was performed in
 France  before  the  English surgeons  had  received  it.   Pelletan
 (Heurtault, Consider, sur Difif. Points de Chir., p. Ill, 1811,) had re-
 course to it at the HotebDieu of Paris, the 7th Thermidor, and year
 VII, on an infant aged  twenty-two months.   A canula was left re-
 maining in the  parts, and the patient died at the expiration of five
 days.   Besides the above examples, we might mention at the present
 time many other instances  of puncture of the  cranium  in  cases of
 hydrocephalus.   Thus M.  Graefe  (Arch. Gen. de Med., t. XXVIII.,
 p. 409,)  and M. Russel  (Gaz. Med., 1832, p. 641,)  have each had a
 successful case.  M. Hoefeling (Encyclogz.  des Sc. Med.,  1838, p.
 251,) gives a  case of hydrocephalus in a child aged five years, who
 having received a kick from a cow, had the cranium fractured  and
 was thus cured of his disease.  I will add that M. Allaire, (Jour, des
 Conn. Med.  Chir., t. II., p.  305,) who drew by this operation, re-
 peated three times in one month, six ounces of liquid at each of the
 two first punctures, and four at the last, had not the same success, as
 his patient died soon after.  It  is nevertheless true that the cases of
 M. Conquest (Gaz. Med., de  Paris, 1838, p. 251,) are now sufficient-
 ly numerous to merit all the attention of practitioners.   In his last
 table  this  practitioner relates nineteen cases of this operation per-
 formed by him during the last ten years.   In the first of his cases,
 M. Conquest, who made but one  puncture, drew off 32  ounces of
 liquid, and obtained complete success.  The second  underwent three
 punctures, which yielded thirty-four  and  a half ounces of serosity,
 but  ultimately  ended in  death.   The third recovered after  two
 punctures and the evacuation of twenty-four  ounces of liquid.
   In the fourth, death occurred after the fifth puncture  and the re-
 moval of 48| ounces of fluid (de matiere.)   The fifth died also after
 four punctures, which furnished 45 ounces  of serum; the sixth was
 cured  by the extraction of 26 ounces of liquid in  three  punctures;
 whilst in the 7th, 8th,  9th, and 10th, who  died,  as well  as the  12th
 and 15th, it was not practicable to  make [respectively]  but two, one,
 two, two, one,  and four  punctures, which obtained 20, 8, 22, 17, 7,
 and  33  ounces  of serosity.  The  11th, 13th, 14th,  16th, 17th, 18th,
 and 19th, which recovered, furnished [respectively] 55, 13, 9, 6, 31,
 14, and 9 ounces of liquid, by means of 5,  1, 2, 4, 3, 2 and one punc-
 ture for each ;  from  whence we have 9 deaths  and 10  cures, on the
 total amount  above  mentioned.   If it were  allowable to count on
 so large a proportion of successful  cases  as this, there  could be no
 doubt that  paracentesis of the cranium ought to be practised  in cases
 of hydrocephalus.  But,  on one hand, the observations  of Pelletan,
 many  similar attempts, collected in  the practice of Dupuytren, to-
 gether with the facts of M. Bedor and M. Allaire, show that up to
 the present moment, it has  scarcely ever succeeded in France.   On
 the other hand, when we reflect upon the possible chances that certain
 patients might have of living a long  time with  a hydrocephalus of
 considerable size, while by  puncture they generally succumb at the
end of a few days, we have good ground  fo  not deciding upon this
operation without some  apprehension.  In the halls of the Clinique
of the Faculty, I have seen a hydrocephalous child of from 5 to 6
years  of age, who in other respects  appeared to be in  sufficiently 
184
NEW ELEMENTS OF OPERATIVE SURGERY.
good health.   I have also had an  opportunity of seeing a child of
from four to five years of age, who had the cranium quadrupled in vol-
ume, and which a man hawked about  the  country to  exhibit as a
curiosity.  A hydrocephalus of considerable size, did not  prevent a
patient who was for a long time seen at  the hospital of Perfectionne-
ment, from living to the age of 25  or 30 years,  and Marechal  gives
an instance of a patient with hydrocephalus, who attained to his 70th
year.   These, however, are  but rare exceptions, and  no one will
dispute  that hydrocephalus is almost a certain cause of death.  A
consideration,  moreover, which would perhaps  influence me in such
cases is this, that the existence of hydrocephalic subjects,  being ac-
companied with more or less complete paralysis, and an  absolute an-
nihilation almost of the intellectual  faculties,  is reduced  in  fact to a
vegetative life, and can be  of no great moment either to society, the
family, or to the individual himself; from  whence it follows,  that  with-
out deceiving ourselves as to its importance,  we ought, nevertheless,
to have recourse to this operation in patients who seem  in other re-
spects to be placed under the most favorable conditions possible.

                  Article V.—Spina  Bifida.

  We ought, perhaps, to have treated of spina bifida, under the chap-
ter on Serous  Cysts.   But the relations  of this description of tumor
with the encephalon,  have in some sort forced me to examine it im-
mediately  following  hydrocephalus.  Modern surgeons  believing
that they had established the fact that spina bifida always communi-
cates with the arachnoid or sub-arachnoid cavity of the  spinal  mar-
row, have thence concluded that it  was a disease placed  beyond the
domain of operative surgery. Under that  view the same opinions have
been expressed of this disease as of hydrocephalus, of which spina
bifida was considered as nothing more than a dependence or variety
which might be called  hydrorachis.  On the one hand, however, it
may be supposed that  many serous  cysts, noticed on the  posterior
plane of the spine, do not communicate with the envelopes of the
spinal marrow, and that they originate outside the dura mater.  This
is  nearly  demonstrable, especially  in one of the patients operated
upon by M. Trowbridge, (Journ. des Progres, t. XVIL,  p.  274,) and
who had a serous cyst, with  numerous  cells, in the lumbar region.
On the  other hand, we possess, at the present day, sufficiently nu-
merous  examples of cures of  tumors of  this description  obtained by
various  operations.  An infant a year old, and who had one of these
tumors along the vertebral column, was relieved of it by  means  of
five punctures  (mouchetures, see Vol.  I.) by M.  Labonne (Revue
Med.; 1826, t. II. p. 281,) who professes to have in this manner cured
a spina bifida.
  An infant aged three months, and who had had  a similar tumor
from its birth, was submitted to puncture by M. Probart,  (Biblioth.
Medic, 1828,  t.  II., p. 120.)  Erysipelas  and convulsive move-
ments supervened ; leeches, purgatives  and plasters were had re-
course to, and the cure was accomplished.  M.  A.  Hawarden (Ibid.)
is referred  to for a fact  in every respect similar, and which possiblv
might be the  same.   Two examples of successful  results obtained 
SPINA bifida.
185
 by small punctures on tumors  which were situated on the posterior
 face of the sacrum, have been related by M. Bozetti, (Journ. des
 Progres, t. V., p. 253.)  An interesting case  of this kind  has  been
 given  by M. Wardrop,  (The  Lancet, 1828, vol. I., p. 308.)  The
 tumor, which was also  situated upon the sacrum, was fourteen inches
 in circumference.   After several punctures, it was found at the expi-
 ration of six weeks to have been reduced two  thirds of its dimensions.
 But convulsions and death, which then took place almost suddenly,
 afforded an opportunity of proving that the serous pouch commu-
 nicated directly with the  vertebral canal, and that the spinal mar-
 row was sound.  M.  Trowbridge, of whom I  have just spoken,
 states  that he  has in  two instances,  succeeded by excising  these
 tumors after  having submitted  them to a gradual constriction (con-
 striction).  From whence it follows, as it appears to me, either that
 many  of the cysts described under the name  of spina bifida,.do not
 communicate with the interior of the spinal membranes, or that
 hydrorachis  with hernia  of the cyst, is  not absolutely  incurable.
 According to this induction we should naturally be led to  conclude
 that it is proper to treat  spina bifida  by surgical means.   In these
 cases I think we have it in our power to lay down the following
 rules:  1. If  the tumor, is  not accompanied with paraplegia and  the
 cyst is not too much attenuated, we ought to wait and confine  our-
 selves to the use of topical astringents or compression ; 2.  Although
 there may not  be paraplegia, if the cyst is very prominent and with
 a large base, we should perform the puncture with a lancet  rather
 than with a trochar, and repeat the same operation weekly, at  the
 same time that astringents and  compression should also be used; 3.
 Whether  the cyst be  attenuated  or  not, or accompanied or  not
 accompanied by paraplegia, it should be strangulated at its root pro-
 vided it is pediculated ; and we should  wait until it is shrunk  before
 incising it outside of the constricting ligature; 4. When paraplegia
 is present, whatever be the  form, volume or thickness of the cyst,
 the treatment to be employed by preference  is repeated punctures.
 Though the  surgeon ought to  hesitate with a child who is in other
 respects in the enjoyment of perfect health, the case, in my opinion,
 is very different when  complicated with a profound alteration in  the
 functions  of  the spinal marrow.   In this  state the little  patient is
 devoted to a  certain death if nothing is done, and we have seen by
 what precedes, that by means of an operation there is some chance
 of saving him.  In 1824 I saw  at the  hospital of Perfectionnement,
 an infant  two  months  old, who had at the point of the sacrum a
 serous  cyst, which was flattened in shape, of a reddish color, and of
 the size nearly of the fist; and  which was ultimately  cured  by
 means  of four punctures practised during  the space of a month, to-
 gether with  compression,  aided  by topical  astringents, continued
 about five months.   A young boy whom I saw at the Hotel Dieu,
 in 1835, had on the base of the sacrum a transparent tumor, existing
 there for several years, and  having the size of a large pullet's egg,
 and which certainly would have received the  name of spina  bifida,
if it had been met with in a new-born infant.   I have since learned
that this tumor, treated  by puncture and afterwards by  incision, had
ultimately entirely disappeared.   As for the rest, it is at the base of 
 186          NEW ELEMENTS  OF OPERATIVE SURGERY.

 the lumbar region, and on all the posterior surface of the sacrum, that
 the operation in my opinion  presents the best chances of success.
 There in fact there is no longer any spinal marrow, and the inflamma-
 tion must necessarily be less dangerous than in the other regions of
 the spine.  Certain it is that, restrained by this idea, I did not venture
 to meddle with a spina bifida which was  situated  in the cervical
 region, another which was found  near the middle  of  the  dorsal
 region, nor a third which was  sent to me in November, 1838,  by M.
 Larrey, and which had its seat  in the upper part of the lumbar re-
 gion.  I  have,  however, at the maison  de sante of M.  Dufrenois,
 made trial of repeated punctures with the  lancet on a spina  bifida
 in this last-named region, in a new-born  infant.   The tumor had the
 dimensions of two five-franc pieces; its walls  were thin  and of  a
 bright rose color, and threatened to become ruptured ; a first punc-
 ture sensibly diminished the  paraplegia ; it was the same with  a
 second and third, and finally with the fourth.   But on the twentieth
 day, convulsions and other signs of arachnitis announced to us that
 the scene was changed; death took place at the end  of the month,
 and the opening of the dead body performed by M.  Behier, in pres-
 ence  of M. Guersent,  showed that a purulent  inflammation  which
 had  commenced  at  the cyst, had  extended  itself  throughout the
 whole length of the spinal marrow, reaching into the cranium.  I
 will  add  to these details, that in the last  century, Orth, (Theses de
 Holier, t.  V., p. 218, Juillet, 1719, French translation,) following Salz-
 mann, had already endeavored to make  it appear that certain cysts
 which are developed  along  the track of  the spine ought not  to be
 confounded with spina bifida, and that in our time, M. Busche (Revue
 Med., 1829, t. IV., p. 118*)  has exerted himself to prove that  many
of those cysts were  partitioned  (cloissonnes) like the ovaries, and
 without communicating with the cephalo-spinal cavities.  The four
examples related by this last author, are calculated in this respect to
inspire practitioners with a certain degree of boldness.  Finally, the
case of an infant seven months old, who had in the lumbar region  a
legitimate spina bifida,  which Skimer (Arch. Gen. de Med., 3e serie,
t. II., p. 494) attempted to treat by repeated punctures, was not more
fortunate than the one I have mentioned above.

  Article VI.—Cephalematoma  (Sanguineous  Tumors  of  the
                           Cranium).

  Sanguineous  cysts of the cranium are sufficiently often encoun-
tered in new-born  infants  to induce many practitioners to consider
them  a specific disease, generally known at the present  day  under
 the name of  cephalematoma (cephalematome).   Having elsewhere
 (Art des  Accouchements, t. II., p. 590, 2e edition) treated of these
tumors, I  will now speak of  them  only in their connection with
operative  surgery.  These cysts, moreover, have been  sometimes
 confounded with encephalocele, as is proved by the  observations of
 Le Dran, Trew, M. Michel, and some others.  M. Champion informs
me that he has seen a  surgeon, in other respects a man of great ex-
 perience, make also a mistake of this kind a short time since.  We
should, moreover, be  deceived  if we calculated on finding cephale- 
CEPHALEMATOMA.
187
 matoma only among new-born infants.  Since the publication of the
 work above cited, I have met in an infant twenty months old, with
 a sanguineous cyst of more than  three inches in diameter, and which
 covered almost the whole of the  frontal bone.  Another infant, aged
 six months, whom I saw  with Dr. Demey, had one of similar dimen-
 sions on the  left parietal bone and a portion of the occipital.  A
 woman, aged 49 years, and a man 26  years of age, presented to me
 similar  examples, one on  the  right  region  of the forehead  and
 temple, the other on almost  the entire right half of the  cranium.
 Other analogous  facts, but less striking than those  last mentioned,
 have also assisted  in confirming me in my first opinions  on the
 mechanism and nature of sanguineous  tumors of the cranium, to wit:
 that these cysts are formed by an effusion of blood, which takes place
 in consequence of vascular rupture or  spontaneous exhalation, some-
 times between the  skin  and  aponeurosis, more frequently between
 the aponeurosis and  pericranium, quite frequently also between the
 pericranium and  bones, and sometimes between the  bones  and dura
 mater.  A case noticed  by M. Neve  (communicated by the author
 to M. Champion,) would  go, in fact, to show that the blood primarily
 extravasated between the dura mater and cranium, may transude and
 pass through the bones, and arriving externally, constitute  a  throm-
 bus or cephalematoma.  The mode of curing these tumors is not
 considered in the same point of view by all practitioners.   Puncture,
 followed by compression and topical  resolvents, have obtained de-
 cidedly successful results with M. Champion.  Others have had the
 boldness to recur to large incisions, and even  to the seton ; but I
 have satisfied myself that  with  a little patience  and some  topical
 astringents, we may almost always succeed in dispersing the tumor
 without the necessity of an operation.   The cephalematoma which I
 treated in this manner, in consultation  with M. Cisset, disappeared at
 the expiration of a few weeks.  The  child that M. Demey sent to me,
 got well in fifteen days. I have seen others which recovered still more
 rapidly.  In the  man and woman whom I have mentioned  above,
 the tumors, notwithstanding their extreme dimensions, receded more
 and more, and ultimately disappeared in the space of a month.  It is
 however true, that in the patient first  mentioned, after having made
 a puncture on the forehead and extracted from it four to five ounces
 of a sanguinolent liquid, I found that the walls of the tumor aggluti-
 nated, and that a complete cure followed.
  In conclusion, then, I would, in these cases, advise  temporization,
 afterwards compresses wet with a solution of muriate of ammonia,
 tannin  or alum, or  some other astringent liquid.  Puncture would
 not be admissible until after unavailing attempts by compression, or
 unless at the end of a month's treatment, the tumor remaining sta-
 tionary, seemed  rather to have a tendency to increase.   Pure and
 simple puncture will then, in most  cases, succeed, especially if we
 associate with it for some days a slight degree of compression properly
 applied.  To  cover the whole extent of the cyst with a temporary
 blister, would also be an excellent remedy as an adjuvant to puncture
 or the simple incision ; but the most  certain remedy in all  these old
cases, and  especially where the cyst contained scarcely any thing but
liquid matter, would be the iodine injection, the same as  in cases of 
188
NEW ELEMENTS OF OPERATIVE SURGERY.
hydrocele.  I would not, in fine, decide upon laying open the tumor
largely or on many  of its points until after having made use of all
other means, or unless there should exist some serious  accident, or
that a  suppuration kept up by the cephalematoma had  actually be-
come established.

Article VII.—Operations  required by  the  Diseases  of  the
                         Frontal Sinus.

   There are two regions in the  cranium where the diseases may re-
quire operations so diversified, that we are almost tempted  to make
them the subject of two special articles.  These regions are the fron-
tal sinuses, and the mastoid process; but as it  is  next to impossible
to separate what relates to this last from the  operations required for
the diseases of the ear, I shall not treat of it upon the present occa-
sion, but speak only  of what relates to the frontal sinus,  properly so
called.  Operations have been  performed upon the frontal  sinus, in
cases of fractures, caries, necrosis, abscesses,  hydatids, polypi, the
presence of foreign bodies, collections of fluid, and various kinds of
degeneration.   The  relations of the frontal sinus with the interior of
the nasal fossas,  and  with the cranium and orbit, will  always render
its diseases difficult to diagnosticate and cure, at the same time  that
they generally  increase their  danger.   The  operations which they
render necessary must, moreover, in their nature  be sufficiently deli-
cate, and sometimes  in themselves formidable.

                               § L

  When from a fracture in the forehead, some fragments remain dis-
placed posteriorly, in such a manner as to give rise to accidents, it
may become advisable to remove the anterior wall of this sinus, either
wholly or in part.  Facts of this kind have been related by Fallopius,
Trew, Marechal, Colignon, Jackson and many others.  In a patient
whose case is given by Home, (Acad, de Chir., t. VI.,  p. 203, in 12°,)
there was a fracture  at the superciliary ridge.  The ablation of the
osseous projection was effected; accidents supervened, and bleeding
had to be resorted  to eight times ; but the patient recovered.   Lassus
(Med. Op., t. II., p. 259) and M.  Larrey, as well as Fichet de Flechy,
(Observat. de Med. et de Chir., p. 213,) have related examples of cures
obtained in the same way, and without the patients having been- ex-
posed to the slightest dangers.   Muys, (Nouv. Obs. de Chir., p. 43S,
obs. 5, decad. 8,) who was already aware that the opening  into the
frontal sinuses has  a  tendency to become fistulous, and who, on  that
account directed his  attention to the passage of the air, and then to
the rolling up  (recoquillement)  of the skin, recommends  that we
should be careful to contract (raccourcir) the borders of the wound
in a proper manner  immediately after  the  operation.  It is  readily
conceived also, that  in cases of* fracture it  may  sometimes  become
necessary to enlarge the pre-existing wounds, at  other times  to es-
tablish new ones, also that if the fragments are somewhat loose, we
may be enabled to detach them by means of a good pair of forceps,
while, on the other hand, if they remain adherent at some  point, it 
FRONTAL SINUS.
189
may become  necessary to employ the osteotome, gouge, mallet  and
trephine.  In these cases, the surgeon should not forget that purulent
collections are especially to be apprehended in the direction of the
orbit, and that in order to prevent them, there is  no better method
than to leave or to establish  a free issue for the fluids in this quarter.
The incisions required, therefore, should be placed as much as it is pos-
sible to do so, rather below than above the eyebrow.   I will add, that
it is better to make them  large than small, and that the cutting pliers,
modern osteotomes and trephine should be employed in preference to
the chisel or hammer, whenever their application would not seem to be
attended with too much difficulty, or except the slightest danger was
to be apprehended from any concussion upon the cranium.  It would
appear that Langguth (Tfieses de Holler, translation, t. L, p. 125) had
foreseen this  danger when he advised the employment of the scissors
rather than recur to the trephine.  O. Acreil, (Sprengel, Hist, de la
Med., t.  VII., p. 31,) on the  contrary, confined himself to trephining
upon the superciliary ridge,  in a patient where the frontal bone  had
been fractured and driven in.   In spite of the  unsparing censures of
Bertrandi, in 1763, on the use of the trephine to the frontal sinuses,
and the  accusation he makes against it, of  leaving an incurable fis-
tula, and of being inconvenient  in its application,  M. Larrey (Cam-
 pagnes  Chirurg. d'Egypte,  p. 136) employed it with advantage, even
 in perforating through the cranium;  Collignon  (Biblioth. Chir.  du
 Nord, p. 179) speaks of a fragment of ball which, having become ar-
 rested in the upper eyelid, produced  an exfoliation  of the  anterior
 wall of the  frontal  sinus, without  being followed by  any  fistula;
 and we  find in the Memoir of M.  Gaultier de Claubry (Bull, de la
Fac. de  Med. t. III.)  a great number of instances where trephining
of the frontal sinuses  was  evidently attended with utility.

                   § II.—paries and Necrosis.

   Caries and necrosis of the frontal sinuses are a double disease, which
there, as elsewhere,  are  sufficiently  often found  blended  together.
Beranger de  Carpi and Dulaurens (Portal, Hist, de VAnat. et de la
Chir., t. VI., p. 491) had already noticed that the vault of the frontal
sinus was sometimes  perforated with holes and, as  it were, worm-
eaten, and to such extent as to  allow of the  fluids penetrating into
the  cranium.   Similar facts have since been  pointed out by Fabre,
(lb., t. XL, p. 164.)   Sellien (Biblioth. Chir. du Nord., p. 100) gives
a case of venereal  caries, with  fungosities  of the  frontal sinus,  and
which he cured by means of red precipitate.  A man had a caries
with softening of the interna]  orbitar process; Janin (Memoire et
Observations sur les Maladies des Yeux, p. 290) having made an in-
cision, then excised a portion of the lips of the wound, and removed
all the bone he could by  means of the  bistoury.  Camphorated  oil
was then applied to the remainder of the  caries, which ultimately ex-
foliated and allowed the whole wound to cicatrize.  Delpech (Revue
Medicale, Mai, 1838) speaks of a necrosis, the extraction of which left a
large opening into the nose and frontal sinus, which opening he treated
by rhinoplasty.  The frontal bone was altered  to the extent of an
inch; a  crown of the trephine  and  some  strokes upon the gouge 
190           NEW ELEMENTS OF OPERATIVE SURGERY.

removed the  caries entirely.  Obstinate hemorrhages took place at
first, but the patient nevertheless, says Cavalier, (Societe de Medecine
de Marseilles, 1817, p. 38,)  got well  in the space of a month.   M.
Riberi, {Gaz. Med., 1838, pp. 795, 796,) in two cases with caries, ac-
companied by necrosis of the frontal sinus, was not enabled to succeed,
except by means of the gouge and  mallet.  So that examples at the
present day are not wanting  to  show the resources of surgery  in
cases of necrosis or caries of the frontal sinuses.  In these  cases, the
operation to be preferred is  the  same as for caries or necrosis  in
general.  It ought moreover to vary according as the disease is more
or less extensive, or according as it exists in a simple state,  or with
different complications.  Should the soft parts be  sound, it would
be advisable  to cut from them a semilunar flap, with its free or con-
vex border turned upwards  and inwards, so that its lower extremity
might terminate on the ascending process of the maxillary bone.
  In cases where ulcers and  fistulas existed, all that would  be  re-
quired perhaps would be, to enlarge  them  without making any dis-
tinct incisions.  In whatever way we have proceeded in laying bare
the diseased  region, we  should, in order  to  complete the operation,
employ the forceps to extract the  movable fragments, the bistoury,
or a strong scalpel to destroy the  softened  bones, the chisel or the
gouge and mallet, if there were only some  splinters to remove,  the
cutting pliers, or Liston's scissors, in cases where the diseased por-
tion might be very projecting and well circumscribed, and the osteo-
tome of M. Heine or M.  Charriere, or even the trephine rather than
strokes with the chisel, should it be necessary to go down deep and
take away a  large portion  of bone.  Caustics and  the red hot iron
employed by some surgeons, and again recently by M. Riberi, would
not be advantageous in such  cases, unless we had to destroy simple
fungosities, as in the case related by Sellien, or thin lamellae.

                        § III.—Abscesses.

  Caries and  necrosis of the frontal  sinus frequently result from an
abscess which has formed  in the  interior of this cul-de-sac.  The
pus confined in an unyielding cavern, ulcerates the mucous mem-
brane which lines it, denudes  it, soon mortifies its walls, and finishes
by making a  passage to itself, either in the direction  of the orbit, or
the nasal passages, or even into the interior  of the cranium ; but be-
sides that such purulent collections  in themselves involve sufficiently
severe dangers, there may also result from them fistulas or an altera-
tion of the bone which could scarcely be cured but by one of the opera-
tions which have  been described above.  It would be advisable, there-
fore, to remedy  the  difficulty in the beginning, if it can be done.
Although Borelli, Bartholin, Boetius, Tulpius, Marchettis, Chevassieu,
D'Audibert and Celier, have  seen cases where abscess in the frontal
sinus has got well by making its  way through the  nasal passages,
Richter (Bibl. Chir.  du  Nord., p.  242 to 249,) nevertheless advises
that we should  endeavor to  re-establish  the natural passages, or to
create  a  new one, rather than to destroy the mucous membrane of
the sinus.  Sauvages, (Nosologic, t.  VIII.,  p. 345,)  who first makes
trial of detergent injections, also orescribes the trephine.  An abscess 
FRONTAL SINUS.
191
of the frontal sinus having invaded the ethmoid bone, led to the sup-
position that it had extended to the maxillary sinus, which was unne-
cessarily perforated.  Other remedies, says Jourdain, (Maladies de la
Bouche, t. II., p» 101,) directed to the frontal sinus, effected the  cure
of the patient.  In another, Jourdain (Op. cit., t. I., p. 78,) destroyed
the anterior nasal wall of the maxillary sinus, in  order to reach into
the frontal sinus, which was filled with pus, and to introduce injections
into it;  Frank (Medec. Prat., t. V., p. 38, French translation,) says a
physician of Vienna has frequently trephined the frontal sinuses in
order to extract from them inspissated mucosities.  I should certainly
however not recommend that we should go to the extreme of trephi-
ning the forehead, for the sole purpose of extracting mucosities or some
few drops of pus accumulated behind the  internal  orbitar process.
So long as the collections in this cavity have not disorganized its
walls, there is reason to hope  that they will make their  way through
■the nares ; and this is the termination which we ought to encourage
by means of fumigations, injections, or even sternutation, before think-
ing of the trephine. But should the disease have been of long standing,
and have resisted  every thing, and caused violent pains  and severe
accidents, and that its diagnosis can be clearly made out, trephining
in my opinion would be the best remedy.   Two processes may then
be employed : either after the manner of M. Riberi, we may incise
the soft parts in the upper portion of the great angle of the eye, and
perforate with  a punch or  the  perforating  trephine,  or with  the
scalpel  only; or  what is better, with a small crown of  the trephine,
the upper part of the os unguis, or the ascending process  of the maxil-
lary bone, and  the extremity of the internal orbitar process, in such
manner as to penetrate into the nares and create there a passage for
the liquids, and to  be enabled to  shut up  the solution of continuity
in  good season, without  having  any apprehension  of the  forma-
tion  of  a  fistula.   It  is important, under  such circumstances  to
avoid wounding the lachrymal sac, and the tendon of the orbicularis
muscle ; also, it would  be advisable to cut out a semilunar flap whose
free border should look  inwards and forwards.  No doubt this me-
thod  would be successful, if the collection in  the frontal sinus was
prolonged very far downwards, and if it were not yet complicated
either with caries or  necrosis.  Otherwise it is better directly to at-
tack the frontal  sinus itself; taking care if it is not yet ulcerated to
open  it  at its most depending part, that is to say, between the upper
eyelid and the  top [or the inner  extremity (la tete)] of the superci-
liary  ridge.   The operation moreover would, in almost every parti-
cular, be the same as that which I have pointed out in the preceding
case.   It would differ from it only in having to prolong the incision
in the form of an  arc  a  little higher up  and somewhat more  out-
wardly, and that  the  trephine and perforators would act exclusively
on the frontal bone, instead of including  at the same time both the
maxillary bone and the os unguis.

                     § IV.—Foreign Bodies.

  Besides pus, there have been found in the frontal sinuses, under
the character  of  foreign  bodies, clots  of blood,  polypi, stones, 
192          NEW ELEMENTS  OF OPERATIVE  SURGERY.

worms, &c.  Chaptal, the father, (Sauvages,  Nosologic, t.  VI., p.
177,)  having noticed that pains of the head  which had  persisted
with violence for a long time,  disappeared in consequence of a nasal
hemorrhage, concluded on that account, without, as it seems to me,
being perfectly authorized to do  so, that blood retained in the frontal
sinus  had been  the cause  of  this suffering.   Instances of calculi in
the frontal sinus, Telated by Bartholin, F. de Hilden, and Schenckius,
are somewhat more positive, since an opportunity presented of iden-
tifying the objects by direct observation.  The  same may be  said of
the cases of a tent there mentioned by Holegost, and also those of
a ball which, according  to  Zacutus Lusitanus, would constitute con-
ditions calling for the application  of the trephine.  Cesar Magatus
(Journ. Gen. de Med., I. XLV., p. 331,) says a patient was cured by
trephining his frontal  sinus for a worm, and  Rossi (Medec. Oper., t.
II., p. 116, note 5,) had recourse to this operation in order to place a
ligature around the root of a polypus, which he  afterwards extracted
through the nares.  A fistula which was thereby caused in this case,
lasted for  the  space of three  years, and was not  cured until after
the rupture of the osseous lamina which separates the  sinus from the
nasal  cavities.   In the case of M.  Hoffman {Rev. Med., 1826, t. II.,
p. 152,) it became necessary after the extraction of the polypus, to
pass a seton from the sinus  into the nose. M. Langenbeck (Biblioth.
Chir., or  S. Cooper's Dictionnaire de  Chir., t.  I., p. 439,) finding a
large  tumor external to and above  the root of the nose, had recourse
to the trephine  in order to open into it, when he recognized that it
was made up of an enormous hydatid mass.  A cavity two  and a
half inches deep remained at the place which the tumor had occupied.
Other foreign  bodies  also  have been  noticed in the frontal sinus:
Salzmann (Convulsions des enfo.ns, p. 248,) states that he has found
and killed worms there.   M. Maunoir (Questions  sur  les  coi-ps
etrangers, p. 204,) and also M. Breschet (Diet, des Sc. Med., t. VII.,
p. 4,)  speak of balls  retained  in this  cavity for the space of three
months.  M. Larrey (Campag.  Chir., t. IV., p. 89,) relates that the
Chevalier Erasme retained the point of a javelin for fourteen years
in the frontal  sinus.   M.  Dezeimeris  (L'Experience,  t. I., p. 572.)
has extracted from the cartons of the ancient Academy of Surgery,
the case of a fungous tumor of the form of the patella, and which was
situated in the frontal sinus. M. Brunn, (De  Hydrope Cystico, &c,
Berlin, 1829 ;  Journ.  des  Progres, t.  II., ser.  2, p. 255 ;  HExpe-
rience, t. I., p.  568,) a Prussian surgeon, speaks  of a young girl who,
being tormented  by a supra-orbitar tumor,  died after having been
submitted  to a crucial incision upon the same and the employment of
the seton.  Now this tumor, which was attended with a  sero-san-
guineous liquid and a fetid suppuration, and which was five  and a
half inches long and four and  three-quarters  in breadth, situated in
the frontal sinus and composed of cells or small bladders, which had
become developed in the space  of five years, might have evidently
been extirpated if it had been  attacked at an earlier period and in a
proper manner; an instance of a hydatid tumor of the forehead had
already been mentioned by M. Corby, (Biblioth. Medic, 1829, t. III.,
p. 20,) but in this case the disease was  altogether independent of the
sinus.  The presence of foreign bodies in the frontal sinus would still 
FRONTAL SINUS.
193
more positively call for the application of the trephine than any other
of the  diseases of which I have hitherto spoken.   Their  diagnosis,
therefore, is a point of great delicacy.   As  to the operative manual
here, also, two modifications would be offered, according as the sinus
was intact or already laid open.  In the first case it would be neces-
sary to cut down  in such manner  as to lay bare the tumor  exten-
sively, and in preference by the semilunar flap which I have indi-
cated in the beginning.   The crown of the trephine would be better
adapted here  than any where  else, and even than the other osteo-
tomes : only that it would be advisable to apply two small ones, one on
the side towards the orbit below, the other at the top [inner extremity]
of the  superciliary ridge  above, which should be done  in order to
obviate the inconveniences which result from the irregularities of the
frontal bone in this region. The points, bridle or bridge left between
the two crowns, could afterwards be easily destroyed by means of
the scalpel, cutting  pliers or  chisel.   Should  there  have already
existed any fistulas or ulcerous passages, they could be made  use of
as a guide by which to reach the foreign body, and the enlargement
of  these  might be all that was required to give to the incisions the
form and extent that were necessary.   I have no need of remarking
that the foreign body itself when once laid bare, may require the aid
of  the forceps, even the cutting pliers, and  elevators and  ligatures,
and the  use of the bistoury and dissections, more  or  less cautiously
conducted, according as it is movable in the sinus or implanted in the
bones, or is in a fluid state or concrete.   This remark applies also to
necrosis  as well as to foreign bodies.

                              §V.

  Though the immediate consequences of this operation might be se-
rious, they are nevertheless ordinarily very simple.  One of the most
disagreeable is that of often leaving a fistula, which is exceedingly
difficult to close up.  I have, however, seen this fistula heal up  in two
instances in patients who had  the anterior wall  of the frontal sinus
destroyed by necrosis, and in  a third  in whom this wall was  lost in
consequence of  a comminuted  fracture.  That of P.  Gerardi, after
receiving no benefit from the dilatation of the frontal  sinus through
the nares, yielded  to the action of a machine similar to  that which F.
ab Aquapendente and Petit made use of to compress the lachrymal sac,
a contrivance which Rossi, (Medec. Oper., t. II., p. 244.) who does not
pretend to have  invented it, calls a presser (pressoir), and which M.
Riberi, who again revived it in 1838, appears to have  employed like
his  countryman, but without obtaining, however, any real advantages
from it.   Perhaps  it has not been sufficiently examined  in these cases
if the interior  of the sinus was  perfectly free of disease.   I suspect,
in fact, that the fistula here depends chiefly upon certain  particles of
altered bone, or ulcerations, or points of caries, much more than on the
physical and natural disposition of the sinus.  I would, therefore, ad-
vise before all other steps, that  we should carefully explore the parts
and remove from the region every thing which has the least appearance
of disorganization.   If after this, lotions and detersive and  astrin-
gent injections, and even slight cauterizations should not suffice,  I
                               13 
194
NEW ELEMENTS OF  OPERATIVE SURGERY.
would then willingly give the preference to  perforation of the inner
wall of the sinus in its lower portion, and in such manner as to make
it communicate freely with the nose.  Rossi (Med. Oper., p. 116, note,)
by dilating the internal orifice and breaking the nasal wall of the sinus,
succeeded  completely.   Perhaps even  an opportunity  would here
offer of inserting  a large  and  somewhat short canula constructed
after the model of lachrymal canulas.  In conclusion, the facts which
relate to the operations required for the frontal sinus, are so dispersed
through works of science, and  given mostly with  details  so vague,
and these operations have been so rarely performed with us, that  it
would be difficult at the present time to  subject them to general rules
that are either very  precise or very useful.  [See a note farther on. T.]
                        CHAPTER  II.

                             FACE.

  The operations which are performed on the face are numerous and
varied, but many of them have been described elsewhere, (see Vol.
I. and Vol. II. of this work, on the respective subjects of Anaplasty,
Exsections, and  Tumors.)

  Article I.—Operations  which are  performed  on the Nose.

  I have not  to  consider here the different  forms of rhinoplasty, the
details of which  will be found under the chapter on Anaplasty, (Vol.
I.  See also our  notes there.)

                          §  I.—Tumors.

  Tumors of various kinds may be developed in the nose, the same as
in any other region.  As I shall have to treat of  polypi of the nasal
fossae after having spoken of the operations which are performed on
the velum  palati, I do not design at the present moment, to touch
upon  any other than tumors which are  situated  in  the substance of
the nose, properly so called.   As respects the operation they require,
these tumors form two  classes, some of them having their seat on the
body of the organ, others in the septum.
  A.  The nose,  properly so  called.—I. We find on the body of the
nose three principal varieties of tumors which  occasionally require
the aid of operative surgery.   These are worms (tannes or maggots),
cancers or elephantine  masses.  In no region, perhaps, are the sebace-
ous follicles more frequently altered than upon the nose.  So long as the
substance with which they are filled does not exceed the dimensions
of a pin's head, and are unattended with any degenerescence of the
cutaneous tissue, the disease would not justify any kind of operation.
On the contrary, should the crypt itself become thickened and trans-
formed into a tumor which had acquired  the size of a  bean or the 
NOSE.
195
 head of a nail, it might be advisable to attack it by other means than
 by simple pressure.   In such cases the subject of extirpation  might
 be- taken  into  consideration;  but cauterization  with a crayon  of
 nitrate of silver cut into the shape of a cone, with its point  carefully
 introduced into the aperture and down to the bottom of' the sebaceous
 follicle, will almost always answer.  If the tumor were still more de-
 veloped ;  if, for example, it exceeded the volume of a small nut, and
 presented itself under the aspect of a cyst with thin walls, filled with
 matter of a purely fatty character, then extirpation would evidently
 be preferable.    [See  our note above, pp. 60-63, giving  the case
 (with plates) of those  enormous  tumors of this  kind, which  I suc-
 cessfully removed at Nassau, capital of the Bahamas, in 1824.   T.]
   II. Tumors and cancerous degenerescences of the nose usually exhi-
 bit characters that are altogether peculiar.  They are usually rather
 plates, bumps,  (bosselures,) or incrustations, than tumors that are ex-
 actly circumscribed, or that can be arranged under scirrhus, or those
 that are encephaloidal, or melanotic, or of the  colloid tissue.   Their
 origin most  frequently seems to  be connected  with a vitiated secre-
 tion or degenerescence of the sebaceous follicles themselves.   In all
 cases these  tumors, which  are usually badly defined, and  scarcely
 found except in persons advanced in age, exact certain precautions
 in a surgical point  of view.  The  treatment  by caustics generally
 succeeds with  them perfectly well.  A lady who had one of the dia-
 meter of an inch for  many years, was cured by means of four cau-
 terizations with the  nitrate acid of mercury.   An ancient officer of
 marine, whom M. P. Pelletan sent to me, had,  on the left side of his
 nose, a cancerous, bosselated, sanious plate of a reddish color, which
 had been there over two  years.  Every kind of topical and internal
 treatment had been resorted to  in this case.  Slight cauterizations
 with the  liquid above  mentioned,  effected a cure in the space of six
 weeks.  The father of a young physician, in the environs of Nantes,
 had,  on the  lobule of  his nose, one of those plates, (plaques,) which
 completely disappeared under the influence of four similar cauteriza-
 tions ; and I could at the present  time relate a great number of simi-
 lar facts.  To  succeed in such cases, it becomes necessary to clean
 the tumor carefully of all the crusts with which it may be covered.
 I then besmear  it with butter in the evening and morning, with the
 view of softening this incrustation the night before each cauterization.
 All the crusts  thus besmeared easily allow afterwards of being de-
 tached, and we thus have the altered plate immediately naked before
 us.  I then take a small pinch of  lint which has been saturated with
 the liquid  above mentioned,  to touch in  every part, and even a little
 beyond it, the surface to be destroyed.   The pain which it produces
 at first  is sometimes quite severe.  The  parts touched by  the acid
 become white,  and excite occasionally  a  slight exudation of blood;
 there is then formed upon the surface a yellowish crust, which  may
 be detached at the expiration of four or five days, in order to renew
 the same operation, and so on to the end of the  cure.   From four to
 six or eight cauterizations applied  in this manner are  generally  suffi-
 cient.  If the plate should be composed of an agglomeration of seba-
 ceous follicles, the cone of nitrate of silver introduced to the bottom
of each one of them would succeed equally well, and would  even be 
196
NEW ELEMENTS OF OPERATIVE SURGERY.
more suitable.   When  it is thicker, hard, and of a certain breadtn,
the zinc paste appears  to me  to  be preferable.   Having vivified
(avive) the altered surface, by means of ammonia 01 a blister, and
taken  care to  do so effectually, which the nature of the tissue in
these cases sometimes renders difficult, we apply over it a plate of zinc
paste, (pate de zinc) from one to three lines thick, in such  a manner
that this plate goes half a line beyond the entire circumference of the
tumor; we then  fix it  here by means of a suitable containing ban-
dage, taking care that nothing is disturbed, at least during twenty-
four hours.  All the degenerated tissue is transformed, by  means of
this caustic, into an eschar, which falling off at the end of six to twelve
days, leaves in its place a wound whose aspect soon announces that
cicatrization is about to commence, and w^hose bottom dries up and
quickly becomes a  sufficiently regular portion of the surface of the
nose.  Moreover it  is important, when we employ zinc paste, potash,
or butter of antimony on the  nose,  not to penetrate too deeply, and
to remember that in this region the teguments are very thin, and that
it  would be easy to come down upon the bones or to the cartilages.
so as to produce a necrosis there, as M. Champion has seen in two
instances.   Upon the  supposition  that the tumor  had much  more
thickness than breadth, we might perhaps attack it with the bistoury
rather than by caustics.   We should succeed by this method if, after
the tumor  was removed, the lips of  the  wound could  be readily
brought together, either by simple tractions, or after having detached
them on their deep-seated surface  to the extent of some  lines,all
round.  Should the loss of substance be too considerable to do this
with facility, we. should have nothing more to do than to recur to the
resources  of rhinoplasty, or  be contented  with  a cicatrization by
second intention.   This last practice would have to be adopted for
the operations  performed on the sides  of the nose,  and between the
forehead and the wings  of this organ;  and in this case there could
be no other  than advantages follow from cauterizing at the first the
whole bottom of the wound.  At the root of the nose anaplastic pro-
cesses present sufficient  chances of success  to authorize their employ-
ment.   At  the  point or the alas, they would  become still  more
important,  since  cicatrization there by  second  intention is almost
always followed by considerable deformity.
  III. Elephantine Tumors.—The nose, in certain individuals, is some-
times transformed into a reddish mass of a violet color, at other times
simply greyish and covered with bumps,  and which has given rise t<>
the expression of mushroom or potato nose.  This  alteration, which
seems to be no other than an extraordinary development of the natural
integuments of the part, may acquire so great a degree of extension that
there results from it upon the nose an actual tumor, very analogous as
to its nature to elephantine tumors of the scrotum.   These tumors have
sometimes been seen to acquire a weight of several pounds.   As they
do not cause any pain, rarely ulcerate, or undergo  any transformation
of a bad character ; and as it is also almost impossible to get rid of
them by other than by surgical means, patients do not usually pay any
attention to them until  they have arrived at a very advanced  stage
of their development.   Imbert de Lonnes  (Oper. Faite, le 16 Bru-
maire, an VII, in 8°,  8 pages,) has published a very remarkable exam- 
NOSE.
197
p%> of one.   A former mayor of Angouleme had on his nose a bos-
selated tumor of the weight  of  about two pounds,  and which hung
down as far as the chin, hermetically closing up the nostrils  and the
mouth.  This man, in order to breathe and speak, was obliged to bend
down with his head forwards.  He could neither eat or sleep except
by raising up his tumor, which he suspended by means of a sling fixed
to his  night-cap,—a ligature, which had been made trial of, caused
such pain that it had  to  be  laid aside.  Imbert then decided upon
extirpating it, and was obliged to lay bare the whole surface of the
nose, which operation required twenty-two minutes.   No  accident
took place,  and the  patient got perfectly well, preserving a nose
which  was not very greatly deformed.
  Analogous facts have been related by the Academy of Surgery,
(Memoires,t.Ill., p. 511,) and  the work of Hey contains some which
are not less interesting.  The  subject, however, had no longer been
spoken of by practitioners, when M. Dalrimple  (The  Med. Quarterly
Review; Gaz. Med., 1834, p. 136,) communicated new facts in re-
lation to it.   In his first patient, who was fifty-four years of age, the
tumor hung down upon the mouth and reached nearly as  far as  the
chin ;  the surgeon removed  it on the  4th of August, 1826, and  the
wound healed up in a month without  leaving  any disagreeable  de-
 formity.   Another patient operated upon in the same manner, got
 well in as short a space of time.  In performing this operation in 1831,
 in a man who was more than eighty years of age, M. Dalrimple was
 obliged to remove a tumor almost  as voluminous as that which has
 been described and figured by Imbert  de Lonnes.  No indications
 of a return have  shown themselves since.   In  these different cases,
it is important during  the dissection of the parts, that the surgeon
should place one of his fingers in the nostril, in  order  to direct the
action of the bistoury, and to guard himself better against every per-
foration.   As for  the rest, the removal of maggots, cancers, and ele-
phantine tumors of the nose does not differ from that of diseases of
the same kind which are seen in any other region.  It would be  the
same also with erectile tumors: Marechal (Archiv. Gen. de Med.,
t. XXIIL, p. 149)  successfully extirpated one which was of the size of
a nutmeg, and which was situated at the tip of the nose.
  IV.  I will nevertheless remark, that  on this  last point it is impor-
tant to recollect the cul-de-sac which lies under it, and that the lobule
of the nose is hollow behind, and generally furnished with walls that
have but little thickness.  So that in fact  this  organization renders
their perforation almost inevitable when the cutting instrument is ap-
plied to it, or  the slightest caustic of  any activity.   From whence
there results  a species' of hole which  is readily transformed into a
fistula, and. which being once cicatrized in its periphery, cannot after-
wards  be closed but with  an  extreme degree of difficulty.   I  have
met with two patients in whom the end of the nose had been excised
in order to destroy a cancer, and in whom this fistula resisted every
kind of attempt directed against it.  A young girl, who  in falling
from her bed cut her lip and  the lobule  of the nPse, in striking  her
face against a chamber-pot, which she broke, rapidly got well of all
her wounds, with the exception of a point  of the lobule of the nose,
which  remained fistulous.  I was not however enabled to cure  this 
198
NEW ELEMENTS OF  OPERATIVE SURGERY.
fistula, until after having abraded it by means of the  bistoury, and
reunited its borders by a  point of the twisted  suture.  The attempt
at reunion by every different kind of bandage or plaster, cauteriza-
tions with the nitrate of silver, nitrate acid of mercury, and the  head
of a probe heated to a white heat, which had been  made  trial of du-
ring the space of two  months, had completely  failed.   We should
have, therefore, in such cases, to resort to abrasion and  the  suture,
provided the suspension or  the elevation  of the end of the nose by
means of adhesive plasters or any kind of bandage and cauterizations
well applied, did not answer at first.
   B.  Tumors of the Septum, (cloison.)—The septum of the  nose in
front of the cartilage which divides  the nares  into two passages, is
quite frequently the seat  of  tumors, to which the  moderns only have
paid any serious  attention.  These  tumors sometimes  concrete, but
most  usually  liquid,  establish themselves  between  the  two tegu-
mentary layers which are continuous from  the exterior to the interior
to line the nasal  fossas.   An English surgeon,  M. Fleming, (Dublin
Journal, 1833 ;  Gaz. Med., 1833, p. 798,)  has  frequently met with
tumors purely sanguineous in this part, a disease which is  sufficiently
common in that country, says the author, in consequence of the mode
of attack which the  English so often make use of in their pugilistic
combats.  M. Cloquet  (Journ. Hebd., No.  91, p.  544, 1830) appears
to have observed abscesses  here  very frequently, and M.  A. Berard
(Arch. Gen. de Med., 3e  serie, t. I., p. 408)  has published  two cases
similar to those of M. Cloquet.   I  have also on my part  seen in the
substance  of the sub-septum of the nose, collections of blood or of
pus and masses that were semi-contrete, and, as it were, tuberculous.
Whether liquid or concrete, the tumor, nevertheless, in such instan-
ces, protrudes on each side into the openings of the nose.  If it is a
deposit of blood from external violence, time and topical resolvents
will generally remove it in the space of fifteen  days or a month.   In
case of failure, we should have at a  subsequent period to  treat them
by incision, or in the manner I have  said of cephalematomata.   Ab-
scesses  should be laid open as soon as possible upon one side, and
freely, if the same sac projected to the right and left; upon two sides,
on  the contrary, if there were two abscesses there in place  of  one.
We should proceed also  in  the same manner if the abscesses were
simply tuberculous, except that we should then have to apply after-
wards the nitrate of silver throughout the whole extent of  the morbid
cavity.  For tumors that  were purely concrete, or where there  was
an alteration of  the  anterior border of the cartilage of the septum
narium, we should have to proceed in another wray.  In describing the
sub-septum  of the nose,  Bichat indicates the possibility of an opera-
tion, which up to the present time had existed only as  a project, but
which M.  Rigal has performed.   In  backing on the median line, the
cartilages  of the lobule leave between them a small groove, percepti-
ble even through the skin, which enables us to separate them apart
by means  of the instrument, and to penetrate as far as to  the septum
narium without opening into those cavities.  A cancerous tumor de-
veloped under the anterior nasal spine, and which had gradually ex-
tended in front, downwards, and on  the side, as far as  to the alas of
the nose, had nevertheless scarcely  altered the tegumentary layer. 
NOSE.
199
Two incisions, united in front and passing around behind and  out-
ward in such manner as to represent a ^ reversed, having surround-
ed the cancer .laterally, it became easy, by means of a transverse in-
cision, to detach it below  from the upper lip, then  by doubling back
the two lips of the first wound, to arrive at the cartilage of the sep-
tum, to excise  its anterior  border and remove  the entire morbid
mass.   The sides of the division were afterwards brought together,
and the cure was  uninterrupted  by  any  accident, unless  it  was
that the  progress of  the cicatrization, by drawing the tissues back-
wards, had ultimately flattened a little the  alas and the top of the
nose.

          §  II.—Occlusion and Contraction of the Nares.

   In consequence of confluent small-pox, syphilitic or other inflamma-
tions, rhinoplasty itself, and  all lesions in fact which may alter the
form of the nose, the anterior opening of this organ is liable to be-
come closed up, or at least to be narrowed to so great a degree as to
interfere very materially with respiration.
   A.  Ordinary processes.—We remedy such  inconveniences  by
three different modes : 1. Dilatation ; 2. Incision ;  3.  Excision.   It is
rare that dilatation alone suffices ; it is besides applicable only in cases
of narrowing, and not of entire closure of the passages.  Incision in its
turn almost always requires  dilatation to be  associated with it.   Ex-
cision becomes  useful only  where tubercles or  morbid  projections
are to be removed.   Should the opening be merely narrowed we in-
cise it by numerous excentric cuts, and to greater or less depth, ac-
cording to the extent of the disease.   When it is  entirely closed up
a narrow bistoury should  then  be plunged  in at  the place which it
usually occupies.  We  make  in  this manner an antero-posterior in-
cision, the borders of which  it would  be  afterwards advisable, as I
think, to divide on two  or three points of their length.  To prevent
the wound or small wounds  from reuniting and destroying the effect
of the operation, it is  recommended to keep them open and separated
apart by means of a tent of lint or linen.   As we must by every
means  in our  power force  them to cicatrize separately, and in the
position we have first given  them, it appears to me that we  might at-
tain our object better by means of a  piece of sheet lead rolled up in
the shape of a ring, and to which we could moreover give such form
as we desired, than  by means  of the dilating bodies generally em-
ployed.  It is, however, an  operation  too simple  to  require that I
should dwell any longer upon it.  Nor have  I found that it has  been
as difficult as has generally been said, to give to  the opening of the
nares again in this manner, their  necessary dimensions.  A young
girl whom  I received into  the hospital of La Pitie  in 1833, and in
whom the openings of the nose had  been  reduced to a small aper-
ture, in consequence of an eczematous affection, which had been for a
long time cured, was submitted by me to the  excentric incision of the
cicatrix, afterwards to dilatation by means of a large canula of gum
elastic, and recovered perfectly well.   I saw her again more than a
year after, and there was not the slightest tendency to any contrac-
tion of the anterior opening of the nares. 
200           NEW  ELEMENTS OF OPERATIVE SURGERY.

  B. New method.—If the incision or the simple excision should not
appear to present all the chances of success desirable, there might per-
haps be a mode of arriving at  something more  certain, by adopting
the following course.  The surgeon, provided with a straight bistoury,
would circumscribe the  whole of the deformed cicatrix, by surround-
ing its base on the border of the  former opening, and very near the
skin  of the nose.  Afterwards  dissecting this circle as  if to isolate
it, as it were, from the internal surface of the organ, and in such man-
ner, that after having removed the entire arcade of morbid tissue we
should  have in its place a prismoidal groove, there would be nothing
more to do than to bring together the two borders of this new wound
by a sirfficient number of points of suture.   We should thus procure
immediate  reunion  by  means  of an  operation, which  leaving no
wound, nor any traumatic surface in the interior, would not expose to
a new contraction.  It would be, moreover, applying to the openings
of the nose, what I   have proposed as  one of the best methods for
contractions of the mouth.  I will add,  that by following this method,
it would be  rendered almost unnecessary, to keep a canula or any
foreign body in the nose  during the  cicatrization of  the  wound.
Having treated of the manner of reconstructing the sub-septum and
the alas of the nose  under  the  chapter on Anaplasty, I do not pro-
pose to recur to it again at this time.  I will only remark, that hav-
ing seen in 1838 the person formerly operated upon by M. Gensoul
and  previously by Dupuytren,  I was enabled to ascertain that the
flap borrowed from  the upper lip and fixed to the lobule of the  nose,
in order to construct the fibro-cartilaginous septum, which a lupus had
destroyed in this patient, had maintained itself in a  sufficiently  satis-
factory condition.   The  only inconvenience which results from it is
a slight depression of the lobule of the nose  and too great a  projec-
tion of the sub-septum (or  columna)  below.   This  fact  proves then
incontestably, as do those also which have been published by M. Lis-
ton, that the sub-septum of  the nose may be  perfectly well re-estab-
lished by means of an elongated flap taken  from the middle of the
upper lip.   (See notes on Anaplasty, Vol. I.)
  C. Rhinoraphy, or the simple suture of a slit, either in the alas or
in any  other part of the  nose, as practised with success by M. Roux,
and also by myself, being no other than a modification of rhinoplasty,
or subject to the same rules as cheiloraphy, does not require to be de-
scribed separately.

           Article II.—'Lachrymal  Passages  (voies).

   The nasal canal,  formed on the inside by the posterior border of
the ascending process of the superior  maxillary bone, and the an-
terior third of the   os  unguis,  and altogether  below  by a  small
lamella of the  inferior  turbinated bone;  outwards, forwards, and
backwards, by the maxillary bone, and its turbinated bone, and then
in a  slight degree by tbe ensiform process (crochet) of the  os unguis;
having a length of three to five lines ;  circular  at  the middle  part;
a little" wider from before backward than  transversely, on its upper
portion;  and terminating below  by  an orifice which  flares open in
the manner of a funnel,—possesses in  reality no solidity  except in 
lachrymal passages.
201
the antero-internal third of its circumference: from whence it follows
that in attempting to pass an instrument (traverser) through it, it is
very easy to break its other walls, and penetrate either into the nasal
fossas or the  maxillary sinus.  The  lachrymal groove (la gouttiere
lacrymale,—i. e. gutter,) which seems to prolong its internal  wall as
far as to the corresponding  orbitar  process of the  frontal bone, and
which is more and more superficial in proportion as we ascend into
the orbit, presents on the  other hand inferiorly two lips,  which are
easily recognized; one anterior belonging to the ascending process,
the other posterior and  formed by the outer crest  of the os unguis.
The fibro-mucous membrane, which lines the  nasal canal, and to
which it is but slightly adherent, becomes much  stronger  and  more
complicated in the gutter,  where it takes the name of the  lachrymal
sac.  Here the direct tendon of the orbicularis muscle crosses its an-
terior face at a right angle, as if to divide it into  two halves, the one
superior upon which this tendon sends off a fibrous expansion, known
under the name of reflected tendon,  the other inferior and lined out-
wardly by cellular tissue, and which has boundaries which it is exceed-
ingly important should be understood.   This  last mentioned  portion
[of the  lachrymal sac] is always confined within that triangular space,
which is bounded above by the direct tendon, below by the  border
 (rebord)  of the orbit,  and  outwardly  by a  vertical line  which
would fall upon the  outer side of the caruncula lachrymalis.   It is,
moreover, covered only by some fleshy fibres, and by lamellar tissue,
 and the teguments of the  nasal angle of the  eye.  Being  but feebly
supported by the surrounding tissues, it  readily  yields  to  the influ-
ence of causes which have a tendency to dilate it, and thus frequently
becomes the seat of tumor and of  fistula lachrymalis.
   The  apertures for  absorbing the tears,  (puncta lachrymalia,)
and which are  surrounded  by a  small  elastic  and dense, but not
cartilaginous circle,  have  a  direction perfectly vertical, but  form a
very distinct angle (coude) where they become  continuous with the
lachrymal duct, properly so called.   This last, which traverses only
the inner fifth of the free borders of the eyelids, is situated more
especially  upon  their  posterior  portion.  Being  formed  by the
mucous  membrane  only, it is  exceedingly thin,  and   superficial
in its postero-superior half;  while the remainder of its  circumfer-
ence, making part of the  body of the eyelids, presents in front and
below a far greater  degree  of solidity of texture.  Now, it  is  this
anatomical arrangement which obliges us to enter perpendicularly
at first,  in order  to rest afterwards much more in a direction towards
the eyelid  than  the eye, when we  catheterize the lachrymal ducts
themselves.  At their entrance into the sac these  ducts are  sometimes
separated by a small projection or sort of spur ;  frequently also, they
unite together by one opening.  Taken together, the lachrymal sac
and nasal canal present a double curve, which has some resemblance
to that of an Italic S, that  is  to say, that the first  [the sac]  is slightly
convex posteriorly and inwards, while the second [the nasal canal] is
so in the contrary direction; so that in order to  perform catheterism
on the upper eyelid, we must take care while the probe is traversing the
sac, to incline its lower extremity rather forwards and outwards, than in
an opposite direction, and that in order to traverse  the nasal  canal, it is 
202           NEW JL.EMENT3 OF  OPERATIVE  SURGERY.

better, on the contrary, to push the instrument  from before back-
wards, and  from without  inwards.  As every one  must have  re-
marked,  the axis  of  the nasal canal in its relations with the supra-
orbital- projection, presents  very numerous  modifications; as does
also the depth to which we have to -go to find it in the orbit.  In
persons in whom the root  of the nose is flattened and broad (large)
it  appears  to be  thrown outwards,  and perceptibly  contracted.
When on the contrary, the ossa nasi (les os carres) are very nearly
approximated to each other at their inner surface, we cannot reach
it  except by  coming much  nearer to  the  median  line.   When the
frontal bone is very  projecting, and the  maxillary bone very pro-
minent,  the nasal  canal (conduit  des  larmes)* is  found  at  a very
considerable distance from the posterior surface of the direct tendon,
while  in  persons who have the  canine  fossa very.deep, and the
forehead depressed, it appears to come  out  a  slight  distance beyond
this tendon.   The species of valve or diaphragm  which contracts its
lower  extremity, is usually perforated only in its  posterior half.   Its
orifice [i. e., the  outlet of the  nasal  canal into  the nostril, T.] is
situated at the depth of six  or  eight lines in the nose, at th,e apex
of a cavity which is  bounded in  front by the base  of the ascending
process of the os maxillare, and  inward by  the concave  surface of
the inferior  turbinated  bone.  As  this cavity is prolonged  a little
more in front of than posteriorly to the lachrymal valve, it happens
sometimes that catheterism at this lower part (catheterisme inferieur)
is  very  difficult if the surgeon  is not aware of this arrangement.
The length  of the nasal canal itself rarely exceeds from six to eight
lines.  Demours  has met  with  bridles in  the  nasal  canal.  M.
Taillefer (These, Paris,) describes a membranous  duplicature [repli]
which w\s situated in its upper third, and the free border of which,
directed  downwards,  sent off several filaments, which attached it to
another point in the same canal; so that if a probe had been passed
from below  upwards  it would evidently have been arrested  by this
anomaly.   Different   authors whose  observations  are  given  by
Sandifort, relate examples of small calculi found in the lachrymal pas-
sages ; similar instances also have been since  related by Schmucker,
Eller,  Walther,  Krimer,  M.  Levanier, M.   Graefe,  and formerly
by Kern.   More than  this, the  nasal  canal has been found entirely
closed ;  Morgagni gives an  instance where  both were closed, [en
relate un exemple double,]  and Jurine as  well as Dupuytren, have
both met with one.  The lachrymal passages may be  the  seat of
lesions in each of their three principal divisions,  viz., in the sac, the
ducts and the puncta lachrymalia, and also in the nasal canal.

                §  I.—The Puncta and their Ducts.

   A. The puncta  and lachrymal ducts may be  obliterated.   Small
pox, purulent ophthalmia, a long  protracted blepharitis, wounds and
ulcers on the internal portion of the eyelids, are the principal sources
of this alteration.   The tears being then no longer able to penetrate

  * As our author a few lines above, applies  conduit lacrymal to the lachrymal or tear
ducts properly so called, this inadvertence might lead to ambiguity, but for the subse-
quent rectification it receives by his admirable anatomical  precision. T. 
LACHRYMAL PASSAGES.
203
into the sac, run over upon the cheek, so that the eye is moistened as
if weeping, (lave,) while there is present at the same time a peculiar
dryness in the corresponding nostril.   We may then have present
epiphora, an alteration, or even the disappearance of the punctum
lachrymale, and ulcerous, purulent, atrophied or hypertrophied con-
dition of the border of the eyelids, and afterwards of  the nose, with
the absence of all kind of tumor or fistula lachrymalis.
  Gunz states that he has seen a case of this kind in which however
the tears found their way into the nasal canal by means of porosities
which were recognizable to the naked eye.   This kind of alteration,
which has not been taken notice of but  by a few  persons, is worthy
of additional researches and appears to  be altogether  incurable.   J.
L. Petit and Pellier, who pretend to have reconstructed an oblite-
rated lachrymal duct, by passing a sharp pointed  probe through  the
place it had occupied, were certainly deceived by some of the cir-
cumstances  of the case.  Whatever in  fact may  be the instrument
made use  of to fray out a passage so delicate as the lachrymal duct,
and  whatever may be the kind of seton  afterwards employed in this
passage to keep it open  permanently, we may rest assured  that  the
tears will not take that course, and that it will shut up  as soon as  the
dilating body is  removed.  Such operations therefore are perfectly
useless; it  is  better in such cases to imitate  Bosche (Malgaigne,
 These  de Concours, 1835,)  and  cauterize  the puncta in order  to
close them permanently, should there be any trace of them  left.   If
they were merely contracted  or only obstructed by some thick mat-
ter, all  that could be done  would be to clean- out the passage  by
means of Anel's syringe and injections.   In such cases A.  Petit
(Peiffer, Theses de Paris, No. 222, 1830) and Leveille (Traduct. de
Scarpa, t. I., p. 84,) are of opinion that we ought to establish an open-
ing to the lachrymal sac by means of loss of substance between the
caruncula and eyelid, at the place which Pouteau had selected. But
it is  not probable that such an opening would keep open for any con-
siderable  time, nor  that it would afford any particular relief.  An
artificial opening by excision to the duct itself, upon the inner side of
the punctum obliterated, would do much better.   It continued open
in  two  patients upon whom I had operated with  another obiect  in
V10TJI7                                                    J
view.
  B  Fistulas of the Duct-Should  any ulcer or lesion  happen to
perforate  the  lachrymal duct on the side towards the  eye,  there
might result from it a particular form of fistula which is  one of the
most difficult to heal.  A thread of gold  or silk, or small cord of cat-
gut, passed m the manner of a seton  through the injured  duct, from
the  punctum as far as the lachrymal sac, is the only remedy that art
possesses against an infirmity of this kind, unless we should  have
lecouise to opening the nasal canal on the inside of the eyelids.   I
roantpTT°Vert:m,LW0CafS' Seen thetears  Pass through the  new
vat;   th 1S'  h7 t aC?d6I?tal &Perture int0 the duct>i* the  same
esult^A  gf    G "fff  PuUnCtUm' without  any inconveniences
esul ng therefrom, and I doubt if fistula of the puncta lachrymalia
in reality constitutes a disease.

h£«SySt^Ametl?eS also one of the Puncta of the lachrymal duct
becomes dilated m the  manner of a  cyst.  So at least J. L.  Petit* 
204          NEW ELEMENTS OF  OPERATIVE SURGERY.
Bover and Pellier state that they have seen it.   As the tumor causes
no pain, it should be treated by resolvents, so long as it shall not have
acquired  such size as to render it too troublesome.   It would more-
over be unnecessary to extirpate it in order to obtain a radical cure;
as it would be equally certain to disappear by laying  it open and
cauterizing its interior.  Formerly they used to  expect that there
would result from this an  obliteration of the duct and probably also
an incurable epiphora. But I shall have occasion farther on to refer
to some facts which will  have a tendency to allay the fears of sur-
geons on this subject.
  D. Polypi.—The lachrymal puncta are also liable to  a species of
small vegetations or kind of polypi.   Demours (Precis des Maladies
des Yeux, 1821)  speaks of a small fungus which protruded from the
lower lachrymal punctum, and which he cured by excision followed
by cauterization.

      4  II.—Lachrymal  Tumors and Fistula  Lachrymales.

  The lachrymal tumor is rarely if ever a dangerous disease: it in-
commodes by the crustaceous condition which it keeps up on the
border of the  eyelids, causing thus  d predisposition  to ophthalmia;
the sensation of dryness which it produces in the nostrils, the purulent
matters which it forces to flow back upon the eye, and by the deformity
it causes  in the great  angle;  but it compromises neither life nor the
general health, nor even the physiological  condition of the  globe of
the eye, properly so called.  It may however ultimately, and  it is
thus in fact that it most  frequently terminates, give rise to acute
inflammation in  the sac, then  in the neighboring tissues, or it may
become  transformed  into an  internal  anchylops, and  finally  pro-
duce a fistula lachrymalis.  This inflammation of  the  lachrymal sac
sometimes reaches the periosteum of the neighboring  bones, as of
the 6s unguis (lachrymal bone),  for example,  or the maxillary or
ethmoid,  or  even the  frontal and  nasal  bone, so as  to denude them
and cause necrosis or caries of the inner wall of  the  lachrymal sac
or nasal canal.   I have seen this inflammation extend itself to almost
the entire side of the  face, and terminate in the manner of phlegmo-
nous erysipelas in the  eyelids  and at the root of the nose.  Happily
these are but exceptions, and the lachrymal tumor rarely gives rise to
any other than a very circumscribed abscess  before it becomes trans-
formed into  fistula.
  Fistula lachrymalis therefore  is but one of the consequences of
the tumor of the same name.   It appears to me however that this fis-
tula may in some instances be formed without having been preceded
by tumor of the sac.
   We may conceive for example, and I  have now instances in point,
that a loss of substance, either in  consequence of  certain operations,
or we will suppose, from  wounds, contusions, burns,  or  ulcerations,
might destroy a  part of the free portion  of the lachrymal sac in  such
manner as to establish there an actual fistula.   I  believe, moreover,
to have in two instances seen a fistula establish itself from the exterior
to the  interior, after  the  anchylops  had already  made its way out
through the skin.  However this may be,  fistula lachrymalis is an ulcer 
LACHRYMAL PASSAGES.
205
which communicates by an accidental opening with some point in the
track of the tears.   We should, therefore, by that definition, have to
examine fistulas of the lachrymal ducts, those of the nasal canal, and
fistulas of the lachrymal sac.   But these last only have hitherto been
the subject of special attention, and as to the others I have made a
few allusions  to them farther back.   Fistulas of the lachrymal  sac
are sometimes internal, that is, that  they may open into the  middle
meatus of the nasal fossas, into the sinus maxillare or in the direction
of the eye posteriorly to the palpebral commissure; but that they are
almost always external.  Under the last circumstances also, the cu-
taneous orifice, which, in ninety-eight times  out of one hundred, is
found in front of the lachrymal sac, may nevertheless occupy another
position.   I have in one case seen it on the prominence of the cheek,
and in another case near the ala  of the nose;  a  sinuous  track of
more than an inch thus separated  the external from the  internal
orifice of the  fistula.   Ordinarily the«re is but one of these orifices;
but sometimes the skin at the great angle of the eye is, as  it were,
cribbled with them.   Frequently this orifice  makes no projection, but
even appears to be a little depressed ;  at other times it is found situated
on the top of a kind of sac  which is flabby or flattened, or occasion-
ally more or less distended.   It is not an uncommon thing to see it
afterwards surrounded with fungosities, and presenting the aspect of
an ichorous ulcer of bad character.   In fact, nothing is so simple as
the mechanism of a lachrymal fistula.  The sac, for a long time dis-
tended in the state of tumor, is worn through (s'eraille) or ulcerates;
the inflammation extends sometimes  suddenly, at other times  by im-
perceptible degrees, to the  neighboring  layers, and an  abscess is
formed.   Whether this abscess opens of itself or is opened  by art, it
nevertheless  puts  the cavity of the sac in  communication with  the
atmosphere through the skin.  If the ulceration makes its way di-
rectly to the skin, the fistula is direct or complete ; if it spreads (fuse)
or the contrary, either between the periosteum and bones,  or among
the other organic layers in the direction of the nostril, it  is  indirect
and incomplete, and becomes an exception.   We can readily under-
stand how the os unguis, which is so thin and fragile, and the osseous
plates  with  which this bone  articulates,  may ultimately  become
necrosed  and carious, when we reflect upon* their  relations with
such seats of inflammation and suppuration.  As the treatment of
fistulas in practice has generally been confounded with that of lachry-
mal tumors, I propose, in this place, to examine under one  head  the
therapeutic of these two forms of the same disease.  The  treatment
of lachrymal tumor and fistula has,  at every  epoch, occupied  the
attention of practitioners; after having been for a  great number of
ages almost entirely  pharmaceutical, it became almost exclusively
mechanical from  the moment when  the functions of the lachrymal
apparatus became  well understood, At  the present day opinion
seems to have taken another direction.  Recognizing that the lachry-
mal tumor and fistula were the result of an inflamed condition  of
the nasal  canal or lachrymal sac, practitioners  finally asked them-
selves the question, whether the treatment of inflammation, modified
according to the  individual, and  the peculiarities  of the diseased
region, ought not, in a great number  of cases, to have the preference 
206           NEW  ELEMENTS  OF OPERATIVE SURGERY.
over mechanical means.  At the present time, therefore, before pro-
ceeding to surgical remedies, these affections  are to  be treated  by
resources of another character.
  A. Topical Applications and General Treatment.—The first object
of the surgeon ought to be to ascertain the causes, whether individual
or constitutional, of, the tumor or fistula.  If the patient under treat-
ment were affected with syphilis, scrofula, or scurvy, it would  be
necessary, before doing any thing else, to  bring  about the  cure  of
these general derangements  of the  economy.   It is to be understood,
also, that tumors of the  nasul passages,  orbit or maxillary  sinus, as
well as any other disease in those regions, ought to be previously
destroyed, should they have been  the point of departure of the dis-
ease in question.  If  the affection should  have developed  itself  in
consequence of any disease of the skin, of the lips, or the Schneiderian
membrane, it  would  also be necessary  to commence by removing
them.   In  those instances, quite common, of  lachrymal tumor and
fistula, which originate, as it has appeared to me, from an eczema  of
the upper lip and the'encrusted condition of the opening of the nostrils,
I have made use, with advantage,  of  a pomade  composed of a gros
of  white  precipitate  to  an   ounce of lard, and  sometimes  also  of
another pomade containing eight grains of nitrate of silver to  an
ounce of lard.   The  parts  affected are  to be rubbed morning and
evening with one of these pomades, taking  care to remove the crusts
previously, by means  of emollient  cataplasms.   If, on  the other hand,
the case in question is one that comes under those tumors and fistulas
originating from disease of the eyelids, I employ, before all other
things, the means proper to  cure this last.  Influenced by the idea of
an inflammation of the mucous membrane of the lachrymal passages,
all the school of Beer maintain that we should treat it by debilitating
remedies.  It is for this reason that M. Mackenzie eulogizes general
bleeding,  leeches,  and water, as  a topical application and for the
regimen, in the acute, and even also in the chronic state of the disease.
M. Lawrence, still more specific, prescribes leeches  to  the internal
angle of the eye and  upon the tumor, and compresses wet with cold
water as a resolvent.
   The credit of this  practice might equally well be ascribed to De-
mours,  for this  surgeon was in the  habit of treating the  diseased
condition of the lachrymal passages by leeches and regimen; every
where he speaks of having cured lachrymal tumors and fistulas of
long duration without an operation.  Emollients, procrastination, and
cold lotions (les  lotions froides—-means of  course, cold water,)  were
his favorite remedies, and  we  see by the  consultations described in
his great work, that it was the method also of his father.  It is from
not  having been au  courant on this subject with the history of  the
science, that some  surgeons among us between 1820 and 1830, sup-
posed  that they were the  authors of it.  In fact, it  goes still much
farther back; for Manget,  in  1693, wrote that fumigations by  the
nose and general treatment  did exceedingly well with lachrymal  fis-
tula.   Heister, who like Platner  was aware that inflammation was
the immediate source  of this disease, and who compared the affec-
tions of the lachrymal passages to those  of the urethra, treated them
also by injections, bleeding, blisters, and regimen, which are almost 
LACHRYMAL PASSAGES.
207
always sufficient he says, if there be not yet either ulceration or ca-
ries in the great angle.  It is  to  be added, however,  that  before
M. Gama, M. Guillaume, M. Paris,  and some other military surgeons,
(Mem. de  Medec  et de Chir. Milit., etc.,  t. XIV—XVI.) but few
persons in France, except Demours, thought of combating lachrymal
tumor by means of antiphlogistic remedies.
  Practice of the author.—One  consideration naturally suggests it-
self here ; that  is, to know to what extent debilitating measures are
allowable  under  such  circumstances.   A  regimen which is quite
rigid, with some general bleedings,  repeated application of eight, ten,
fifteen, twenty or thirty leeches to  the temple, mastoid processes or
nasal angle, emollient cataplasms, cold topical applications, injections,
or  aqueous  fumigations,  continued for two, three,  four, and six
months, do not  at first succeed but  in a very small number of  cases;
afterwards this  practice  manifestly becomes more painful and dan-
gerous than  most of the  surgical  remedies now employed  ; from
whence it follows that we should  be wrong in according too much
confidence to this kind of medication, and that we ought to consider
well before adopting it.  There are some  lachrymal fistulas, more-
over, which we have it in our power to cure without an operation,
by  means of  a treatment better regulated, and less calculated  to dis-
turb the constitution.   Thus,  unless there are particular indications
to the contrary, I would advise neither general bleeding* nor leeches
to the temples, or behind the ears, nor a seton to the nape, which Fa-
bricius de  Hilden (Bibl. de Bonet, p. 394, 397,)  recommends, nor a
plaster of tartar emetic as eulogized by M. Weller, nor internal re-
medies ; but I willingly employ, and have often done so with success,
some of these remedies applied as near as possible to the parts dis-
eased.  From six to ten leeches on the track of the nasal  canal and
lachrymal sac,  renewed three to four times in the space of a month,
may be useful,  if there be remaining a  certain degree of inflamma-
tion and heat in these parts ;  the same remark applies to the fumiga-
tion of Manget  or  Louis, and to topical emollients.  After this first
period it would be necessary  to recur, as was already the practice in
the time of Rhazes, (Guy de  Chauliac, Traite IV., doct. II., chap. 2,)
to the application of friction to the  tumor or collyria between the
eyelids.  Upon the tumor we may apply either mercurial ointment,
that of hydriodate of potash  or ioduret of  lead, and also temporary
blisters.   As collyria, we no  longer employ the melange, lauded by
Rhazes, but may make use with advantage  of a lotion of sulphate of
zinc, lime-water, a solution of nitrate of silver, and in fact any  resolv-
ent or styptic collyrium. Introduced into the lacus lachrymalis, (le lac
lacrymal,) these liquids are  absorbed there by the puncta lachrymalia,
and thus  tend to destroy the inflammation  which constitutes the ob-
stacle  to  the course of the tears.  Le  Dran, who had already em-
ployed liquid collyria under this form, and  Mackenzie, who has sub-
stituted them for the injections of Anel, have obtained with them de-
cided success ;  I have  myself often used  them and with very excellent
effects. Nevertheless we must not deceive ourselves in respect  to their
efficacy.   Though in the space of  one year I have seen four women
cured of lachrymal tumor and fistula under the treatment I have just
described, I ought to add also  that most of the other cases of the same 
208
NEW ELEMENTS OF  OPERATIVE SURGERY.
kind to which I had before been witness, have since returned to me,
and  convinced me that  the cure was not permanent.  We succeed
by this treatment then only as an exception, and not  eight times out
of ten, as some persons at the present day have ventured to affirm;
but what justifies trials of this  kind is, that  the surgical means at
present known, in spite of their number, nevertheless still leave the
treatment of lachrymal  tumor  and  fistula very imperfect  and mea-
gre.  In truth, the methods which  have been from time to time eu-
logized  for the cure of fistula and  lachrymal  tumor, having almost
exclusively for their object the removal of a presumed obstruction,
which is  sometimes wanting, and which is only in  fact the result
of another disease, could not have otherwise than failed frequently.
   These means, moreover, are so diversified, that in order to appre-
ciate them  properly, it  is important to  separate them into several
classes.   Thus,  among those  who  have proposed them, some like
Mejean  and Anel, by means of catheterism  and injections had no
other object than the cleansing out of the nasal canal by penetrating
through the lachrymal ducts ;  others, namely, Lecat,  J. L. Petit, Ca-
banis, Palucci, Foubert, Jurine,  Desault, Pamard  and Scarpa, had
especially in view the dilatation of this  canal.  Many persons recur-
ring to  the idea of Heister, have supposed it more rational to employ
in those parts injections  of various  kinds, or to apply caustics, in the
same way as is done for contractions of the urethra.   A fourth group
in fine, embrace the methods which,  like those of Woolhouse, Hunter,
Warner, and many others, were designed to establish  a new route for
the course of the tears.   Among these methods there is a considera-
ble number which would deserve to be consigned to entire oblivion ;
but as they are still employed by some practitioners,  I think it advi-
sable to make a brief review of the greater  portion of them.  In
conclusion,  I  would divide the  surgical treatment of lachrymal tu-
mor and  fistula,  into  four general  methods,  namely : the  method
of catheterism and injections, that of dilatation, thirdly, cauterization,
and lastly, the method for establishing an artificial lachrymal passage.
   B. Catheterism and Injections.—To  believe Bianchi and Signo-
retti, Stenon, Valsalva, and Stahl, a veterinary surgeon mentioned by
Morgagni, must  have already made an  attempt to penetrate the tear
ducts, by means of very fine styles (tiges)  more or less adapted to
their object, until Anel attracted attention  to  this subject in  1710.
Portal, (Hist, de  I'Anat. et de  la Chir., etc., t. IV., p. 486,) in fact,
asserts that we find  the  germ of this principle in Cajus Julius, Plato,
Septalius and Duret; but it is easy to perceive that Bianchi was de-
ceived, and that  Manget, in reality,  is the only one who effected the
passage of these  ducts before the time of Anel.  According  to its
partisans, catheterism of the lachrymal passages  is called for,  in
tumors, fistula, simple obstruction, more or less complete obliteration,
partial or general contraction, ulcerations and chronic inflammation
of the lachrymal  ducts, sac and puncta, as well ns of the nasal canal.
We may have occasion  for it in order  to  introduce threads, tents,
different  kinds of meches, injections, and medicated  liquids, and we
may perform it either through the eyelids or the nares.  This method
presents  two principal varieties: with  it in fact we propose some-
times to clear out, sometimes to modify the interior  of the diseased 
LACHRYMAL PASSAGES.
209
ducts: in one, the object of the surgeon is evidently mechanical;  in
the other, it is more physiological.
  I.  The mechanical variety.—a.  Process of Anel.—Anel had two
modes of treating affections  of the lachrymal passages : sometimes
he endeavored to clear them out (les desobstruer) by means of a very
fine probe,  at other times by the aid  of injections that were either
detersive or impregnated with some other medicated property.
   1.  Injections.—To introduce injections,  Anel  devised a  small
syringe of the capacity of two to three gros, terminating in a very
fine syphon, to the point of which was adjusted a copper  pipe much
finer still.  The  patient was made to sit down fronting a well-lighted
window.  With the left hand for the  left eye, and the right hand on
the contrary for the right, the  surgeon  gently depresses the lower
eyelid and inclines its free border forward.  With his other hand he
takes the syringe, introduces its point  perpendicularly into the orifice
of the tear duct, causes it to penetrate in this direction to the depth
of about a line ;  then placing it horizontally, he inserts the  little cop-
per syphon to the extent of two or three lines, then presses his thumb
upon the ring which is at the posterior  extremity of the piston, and
cautiously forces forward the medicated liquid into the lachrymal sac.
The inferior lachrymal punctum is preferred for this purpose, because
the operation by that of the upper eyelid, would in fact be less con-
venient and less  certain. Should the operator prefer placing himself
behind the patient, he would depress the lid of the right eye with his
right hand, and  the lid of the left eye with his left hand.
   He might also, were  he  not ambidexter, employ the same hand
for both sides, by taking care to place himself in front for one of the
eyes and behind for the other.  At first the patient bears  these ma-
nipulations rather badly: they produce  in fact, in some instances, a
good deal  of irritation.  It is  only after having gone through with
them for several days successively that he gets accustomed to them,
and that they become as simple as they do trifling in  pain.  Saint-
 Yves and Heister also had recourse to injections, but they made them
through the fistula.  W. Blizard (Transact.  Phil., t. LXX. ; Journ.
de Med., 1781, t. LXXIII.) influenced  like his predecessors, by the
 principle of clearing out the passage, proposed  that mercury should
 be used in  the injections.
   2.  Catheterism.—When  the  injection does not  arrive  at  all,  or
but in very small quantities into the nasal fossae, Anel recommends
that we should  immediately have recourse to  the use  of the probe.
The  operator, if to  act upon  the  superior  lachrymal duct,  places
himself behind the patient, gently reverses the eyelid  outwards and
upwards, with the left  hand for the right eye  and  with the right
hand for the  left eye, seizes the probe with the other hand in the
manner  of a writing pen,  perpendicularly  applies the blunt point
of the instrument on the lachrymal punctum, afterwards inclines  its
other extremity outwards  and upwards,  as if to carry  it towards
the external  orbitar process, cautiously advances  it in, draws with
his other hand the nasal  portion of the  lid inwards and towards the
internal orbitar  process, as if to give him a vertical direction, imme-
diately  pushes in the probe  in  this last mentioned direction,.taking
care when  meeting with the  slightest  obstacle, to  raise it  up,  or
                              14 
210
NEW ELEMENTS OF  OPERATIVE SURGERY.
incline it a little either in front or outwards or backwards or inwards,
in order to force it in fine to penetrate into the corresponding nostril;
after which  he withdraws it to have recourse again to the injections.
The introduction of this probe is a delicate operation, which cannot
be otherwise than fatiguing to the patient.  It demands on the part
of the surgeon an exact  knowledge of the arrangement of the parts.
The slightest fold, whether natural or morbid, is  sufficient to arrest
the instrument, which, in consequence of its small size and flexibility,
is in reality  incapable of overcoming the least degree of resistance.
I will add that in every point of view it is a useless operation, for the
lachrymal tumor and fistula are scarcely ever owing  to a complete
obliteration  of the nasal canal.  Moreover, if matters  that would
yield to the  action of the probe  could  be the  cause, they might be
displaced full as well by simple pressure made upon the tumor.  This
pressure, which Richter recommends to be made from above down-
wards, and acting in the manner of injections forced into the urethra,
would evidently have more efficacy than Anel's probe.   Neverthe-
less the operation of catheterism  continues to be performed and de-
scribed, because, as will  be seen farther on, some  practitioners have
applied it to the radical cure of fistula lachrymalis  itself.
  b. Process  of Laforest.—Perceiving that injections and catheter-
ism by the method of Anel  were sometimes very difficult, and believ-
ing them moreover to   be of unquestionable utility,  Laforest  and
Allouel, nearly about the same time, proposed to  penetrate into the
lachrymal passages through the nares.   To attain his  object, Lafor-
est had constructed small plain sounds curved into an arc, and cathe-
ters (algalies) of the  same form, which were conical and open at
their apex and terminated at their base by an ear (pavilion)  furnished
with a small lateral ring, designed to fix the instrument upon the side
of the nose in the interval between the dressings.  The plain sound,
inserted from  below upwards  into  the nasal canal, was  intended to
clear it out.   After having  removed  this, Laforest  replaced it by the
hollow  sound,  which enabled him to inject by means  of  a  small
syringe, the  liquids adapted to  the nature of the disease.   Laforest's
sounds in our times have been modified  by a  number of surgeons.
M. Gensoul  has given them much more length and a  curvature ex-
actly shaped to that of  the nasal canal.  Those  of M. S. Pirondi
are of metal at their extremities, and  gum elastic in the middle.
Those of M. Serre differ only in their curvature from  the  catheters
of M. Gensoul.  With this last form of the instruments,  catheterism
of the nasal canal is in reality very simple, however little we maybe
practised in  it, and modern practitioners are in my opinion wrong in
so entirely neglecting to employ it.
  II.  Physiological variety.—The method of Laforest, like that of
Anel,  has been but seldom used  for the  purpose designed by the
author; but other surgeons have endeavored to combine it with cer-
tain stages  of the operation for fistula lachrymalis.   Heister and
Le  Dran had already become satisfied  that in a large number of
cases, injections in the character of topical  resolvents might render
every  kind  of operation unnecessary.   Briot, for example, as M.
Champion also does, was  still  employing the process  of Laforest
with the most decidedly  advantageous results.  These injections, 
LACHRYMAL PASSAGES.
211
either from above or from below, are in reality remedies that deserve
to be retained.  It is  in  fact obvious,  that by directing medicated
liquids upon the seat of the evil, we must sometimes succeed in dis-
persing it; only that the question arises  whether by processes still
more simple, we should not be enabled  to attain the same object, and
whether substances introduced  through the nose by means of fumi-
gations, as Manget proposed, or by inhalation, would not in the same
manner pass into the syphon of the tears, as Monlac and Louis affirm
they have caused them to do with success.
   C. Dilatation.—When the lachrymal tumor has become ulcerated,
or does not  yield to the processes of Anel, Laforest, Louis  and Le
Dran,  nor to general and local antiphlogistic measures, nor  to anti-
scorbutic and anti-syphilitic treatment, &c, it is admitted that it can-
not be cured except by the operation, properly so called.  It is not to
be forgotten, however, that Maitrejean has seen two fistulas of  the
most serious character at the great angle of the eye get well spon-
taneously ; that Demours rarely treated it by the cutting instrument;
that the ancients, with their extensive battery (tout leur echafau-
dage) of escharotics, styptics and caustics, occasionally made some
cures; in fine, that in our own times we have seen cases recover
which  had. been  treated only by local bleedings and  the soothing
regimen.  This remark is so much  the more important, as we may
perceive thereby that all the different methods have occasionally
succeeded in effecting a cure of fistula lachrymalis.   As this  disease
is of a character to get well sometimes  spontaneously, it is not there-
fore surprising that compression, already extolled by Avicenna, and
for which  J. Fabricius, de La Vauguyon, and Schmidt, constructed
bandages of considerable ingenuity, and that tents of lint besmeared
with an ointment of greater or less activity,  and that leeches and
emollient  cataplasms, should, in a  number of instances, have pro-
moted  the cure.   In November, 1831, an adult man was sent to  me
at La Pitie by Dr. Grenier, in order to be  operated upon for a  lachry-
mal fistula, the existence of which, now of several months' duration,
could be satisfactorily established.   After procuring a canula, the  fis-
tula was found closed up, and when I saw  the patient again, at the  ex-
piration of three months, the cure continued  perfect.   If leeches, or
any other  kind of medication  had been  employed, the cure would
undoubtedly have been attributed  to  them.   In  1836, I  saw two
similar results at the hospital of La Charite, and analogous facts have
been related by MM. Moztehan,  Caucanas, (Journ.  Compl.  des  Sc.
Med.,  t. XXXII.,)  Demours,  and Moulinie", (Bull.  Med. de Bour-
deaux, 1833, p. 138,) as well as by F. de  Hilden, (Bonet, Corps, de
Med.,  394 — 397,)  and  Fichet de  Flechy,  (Observ.  Med.  Chir.,
p. 258.)  Dilatation comprises two modifications : in one we act on
the natural passages ;  the other, on the  contrary, exacts an artificial
opening for the  introduction of the dilating body.   Each of these
methods, moreover, includes quite a considerable number of processes.
  I.  Dilatation  by the  Natural Passages. — a. Process of Me-
jean.—Mejean, perceiving  that the employment of injections, and
the clearing out of the lachrymal passages by Anel's probe, afforded
only temporary relief, proposed to apply to the nasal canal the treat-
ment by dilatation, which had been so long in use for contractions of 
212
NEW ELEMENTS OF OPERATIVE SURGERY.
the urethra.  By means of a fine probe, having an eye at its upper
extremity to receive a thread, this author traverses the parts  in the
manner of Anel, and endeavors to insert the blunt end of the probe
upon its arrival near the wall of the nares, into the groove or open-
ing of  the canula,  (sonde cannelee,) which has been introduced
at the bottom of the lower passage, (i.  e.  by the nose,) in order
to meet the probe, and to  draw  it through together with  the
thread attached to it;  forming afterwards a noose with this species
of seton he  unites its  two extremities around a pin,  which is fixed
into the cap or  hair of the patient.  At the expiration of one or two
days,  two strands (brins) of lint, folded double, are attached  to the
nasal  extremity of this thread, in order  to form a  meche, which
is besmeared with cerate or some other medicated pomade,  and has
another thread  fastened to its free extremity.  The  meche is then
drawn from below upwards  through the nose, and as far as to the
upper part of the lachrymal sac.  Each day it  is to be removed, and
its size increased by  adding one strand more of lint.  To remove it
we have  recourse to the thread which retains it in  the  nose, and
which between  the dressings is to be kept fixed upon the cheek by
means of a bit of court-plaster, (mouche de taffetas.)
  By this process the treatment  requires from two to three, four or
six months, and the cure obtained is rarely permanent.  Out of twenty
patients thus treated there are rarely more than three or four in whom
the disease does not reappear at the expiration of a few months.  The
method of Mejean, moreover, presents two difficulties which are not
always easy to  be overcome.  The  probe often gets  stopped in the
lachrymal sac, and does not reach the nasal canal until after long and
fatiguing trials.   Except we are much practised in the operation, we
have generally considerable difficulty in bringing it under the inferior
turbinated bone, into relation with the groove or eye  qf the canula,
or in getting hold of it  in any manner so as to bring it out.
  b.  Process of Palluci.—Palluci suggested that by introducing a
small  gold flexible canula (sonde creuse)  instead of Mejean's probe,
we might be enabled to pass through  this canula a portion of catgut
so fine, that the patient would drive it out in sneezing, when it could
afterwards be made use of to conduct in the same direction a thread
for the purposes designed in the process of Mejean.  But it is obvious
that this modification complicates the operation of the physician of
Montpellier  in  place  of simplifying it, and that  it must be  more
easy to  make our way through the lachrymal passages by means of
a probe than with a canula.
  c.  Process of Cabanis.—Cabanis, a physician of Geneva, has sug-
gested an instrument designed for  seizing with greater facility Me-
jean's probe  in the  lower meatus, and which is composed of two
palettes made so as to  slide  upon each other.   Being perforated
with holes which traverse the entire thickness  of the upper palette,
but go  only to  a certain  depth  in  the body of the  lower one, this
instrument is first introduced below the inferior turbinated bone,
(cornet  maxillare.)  By means of skillfully combined movements the
probe is arrested in one of the holes of the two palettes united, by
which it is soon securely embraced, (exactement pince.)   Cabanis
also recommends, after having brought Mejean's thread through the 
LACHRYMAL PASSAGES.
213
nose, that its  extremity should be  attached to the end of a flexible
sound covered with gold-beater's skin, in order to conduct this sound
with certainty through the lower meatus into the nasal canal, after
the manner of Laforest.
  d.  M  Bermond  of Bordeaux, who revived  this  suggestion in
1825 and in 1827, has very justly remarked, that in order to apply it,
all that is required is to bring the conducting thread of Mejean to
the outside by any  mqde whatever.  Inasmuch as the  instrument of
Cabanis is not indispensable, and removes only a  part of the  incon-
venience of the process of Mejean, and as the introduction  of the
probe and thread through  the superior lachrymal  punctum, counter-
balances  the  advantages which might result from it for the  subse-
quent introduction of a sound, in the manner of-Laforest, surgeons
have not  adopted these modifications.
  e.  Process  of Guerin.—Guerin of Lyons, having remarked that
a simple thread left to remain in the superior  lachrymal duct, exco-
riates and sometimes lacerates its palpebral orifice, recommended to
bring Mejean's tent as high up as this punctum.   Desgranges, who,
like Guerin, finds it more  convenient to  reach the extremity  of the
probe  through the nose  by means of a  small blunt  erigne, than
with the canula, or the palettes of Cabanis, adopted this suggestion,
which Care  on  his part  has more recently endeavored to render
popular.
  /.  The process of this last physician, according  to what he has
stated to me and  from what I have seen in the practice of M. Bougon,
consists in  passing from below  upwards or from above downwards,
by means of  the instruments of Mejean, a  meche of raw  silk, com-
posed of three, four or six  brands, in order that the same may, while
traversing through the superior  lachrymal ducts and puncture, dilate
them as it proceeds. When it has been passed from below upwards,
one of its extremities is afterwards fastened to the forehead  of the
patient, or in  the contrary case, upon the side of the nose.   With the
remainder of the meche we form  a sort of peloton which is to be
attached  in the hair.  A. Dubois appears to have several  times fol-
lowed this method, which I have also made trial of in  two  instances,
and which differs in nothing from that of Guerin.  Care's meche, by
dilating the sound part only, without acting directly upon the diseased
point of the organs it traverses, deforms and paralyzes the lachrymal
puncta and their ducts.  As I have not understood that experience
has pronounced  in its favor, I  do  not see  any inducement to make
any more trials with it.
  II.  Dilatation by an artificial opening.—When in order to dilate
the nasal canal we penetrate by an artificial opening,  we sometimes
make use of temporary dilating bodies, and at other  times of dilating
bodies that are left to remain in the lachrymal passages.
  Temporary dilatation.—For this kind of dilatation, surgeons make
use of meches of lint, bougies, or metallic bodies.
  a. Meches  and Setons.—1. Process  of J.  L. Petit.—Petit was  the
first who endeavored to  inculcate, that in fistula - lachrymalis  we
ought to exert ourselves to re-establish the natural passage  of  the
tears, much rather than to  create a new one for them.  His method
may be considered as the source of all those that are employed at the 
214
NEW ELEMENTS OF OPERATIVE  SURGERY.
present day.   An assistant placed behind the patient draws the tem-
poral ano-le of the eyelids outwards, in order  to stretch  the parts;
the operator then directs the  point of a bistoury into the  sac below
the direct tendon of the orbicularis muscle, and makes at the great
angle of  the eye an incision of about six lines;  glides in the place of
this instrument a canulated sound, which he pushes with more or less
force into the nose, through the  nasal canal, and makes use  of  it to
introduce a tent  or conical bougie of wax, the upper extremity of
which should  be more or less  dilated  and supported by a thread.
The operation is then terminated.  The bougie is  to be renewed or
at least cleaned every day before putting it in its  place, until the canal
no longer furnishes any evidence of suppuration, that  is to say during
two. three, four, five, or six months.  At a subsequent period, J. L.
Pet*  thought  that  he could   make a substitute for the  canulated
sound, by making a groove near the back and  on  the anterior  sur-
face of the bistoury, which would answer to direct the extremity of
a blunt probe ; but as a special bistoury would be required for each
side, practitioners have generally paid no attention to this  pretended
improvement.
  2. Process of Monro.—The approbation  which  the method of
Petit first received did not prevent some surgeons from recognizing
its defects.  According to Monro it would be imprudent to open the
sac without supporting its external or  anterior wall.   It is for this
reason he proposes to introduce through the inferior lachrymal duct,
a small sound, in order to distend it and to enable him to open it with-
out wounding its posterior walj.  Monro also recommends  we should
force through the nasal canal, by means  of a shoemaker's awl, an in-
strument already mentioned by Guy de  Chauliac, rather than with a
sound ; that by means of the scissors we should prolong the opening
upwardly at the risk of dividing the direct tendon, and that in place of
the bougie of Petit, we should make use of a  small  tent of lint or
catgut.   His precepts have been neglected.  The wounding of the
lachrymal sac posteriorly, besides being easy to avoid by the ordinary
process,  cannot  involve  any  danger,  whatever M. Rougier may
say of it, while that of the tendon of the orbicularis is  in itself a
serious accident.  The employment of an awl  would expose us too
much to be misled, and  to the making of false routes, to render it
possible that it can ever be preferred to the blunt-pointed  probe and
the canulated sound.
  3. Process of Pouteau.—Introduced from  above downwards, the
bougie ultimately produces in  the great angle an ulcer whose borders
are reversed inwardly, and which sometimes leaves as a consequence
a cicatrix which is greatly depressed.   Pouteau having in vain tried
the method of Mejean in a young lady, and not daring to propose
the incision of the sac in the manner of Petit, decided upon passing
his bistoury between the lower palpebral border and the  caruncula
lachrymalis, in such manner  as to penetrate into the nasal canal
without interfering with the skin.  There  resulted from it, says the
author, only a slight ecchymosis,  which itself was owing to his having
made the incision too  narrow.  With the exception of one of the
Pelliers,  but few persons, however, have thought it advisable to imi-
tate his example, though it has  since been  lauded by Leveille, and 
LACHRYMAL PASSAGES.
215
that M. Bouchet has employed it in one instance with success.  The
apprehension has been, that the conjunctiva would be too much irri-
tated.  Moreover, the  inconvenience which Pouteau has proposed
to remedy is reduced to so trifling an affair in the modern processes,
that at the present day it is scarcely regarded.
  4.  Process of Lecat.—Lecat  after having  incised the  sac in the
manner of Petit, made  use of meches of lint, which he introduced
through the nasal canal from above downwards, by means of a cat-
gut, a fine bougie, or Mejean's probe.   In this respect he is the first
who  has endeavored to combine the method of Mejean with that of
Petit; but as his meche also had a tendency to produce the reversion
of the borders of the wound, so much  dreaded, very little attention
has been paid to the precepts that he has endeavored to lay down.
  5.  Process of Canolle, (Memoire sur I'etat actuel de la Chir., par
Montfalcon, p. 118, 1816.)—M. Canolle, when he  thinks a seton  in-
dispensable, inserts a treble cord of a violin (chanterelle) which has
been  oiled, through the opening  of the  fistula, as  far as  into the
nasal fossae.   When the patient feels an itching  at the back part of
his mouth, the surgeon  explores this cavity, seizes the foreign  body
with the forceps and brings it  outside ;  he then introduces a  small
bougie into the nostril corresponding to the  side upon which the fis-
tula is, until he has arrived behind the wall of the  palate; he then
withdraws this also with the forceps and proceeds to tie it to the ex-
tremity of the cord.   He immediately withdraws the bougie through
the nostril, then follows the cord ; it is separated from the bougie, and
a thread attached to its extremity.  The  cord drawn through the open-
ing of the  fistula,  brings  with it into  the  lachrymal passages the
thread to which the seton is attached.
  6.  Process of Desault.—To obviate  as much as possible the  in-
conveniences of the preceding processes, Desault  gives  to the inci-
sion  of the sac only two or three lines of extent.  A canulated sound
is immediately made use of to clear out the narrowed canal; a probe
or a  whitlow sound is then put in its place.    A  small silver canula,
from twelve to fifteen lines long, conical in  shape,  and having a ring
on the side of its pavilion, is brought from above downwards, as  far
as into the nose, by means of the probe  which forms its axis or guide,
and  which is  immediately afterwards  withdrawn.   The thread  is
then  made to descend into it, and the patient forces out its extremity
by making efforts to blow  his nose ; after which the operation differs
in no respect from that of  Mejean.
  7.  Modification of Boyer.—In order to be certain of making as
much thread as we desire descend  through the canula of Desault,
we may, after the manner of Boyer, make  use of a small probe of
three to four inches long, bifurcated below, and terminated above by
a ring ; then afterwards, in order to extract this thread, have  re-
course to  the  little erigne of Deschamps,  the dressing forceps, or
merely make the patient blow his nose.  If neither of these suffice we
abandon it in the nose, when in almost every instance the mucosities
ultimately draw its extremity through at the  end of from  twelve to
twenty-four  hours.   In the contrary case, injections driven with a
certain degree of force through the opening of the lachrymal sac,
would not fail to expel it downwards. 
 216          NEW ELEMENTS OF OPERATIVE SURGERY.

   8. Process of Pamard.—Pamard and Giraud, embarrassed by the
 difficulties of extracting the thread according  to the method of
 Desault,  devised, almost  about the  same  time,  an improvement
 which many surgeons of our day still  make use of.  It is  a small
 elastic stem or watch-spring, terminated by a blunt point (bouton)
 and presenting an eye at its other extremity.  The head of this spring
 is inserted into the  canula of Desault.  Having arrived under the
 inferior turbinated bone, its elasticity naturally carries it sometimes
 towards the opening of the nares, and sometimes under the lobule of
 the nose, where it is easy to secure it either with the finger or the dress-
 ing forceps.   Nevertheless, when the spring is not well tempered,
 and even sometimes when it is perfectly constructed, its extremity
 cannot be disengaged from the inferior meatus of the nasal fossae but
 with a considerable degree of difficulty.
   9. Process of J urine.—In order to leave as little deformity as pos-
 sible in the angle of the eye, Jurine  performed the operation with a
 small trochar of gold, and whose canula is pierced near its point.  It
 is plunged in as far as the nose.   After having withdrawn the stilett
 we introduce Pamard's spring; in other respects  we conform to the
 rules established farther back.  If, in spite of its apparent simplicity,
 this process has not been adopted, it is> because, in reality, it is more
 painful  and less easy than many others.  It will  always be more
 rational to open  the lachrymal sac  with a bistoury  than with a
 trochar.   And then the process of Pamard is preferable to that of
 Jurine.
   10. Process of Fourniers—An ingenious modification of the opera-
 tion of Petit, and which I  am astonished to see omitted in our modern
 treatises,  is  the one which has  been proposed by M.  Fournier of
 Lempde.  This physician proposes we should attach a small shot or
 grain of lead to the conducting thread of Mejean ; drawn down by
 its weight this shot  traverses the canula of Desault, and falls of its
 own accord into  the interior of the nose, from whence the  patient
 readily expels it by merely taking the precaution to incline his head
 forward.  G. Pellier had already, with  the same purpose, made use
 of the end of a leaden sound.
   11. Process of Janson.—M. Janson (Compte Rendu de la Prat.
 Chir. de I'Hotel Dieu de Lyon, 1822, p. 51) anoints the lachrymal
 sac and clears out the nasal canal with a whitlow sound, whose notch
 enables him to direct a catgut into the nasal cavities; he then pro-
 ceeds to seek for this last with a  blunt-pointed erigne; on the second
 or third day he substitutes  for it a silk thread, which serves  to con-
 duct from below upwards a small meche of cotton, the size of which
 is gradually augmented until the cure  is completed.  This process
 has the advantage of leaving nothing to appear outside but the portion
 of thread of flesh color, which, from the great angle "of the eye, is con-
 cealed under the head-dress of the patient.  " It would be difficult for
 me," says the.author, " to relate the number of fistulas operated upon
 in this  manner;  but what we  may  assert as  indisputable  is the
 superiority that may be accorded to it  over every  other method
 whatever."
   12. The editors of Sabatier have also remarked that the combina-
tion of the methods of Mejean and Petit may be effected without the 
LACHRYMAL PASSAGES.
217
array of instruments brought into use by Desault, Pamard, Boyer, and
M. Roux.   What need is there, in fact, of introducing successively
into the nasal  canal, a sound, a probe, a canula, and then a watch-
spring ?   Why not be content to place the thread in the conducting
instrument, and to glide this last into the nose as soon as the lachry-
mal sac is incised ?   The species of spring acting jn the  canula  in
such manner as to transform itself into a hook, which was proposed
in 1806 by M. Benezech, in order to  extract Mejean's  probe  more
readily, would have  no advantage over most of  the  other means
which have been hitherto  pointed out,  and consequently does not
require any farther notice.
  13. Process of Jour dan.—Apprehensive that the whole extent of
the evil might not be laid bare, and desirous of avoiding the cicatrix of
the  integuments, M. Jourdan, imitating  Pouteau,  has  proposed  to
open the  lachrymal sac throughout its whole length, behind the in-
ternal commissure of the eyelids within the caruncula.   M. Vesigne
is doubtless wrong in asserting that it would be generally impossible
to conform to this advice ; but it is nevertheless true that the process
of M. Jourdan offers no advantage  over the others, that it would
incur the risk of wounding the  internal  extremity of the lachrymal
ducts and of dividing the muscle of Horner, and that it would present
more difficulties  than any of those that are in daily use.
  14. Process of Manec.—Should the introduction of the conducting
thread of Mejean still present some difficulties, we might readily sur-
mount them by means of the instrument devised by M. Manec.   It
is a  sort of spear-pointed  sound, introduced through the nose from
below, upwards  into the nasal  canal, and as far  as to the palpebral
angle.  The spear point is  then made to pierce through the anterior
wall of the lachrymal sac, and its eye is made use of to draw the
thread through the nostrils.  What will  hinder this ingenious modi-
fication from  being  generally  adopted, is the difficulty that many
practitioners experience in  penetrating, with any  instrument what-
ever, into the nasal canal through the inferior meatus.
  b.  Bougies  and  Cylinders.—1. Process of Scarpa.—While  in
France they endeavored to give popularity to the seton of Mejean,
the  physicians of Germany, Italy, and England, limited themselves
to a  modification of the method of J. L. Petit.  Scarpa, having no
more apprehension  of dividing  the direct tendon than  his pupil, M.
Luzardi (Journal de Med. de Nancy, 1825, p. 234) has since had,
advises that we  should insert into the lachrymal sac and nasal canal,
which he first cleanses by means of meches besmeared with red
precipitate or nitrate of silver,  a leaden  pin or a species of conical
nail,  terminated  above by a flattened head, arid more or less inclined
downwards, in order that  it may accommodate itself to the form  of
the  inner  angle of the eye. This pin  (clou), which  B.  Bell kept
in for eight to  nine weeks only, ought to  be withdrawn from time to
time to  be cleansed, and reintroduced immediately afterwards.
During the first weeks the surgeon himself attends to this duty, and
injects with warm water into the lachrymal passages before replacing
there the metallic stem, which Scarpa calls the tear conductor.  At
a later period the patient has no need of  any person to attend to the
dressing.   As  soon as the tears flow freely into  the  nose without 
218           NEW  CLEMENTS  OF OPERATIVE  SURGERY.

any obstacle, and that the pin ceases to be  covered with purulent
matter, we may, in fact, dispense with its  employment.  Neverthe-
less, it is advisable to continue it for some weeks longer, in order to
be more certain of preventing a return.  " There are some patients,"
says Scarpa, "who  are  so little annoyed by  it that  they cheerfully
carry it all their lives."
  2. I have seen at Paris  Dubois and  M. Bougon, successfully use
a leaden pin, which only differs from that of Scarpa in having its up-
per extremity merely curved in the form of a  hook, in place of being
flattened like the head of a nail.   After having employed  both I  give
the preference to Scarpa's pin, to which  I allow a length only of ten
to twelve  lines, and to  whose point  I  give a  strong curve, while
others prefer to have this end in an enlarged base.
  3. Process of Ware.—There are those who prefer a silver pin  to
the tent that I have just spoken of.  Ware,  for example, has given
rise to the adoption by many  surgeons  in England  of a silver pin,
which in  other  respects is  in almost every point similar to that of
Scarpa.  After having lauded the canula of Wathen, Ware has  sub-
stituted for it the pin in question, and  maintains that it conducts the
tears into the nose by a sort of attraction.   We thus perceive that the
process of  Scarpa was entirely modelled upon that of Ware.  De-
mours, before having adopted the gold canula, employed  a silver pin
sixteen lines in length and curved into a  hook above.
  4. Process of Larrey.—M. Larrey in  his turn substitutes for these
instruments a portion of  catgut, three to six lines in length, fixed on
a plate or sort of button made of taffeta of flesh color, in such a man-
ner that the whole has considerable  resemblance to the little candle,
known under the name of veilleuse.   This instrument is removed,
cleansed, and reapplied  every morning.  Adherent by its head upon
the skin, and requiring only a small aperture, it is scarcely percepti-
ble at the  great angle of the eye and  causes no  annoyance to the
patient.
  5. Beer,  Scarpa, and  Welter, eulogise  also small bougies or catgut,
but under another form.
  D.  Permanent Dilatation.—-a. Permanent Canula.—According  to
Louis, Foubert  had proposed  to place  permanently  into the nasal
canal  a silver canula about  an  inch in  length, conical in shape, and
terminating interiorly in the form of a spoon.   Bell and Richter bave
also mentioned this  canula on the authority of La Faye, who himself
mentions canulas of gold, silver, or  lead,, left in the canal as a com-
mon practice, and without citing Foubert.  But Louis having formally
censured it, it was  scarcely  any longer  spoken  of by the surgeons
of that time  in  spite of  the  efforts of G. Pellier, who in 1783, gave
himself out as  the  inventor  of it, relating in  his work facts which
plead strongly in its favor.   Pellier moreover  had  modified  it  very
ingeniously.  His^ which is of less  length than that of Foubert, was
made to terminate  above in a border, and presented in the middle
another border;  so that being once introduced it became impossible
for it to ascend or descend.   It does not  appear moreover, that it has
ever fallen  into  complete oblivion.  Distel says that one of  his pa-
tients  carried one for more than fifteen years, and that he took one  of
tin from another which had been in place  for forty years.  I perceive 
LACHRYMAL PASSAGES.
219
also by a thesis sustained in 1802, that at the Hospital of Strasbourg
no other method than  this had been pursued for a long period.   M.
Marchal, the author of this thesis, furnishes nine cases which are al-
together  of a  conclusive  character.   In Germany it was employed
also  by Himly and  Reisinger;  but it had been  almost forgotten in
the schools of  Paris when Dupuytren  recalled  the attention of prac-
titioners to it, by giving it only one border instead of two.  This border,
concave inwards, where it presents a circular groove, is arranged in
such manner, that in order to  withdraw the canula if any accident
requires it, it is sufficient  to introduce into its interior the beak of an
elastic forceps terminated by two little hooks, whose points  turned
outwards readily draw it from below upwards.   I will however add,
that  if Ansiaux is to  be believed, these modifications of the canula
of Pellier had been proposed  by  Giraud even  at the Hotel Dieu,
ten years before Dupuytren used them, and that they were adopted
at Liege  in the year 1806.  In place of presenting  a border in the
middle, that of  M. Brachet has the  second one at the lower ex-
tremity.  M. Taddei has  approached much nearer than  any other
person to the views of Pellier, by recommending that we should place
a  slight  border  below its upper third.  M. Grenier, who considers
that  the  canula only  escapes  in consequence of its ceasing to be
pressed upon in  a sufficient degree by the nasal canal, has proposed
to construct one wrhich  may be contracted when it is compressed,
and which on  the contrary acquires a  larger calibre, like a spring, as
soon as it is left to itself.   In the year 1756, Tillolig considered that
it  would  be advisable  to  withdraw it through the nose at the expira-
tion  of a few months ; while in 1781, Wathen proposed to fix  a
thread to its upper  extremity in order to hinder it from descending,
and  M.  Nicault recommends  that we  should  make use  of a  cone
composed of several  plates of sheet  lead rolled around each other.
Other  modifications still  have been  made to  the canula of Pellier.
Some persons  have  proposed to perforate it with holes, the better to
prevent  its slipping.  M. Bourjot finds  that of Dupuytren too long,
and makes the objection to it, that it ultimately rests upon the floor of
the nasal fossas.  M. Blondlot is in favor of a bellied canula, in order
to dilate  the canal gradually and imperceptibly.   The one that I em-
ploy terminates in a blunt point, and not  like the beak of a pen, which
would expose  it too much to the risk of  chafing the wall of the nasal
canal or  perforating the bones ; but practice teaches us that the  form
of the instrument is not a matter of importance in these cases.
   b.  To introduce the canula we may, after the manner of  Dupuy-
tren, make use of a steel, silver or gold  stilett, a sort of lever  bent
almost into a right angle, the lower portion of which, adapted to the
canula, is bounded by a shoulder more or less prominent, and the handle
of which, while it is more or less flattened, has a length of from two to
three inches.   As soon as the canula has penetrated the little wound,
we fix it  in this point by means of the nail of the forefinger or thumb,
during which the stilett is withdrawn.   The patient is then recom-
mended to breathe out with force, and if the air is driven  through
the angle of the eye, the operation is well performed.
   A  bit of plaster or taffeta keeps the  wound united over the canula,
in  such manner that its cicatrization frequently is completed  as  soon 
220
NEW ELEMENTS OF  OPERATIVE SURGERY.
as the following day.   Ansiaux asserts that before introducing the
canula, it is advisable to clear out the  nasal canal with a sound or a
probe.   An incision having been made into the sac, he introduces a
blunt probe through it as far down as  into the  nose, and  afterwards
makes use of this probe as a stilett to conduct the canula into the
nasal canal, the cleansing of which by means of the proper topical
applications he also recommends, as  Delpech (Clin.  Chir., t. II.,
p. 433) had recommended it to be by cauterization, a practice which
is likewise followed by MM. Bouchet and Lusardi, (Journ. Med. de
Nancy, 1825, p. 235.)  M. Blandino  has revived at Paris the modifica-
tion of the Belgian surgeon, which M. Taddei had also believed  him-
self the author of.   M. Cloquet, who does not leave the canula perma-
nently in, until after having made use of tents during the space of some
days, and M. Chaumet and M. Berard, who previously dilate the canal
by means of bougies or catguts, gradually increased in size, have  also
in these respects, gone farther than Ansiaux.  To penetrate upon the
inner side of the eyelids, as M. Vesigne wishes,  with a view of avoid-
ing a cicatrix, would be truly superfluous, and this assuredly is not a
case for  conforming to the precept of Pouteau.  With  a view of
rendering the  operation still more simple and prompt, M.  Daniel has
contrived a sort of trochar or stilett, terminated in a lancet point, to
carry the canula into the nasal sac in such manner that the operation
is thereby reduced to one stage.  This instrument, which the author
«has shown.to me, and which is applicable to the most simple cases,
would, like that of Jurine, possess the  inconvenience  of not making
a sufficiently extensive incision of the  skin,  of  fraying  out with  too
much  facility  a false route  into the substance  of the walls of the
canal, and of not permitting the employment of means rendered ne-
cessary by a variety of circumstances  difficult  to be determined  be-
forehand.
   c. The canula may be of silver, gold or platina; the  important
point is, that it should  possess  some degree  of solidity, and that it
cannot be easily injured.  Its size and length ought to vary according
to the subject.   It is necessary that it should adapt itself as nicely as
possible to the  nasal canal, and that it  should pass a little beyond the
lower extremity, of that passage.  Consequently we ought  to recall to
mind, that in an adult this passage is from five to eight lines in length,
and from one to two lines in breadth.  It is also  advisable that it
should be slightly concave posteriorly, and on its inner side, and that
its point, if it is cut in the shap  of a pen, should  pass  beyond the
antero-external rather than  th  nasal wall of the canal which it oc-
cupies.
   d.  To  adapt its proportions  to the stature of the patient at the dif-
ferent epochs  of life, M. Grenier has proposed a method which,  as it
appears to me, attains this object with sufficient precision, viz., that
the length of the nasal canal is to be estimated by a line drawn from
the point where the incision is  made in the great angle to the supe-
rior depression of the ala of the nose,  at the union of the lower bor-
der of the nasal bone with the ascending  process of the superior
maxillary bone.
   e. Appreciation.—The use of the canula having been  adopted to
great extent in France, requires in this place that I should examine 
LACHRYMAL PASSAGES.
221
with some  care its importance  and its inconveniences.   Many ob-
jections have  been made against it.  It is, they assert, a foreign
body which, by its presence, causes irritation to the system, produces
cephalalgia and pains in the face and in the nose, erysipelatous in-
flammations, phlegmons  abscesses and ulceration in the great angle
of the eye.   Frequently it makes its way upwards under the integu-
ments, and M.  Darcet  relates  twenty-seven cases where its  ex-
traction became indispensable.   In other cases it falls into the nasal
fossae, and the  operation is, so to speak, abortive.  All  these  incon-
veniences were pointed  out by M. Bouchet  in 1816, and presented
in a correct point of view, in Italy, by M. PI. Portal.  Like Delpech,
(Clin.  Chir., t. II., p. 433,) M. Ouvrard, (Med. Chir.,  p.  265,) Be-
clard, (Clin, des Hop., t. IV., p. 106,) and MM. Cloquet, Bourjot and
Laugier, (Diday, These de Concours, Janvier, 1839,)  I have seen
it pass through into the vault of the  palate.  It  is even said that, in
one instance, it fell into the trachea, and that it became  necessary to
have recourse to tracheotomy;  but this  is a statement  that requires
confirmation.   The canula may  also get involved in the  sinus max-
illare, (Ouvrard, Med. Chir. 265,) or into the substance of the alveo-
lar border.
   Mucosities and powders  that many persons put in their nose, ulti-
mately obstruct it and  close up its orifices.  Finally, when we  are
obliged to  extract it, we find  ourselves under the necessity of per-
forming an operation more difficult than that of the fistula lachry-*
maris itself.  If the instrument glides between the maxillary bone and
the soft parts of the face, instead of passing into the nasal canal, as
I have seen it do in two instances, it will cause symptoms more or
less serious, without having the slightest beneficial effect upon  the
fistula properly so called.   The  same result takes place if we force
it into  the neighboring  sinus, or  get its  point entangled in the walls
of the canal, or if it descends between the bones and the membrane
of this passage, or in a wTord, if it does not exactly follow the natural
channel of the tears; it is also clear that a large canula cannot be
conducted  without danger through a canal which is too narrow,
and  that if we insert  a  small one into  a very large canal  the
operation will equally fail of success.  In answer to these objections
I may reply:  it is for the surgeon  to be prepared to avoid these
different mistakes, or at least when he  commits them not to throw
the blame  upon the operative process.   In the other methods it is
necessary to renew the  dressing every day for several months,  and
there are none of them that have not equally caused cephalalgia,
erysipelas, &c.   By the process of Dupuytren  some  seconds only
are required to terminate the operation.   The patients are cured al-
most as soon as they are operated upon ;  no dressing, and no particu-
lar care is necessary ; most of the patients immediately after resume
their customary occupations without thinking that they carry a canula
in the great angle of the eye.  We obtain in this manner from twelve
to fifteen cures out of twenty cases.  A young woman who had the
canal so narrow that in order  to introduce a canula  of very small
diameter, I was obliged to employ  a very considerable  degree of
force, got well, however, after a slight degree of  cephalalgia, during
the space of three days; I was, so  to speak, obliged to pierce (tarauder) 
222
NEW ELEMENTS OF  OPERATIVE SURGERY.
the canal in order to force in a canula in a young man aged twenty-
one years, who, nevertheless, was re-established in  his health on the
following day ;  I kept him at  La Pitie,  and no accident supervened.
The worst that can happen after all is, that we may be obliged to
withdraw the canula;  for that purpose we have to find  the upper
opening  of the  nasal canal, and  to seize hold of the foreign body
with a small  pair of forceps.   When any difficulties are encountered,
the stilett of Dupuytren  with a  double hook, the  little hook of M.
Cloquet or M. A. Stevens, or better yet, the stilett  of Caignou, with
a  double spur, will readily overcome them.   We may also make
use of a dissection forceps, one of whose extremities has been made
to terminate  on its inner side by a small curved point.  With  one of
these instruments, the  beak  of which is placed in the groove  of the
border, or  equally well below the point  of the canula, we  readily
bring it out by making it follow the route which it had already pissed.
Up to the present moment I have removed this instrument a great
number of times, and the dissection forceps ordinarily have, in most
instances, sufficiently  answered  my purpose.   We  will  remark,
moreover, that after the extraction of their canulas, patients  are ab-
solutely in the same condition as those who would have been  treated
during the same  lapse  of time by the dilating method of Petit, and
that many then find themselves radically cured.  In two patients the
canula, which had descended more than half its length into the nose,
could not be  seized hold of through the lachrymal sac.  An ordinary
probe bent into  a hook, and  directed underneath the inferior turbi-
nated bone, enabled me to  extract the canula through the  nostril.
I have also seen that the canula no longer existed  in many persons
who believed they still  had it, and  in whom the fistula or the tumor
had become re-established; for it does in fact often disappear without
the patient being aware of it.  I have  seen surgeons give  up the
idea of extracting it from the impression, as I myself have been in
two instances, that it  had become incrusted  in  the  bones.   If we
perceive nothing  in the nose, if the canal is  free and  we strike
against nothing above, the canula no longer exists there ; it is useless
to look for it.  In conclusion, therefore, the canula is not applicable
to all cases.  When the nasal canal has deviated from its  normal
direction, has become narrowed in one part or in another in con-
sequence of an exostosis, and its walls are greatly approximated (res-
serre) and indurated ;  when it contains ulcers or is  the seat of lesions
of a still more serious character, it is better to recur to  the seton oJ
Mejean, or to some other  process  better adapted to the case.
  Enlightened by a longer experience, I  am in  fact at the present day
obliged to admit that cures by the  canula are infinitely less numerous
in reality, than I had at first supposed.  The error into which many
practitioners  in this respect have fallen,  is owing to the greater num-
ber of patients, under the  belief that they were cured on the day af-
ter the operation, or the day after that, have not afterwards.been seen
by tbe surgeon.  Desirous to know what had become of them, 1 have
followed them up or caused them to be followed up as much as could
be done. I have by this means ascertained that the  canula very often
ascended into the lachrymal sac during  the first four months ;  that, in
a great  number of cases, it escaped through the nasal fossas before 
LACHRYMAL PASSAGES.
223
the ternination of the second year; that those that remained in their
place, became changed, dissolved and destroyed, to such extent as to
be of no value;  that they sometimes break, (Champion, private cor-
respondence, 1839,)  become sometimes filled up by a sort of blackish
colored putty similar to sulphuret of silver, sometimes by stony or
sandy concretions ;  at other times  by lymph, concrete  mucus,  mem-
branous folds, &c, in such manner that at the end of two or three
years, for example, there are  few patients who remaining cured  pre-
serve it unaltered in the nasal canal; that it merits in fact almost all
the objections  that Ware makes against it.   It is, moreover, in fine,
one of the most uncertain remedies that surgery possesses.
  f. Operative Process.—Whatever may be the method that is pre-
ferred in operating for fistula lachrymalis, there is one stage which at
the present day. every body performs  nearly in the same manner ; I
mean the opening of the sac  and the  catheterism of the nasal  canal.
an order to arrive with  the greatest certainty possible into the  canal,
the operator causes the  eyelids to be stretched by recommending to
the assistant to draw them towards  the temple.  With  the forefinger
corresponding with the  diseased side, he seeks in the great angle the
anterior lip of the lachrymal  groove.  After having forced out by
slight pressure the mucosities  (Vempatement) of this part, should any
exist, he provides himself in his other hand with a straight, solid and
narrow bistoury, the  point of which  he directs behind the angle of
the forefinger in  order to plunge it obliquely inwards, backwards and
downwards.  Having thus arrived  in the  sac,  he immediately  raises
up  the handle of the instrument towards the top of the eyebrow,
(la tete du sourcil,) in order to descend perpendicularly into the nasal
canal.   He then  takes a stilett armed with the canula, if he wishes
to follow the method of Foubert;  a  canulated sound  or a probe, if
he  proposes to imitate  Petit or  Desault,  and directs the extremity of
one of these instruments upon the back or anterior surface of the bis-
toury in such manner that  this  last, in coming out, serves as a con-
ductor to the other.   When  the opening of the fistula  is sufficiently
large to permit the passage of the canula or sound, the bistoury is not
indispensable.   In other cases we sometimes comprise the ulcer in the
incision,  sometimes leave it  above, below or  to the side ; in  other
cases we pay no attention  to it: if it is surrounded with fungosities
and that they are troublesome, we in the first place remove them, and
afterwards  proceed according to the usual rules.  When we wish to
penetrate into the nasal canal from below upwards, that is  through
the nose, the  operator holding the  sound like a writing pen,  with its
concavity turned downwards and outwards, introduces it into the
nostril to the depth of about an inch: now raising a little the  pavilion
of the  sound, in order that the  apex of this instrument  may  arrive
under the inferior turbinated  bone and glide upon the nasal  wall, he
gently draws it forward to the distance of  six or eight lines from the
opening of the nostril.  He then turns  its concavity little by little out-
wards and upwards ;  then by an oscillatory movement skilfully man-
aged, he endeavors by feeling about to make its beak penetrate into the
orifice of the nasal  canal'.  We thus arrive without  any very great
degree of difficulty as high up  as to the  angle of the  eye or even
into the lachrymal sac.  Force is never required in these cases.  Re- 
224
NEW ELEMENTS OF OPERATIVE SURGERY.
sistance can happen only from the bad direction given to the instru-
ment  or some anatomical peculiarities.  In inclining  the sound  too
much downwards, upwards, inwards, or outwards,we force its apex
against the opposite wall or the periphery of the lower orifice of the
canal.   The efforts which would then be made, would lead to no re-
sult except that of penetrating into the sinus  maxillare or orbit, or
that of fracturing  the  inferior turbinated bone, which might be so
low down and so strongly incurvated that its free border almost im-
mediately touched the floor or the outer wall of the nose,  and thus
transformed the lower orifice into an actual canal.
  D.  Cauterization.—Before the  channel of the tears was  perfectly
understood fistula lachrymalis was treated by injections, or by tents
or meches of lint introduced into the  lachrymal sac,  and especially
by the application to this part of escharotics and  actual  caustics.
These different  methods are already described with a sufficient de-
gree of clearness in the works of the Greek physicians, those of the
Arabs, and the authors of the middle ages; only that it was under
the same character as the treatment of every other  fistulous ulcera-
tion.  The ignorance  which then existed  in relation to the  anatomi-
cal arrangement of the lachrymal passages did not  allow them to
consider it in other  point  of view.   What Guy de  Chauliac says
of it  proves  that Sprengel was deceived  in attributing  to the
ancients  the idea of injections of the nasal canal.  For more  than a
century mention had  scarcely been made of cauterization,  when, in
1822, M. Harveng proposed to create by it a new method  of treat-
ment.   It  was  immediately recollected  that  the nasal  canal was
somewhat analogous  to the urethra, and that its contractions might
possibly  be  submitted to the same kind  of  medication.  At the
present day we have two modes of performing cauterization  of the
lachrymal passages :  in one we cause the cauterizing  material to be
inserted from above downwards, while in the other it is introduced
through the nasal fossas.
   Through the Lachrymal Sac.—1. Process of Harveng.—M. Har-
veng proposes that after having opened the lachrymal  sac, wTe  should
introduce through a canula a cautery heated to a  white heat, or a
meche besmeared with nitrate of silver upon the contracted points of
the nasal canal; that we should repeat this one or more times accord-
ing as may be  required ; that we should  proceed in  fact as  in the
treatment of affections of the urethra by Ducamp.   According to M.
Vial, whose thesis did not appear until 1824, Mortier, of Lyon, had
a long time since promulgated the same idea, which  is  also attributed
to M. Janson, and which M. Taillefer, who also believed himself the
author of it, revived  in  1827.  But it is in reality a mode  of treat-
ment  which is very  ancient, since Heister had already advised to
touch the nasal canal with nitrate of silver.  Formerly  it was adopted
by many practitioners.   G. de Salicet  made  use of the green oint-
ment  (onguent vert).   G. de Chauliac, who prefers  the red-hot iron,
proposes that we should protect the eye during the operation either
by means of a  canula, as Alcoatin  does, or  with  paste,  as Jesus
recommends, or by means of a silver or brass spoon, as practised by
Theodore.
  2.  Process of Deslandes.—In the  month of May, 1825,  M. Des- 
LACHRYMAL PASSAGES.
225
landes published another process to effect the same object.   An ordi-
nary probe is first introduced into the nasal canal in order to remove
any obstructions and  to clear out a passage  for the caustic-holder;
we then glide in its place a second instrument of the same form, hav-
ing two  parallel  grooves upon  its vertical  branch, and which are
filled with melted nitrate of silver * this is then turned on its axis in
order that the whole circumference of the canal may  be cauterized,
which finishes the operation.
   Through  the Nasal Fossa.—I heard  in the year  1824, that  M.
Gensoul, whose labors were published at a subsequent period, dis-
pensed with the opening of the great  angle  of the eye, and that he
applied the  nitrate of silver through the lower orifice in the  nasal
fossas.   M. Bermond, of Bordeaux, in 1825 inserted in the Journals
a memoir on the same subject.   M. Valat made some mention of it
in his thesis, in 1826, and  M. Ratier, who, without doubt, was una-
ware of these different attempts, announced, in 1828,  that he hoped
to apply the method of Ducamp to the treatment of  fistula lachry-
malis by penetrating  through  the  lower orifice of the nasal  canal.
   These different surgeons first proposed to ascertain the place, form
and  extent  of  the disease; then to .direct the caustic upon it with
certainty and ease.   In penetrating by the great angle of the eye,
as is recommended by Mortier and MM.  Harveng and Taillefer, the
operation ought not to be attended with any difficulty; by the other
method, on the contrary, we must-begin by making ourselves familiar
with the process of Laforest.
   3. Process of Bermond.—After having brought the conducting
thread of Mejean outside  through the natural passages  and without
any  previous incision, M. Bermond without  paying any attention to
the ulceration of the great angle fixes the thread to the noose of a
meche besmeared with wax, which  he then draws into the  nasal
canal in order to receive the  impression of the diseased surface
(l'empreinte du mal).   By means of the thread which is attached to
the free extremity of  this species of bougie, he draws  it out through
the nose, and puts in  its place a tent  made  of some  strands of lint
covered with a solid paste, and  rendered caustic in the part which is
to correspond to the contraction.  This  process has but one  incon-
venience, that of requiring the previous introduction  of a thread
through the lachrymal punctum, duct and sac.  We  perceive that
it is  the seton of Mejean rendered caustic ; but it might evidently
be simplified if, in place  of following exactly the natural passages,
as the surgeon of Montpellier does, we adopted the precepts of Petit
and  all the  moderns for managing the conducting thread.
   4. Process of Gensoul.—A small catheter having a curvature  ex-
actly similar to that of the passages into which it is to  be introduced,
is first directed under  the inferior turbinated bone and as high up as
into  the nasal canal, in order to verify the seat of the  disease, which
is immediately  after  attacked  with  a caustic-holder  charged with
nitrate of silver.   More than three hundred patients have been treated
in this manner by M.  Gensoul, some with the  most perfect success,
others with  only partial results, and  many without any advantage
at all.   In  order  to give  to his stilett and canulas the form that is
most convenient, he has taken the exact impression of them by means
                               15 
226
NEW ELEMENTS OF OPERATIVE SURGERY.
of the fusible alliage of Darcet.  Instruments improved after these
principles were shown to me in 1825, by Dr. Blanc, and I was really
surprised to see with what facility they could be introduced into the
tear duct.
  Appreciation.—In proposing to cauterize the nasal canal, the sur-
geons whom I have just named have had no other object in view than
to apply the method  of Ducamp to the lachrymal passages.  It is
true,  that if cauterization  is applicable to the contraction of  the
urethra, it may also be  so for the diseases of the nasal canal;  but
it appears to me that in the two cases, that neither the action of  the
medicament that we employ nor the nature of the affection  that  we
propose to destroy, have in all cases been clearly understood.  Like
those of the urethra, the contractions of the nasal canal are usually
kept up by a chronic phlegmasia more or less extended, or more or
less accurately circumscribed.  In no case could fistula lachrymalis
have ever originated from the spasmodic contraction, mentioned  by
Janin, and to which Richter  has  given so much  importance.  Nor
does the affection of the eyelids, mentioned by  Scarpa, become the
source of it except by propagating itself to the lachrymal sac and as
far as into the  nose, where it causes an engorgement and obstruction
of the mucous membrane wThich may produce an obstacle to the pas-
sage of the tears.   In other words, lachrymal fistula and tumor de-
pend upon an  induration and thickening or a simple chronic phleg-
masia of some portion  of the lachrymal syphon :  but  in applying
nitrate of silver on organs  that  have been thus changed, it is  not
by producing eschars there and in burning them that we cure them:
but it is  by dissipating  the inflammation, and  by neutralizing and
destroying the stimulus and the germ (epine) which keeps it up, and by
bringing about the resolution of the morbid engorgement.  It hence
follows that nitrate of silver is the only caustic which can be reason-
ably employed, and that those impressions which  have so much
occupied the attention of practitioners are in a measure useless; that
the principal object is to make the caustic arrive in the upper part
of the nasal canal when we introduce it from below;  and near  its
lower extremity, on the contrary, when we follow the opposite route,
in order that we may make it act upon almost the entire extent of
the passage.   All the precautions, moreover,  that  we might take
in order to prevent this general action would not attain our purpose.
As  soon as the nitrate  of silver  is in  contact with the living and
moist tissues, it melts and soon diffuses itself in such manner that it
is only necessary in the nasal canal to touch a single point to ensure
that all the others shall immediately feel its influence.  What I here
say of cauterization I might apply equally well to dilatation.   When
a meche or a solid stem  is  kept either  temporarily  or permanently
in the nasal canal it cannot in my opinion be of any service, except
in two ways :  1. By transmitting  to the affected surfaces medicated
substances that are calculated to destroy the disease ; or, 2. By com-
pressing  from within  outwards  the whole circumference of the
altered passage.   In these cases we cure not by dilating, but in fact
by an actual resolvent  compression, in the same  way as we cure
oedema, certain eruptive diseases, erysipelas, &c.
  E.  Establishment of a New Canal.—We find in Aetius and Paul 
LACHRYMAL PASSAGES.
227
of Egina, that Archigenes  had already pierced through the os un-
guis  with a drill, in order  to  compel the tears or matters to pass
into the nose.  Sabor  Ebn-Sael, quoted by Rhazes and Avicenna,
also eulogizes this resource, which is censured by Mesue.  We have
every reason to  believe that Abulkasem, Roger, and  the  Alcoatin
mentioned by Guy de Chauliac, who all applied the red hot iron on
the os unguis, effected the same purpose.   Certain it is that their pre-
decessor Celsus speaks of the extirpation of the sac and  cauterization
of the os unguis as a usual practice, and that G. de Salicet advises
when the bone is diseased to cauterize it in such manner as  to allow
the tears to run into the nose, and that'this also was the method of
J. de Vigo.   Almost entirely forgotten for many centuries, this me-
thod was again brought into repute by Woolhouse.  It is the only,
or almost the only method of treating fistula which was employed
up to the time of Petit and Mejean.
  1. Process of Woolhouse.—The operator makes at the great angle
of the eye  a semilunar incision which  includes  the tendon of
the orbicularis muscle, opens freely into the lachrymal sac, or even
according  to Platner or M. Malgaigne  extirpates  it, and lays bare
the os unguis; he immediately fills the wound with lint  and  does not
finish the operation until at  the  expiration of  twenty-four hours, or
even two or  three days, in order that he may be no longer embar-
rassed by the blood.   A sharp  probe is then plunged from above
downwards, from without inwards, and slightly from  before back-
wards, as far as into the nasal fossas, through  the lachrymal groove
or lower part of the  os unguis.   A meche of lint or small conical
canula is afterwards introduced into this opening in order to prevent
its closing; then after its borders are cicatrized and become callous,
we introduce a gold canula, which is a little contracted in its middle
part, in order that it may not escape either inwards  or outwards, and
that we may leave it there permanently.
  2. Process of St.  Yves.—Saint-Yves, who  had remarked  that
the process of Woolhouse was almost constantly  followed by ero-
sion or reversion  of the eyelids, perceived that this inconvenience
might  be avoided by respecting the tendon of the orbicularis mus-
cle in making the incision at the  great angle of the  eye.  He more-
over prefers like Guy  de Chauliac to perforate  the os unguis with
the actual cautery, in order to obtain an actual loss of substance.
  3. Process of Dionis.—Lacharriere, Dionis,  and Wiseman, also
recommend the  employment  of the hot iron, which they  apply to
the internal  wall of the lachrymal sac  through a protecting  canula
made in form of  a funnel, the  first idea of which funnel appears to
go back as  far as Alcoatin.
  4. Process of Monro.—Scobinger, Monro and Boudou made use of
a trochar for the perforation of the bone, and had less apprehension
than Woolhouse  of wounding  the ethmoid.   Ravaton  believed that
he could arrive  at the same  result by means of a "curved forceps
with which  he fractured the os unguis to a considerable extent, fol-
lowed by a leaden canula.  But  none of these  methods can  be fol-
lowed by a  perfect cure,  " for very soon- after the aperture of the
bone fills up," says Guy de Chauliac, " and  nothing can any longer
run into or  pass off by  the nostrils."  Whether the artificial opening 
228
NEW ELEMENTS OF OPERATIVE SURGERY.
is kept free by means of a meche, or tent, or by a canula analogous to
that mentioned  by Platner, or a little dilated at its two extremities,
like that of Lecat or Pellier, or still shorter or more contracted, like
that which Dupuytren used, for example, in the  treatment of Ranun-
cula, or by the hooked forceps of Lamorier, &c, it nevertheless almost
immediately afterwards closes up;  and it is rare that the contracted
canula  of Woolhouse  keeps  a sufficiently long time in its place to
render the new passage permanent.
  5. Process of Hunter.—Hunter  believed  that he  could succeed
better by carrying away at oiic§ a disk of the os unguis, and the two
membranes between which it is placed, in  such manner as to form
there a circular opening from one to two lines in diameter.  To at-
tain this object, he devised two particular instruments:  1. A species
of cutting canula similar to  the punch of harness  makers.  2.  A
plate of horn or ebony curved in such manner that it could be intro-
duced into the middle passage  of  the  nasal fossas, and destined to
serve as a point  d'appui to the punch, while we were acting with the
latter from without inwards through the opening of the great angle
of the eye.  We thus obtain a neat perforation,  which only requires
to be dressed with a meche of lint  to  cause its borders to cicatrize
and become rounded and callous.  As  it is almost impossible to ap-
ply the nasal plate, and as the perforation with the actual cautery is
also accompanied with a  loss  of  substance, without thereby ren-
dering it always successful, no person, with the exception perhaps
of MM. Talabere, Rougier, and Janson, who made use of it twelve
to fifteen times, and who censures it, have undertaken  the operation
of Hunter on living man.   If however it should be desired to make
trial of it, we could easily accomplish  it by means of the compass-
punch of M. Talrich, or the  trephine  of M. Montain.   The perfo-
rated branch of the first of these instruments having been introduced
into the meatus, would serve  as  a  point d'appui to  the perforating
branch, which is applied at the great angle of the  eye exactly through
the  wound of the canal.   All that is necessary after, is to press one
branch against the other, in order to remove  the portion of bone de-
sired without incurring the risk of making a mistake.
  6. Process of  Scarpa.—In our  day, Scarpa  and  others have re-
turned to the employment of the  actual cautery,  in conformity to the
views of St. Yves ; that is to say, that after having opened  the great
angle,  as in the  simple operation  of fistula, without touching, and
even at the risk of wounding the direct tendon, they fill the wound
with lint, leave it there  in  this manner during twenty-four hours, or
even more, and afterwards direct upon the lower and inner part of
the  lachrymal sac, a metallic stem heated to a white heat, with which
they penetrate into the nose.  In order to protect the eye and sur-
rounding soft parts, Scarpa no longer used the simple funnel of Ver-
duc or Dionis, but a conical canula  with very thick walls, and which
supports a handle several inches long, which is united with its base
at a right angle ; which canula, figured by Scultetus, and rescued from
oblivion by Manowry, is one which  Desault also used in practice, and
the first idea  of which  is  found in  Roger de Palmer or in Alcoatin.
Rivard and A. Petit recommend that we should  open the sac behind 
LACHRYMAL PASSAGES.
229
like Pouteau, and not in front of the eyelid, whether we propose to
penetrate into the nasal fossas, or intend to stop at the canal.
  7. Process  of Nicod.—At a more  recent  period Nicod has pro-
posed to combine together in this method perforation by means of
the trochar, and cauterization by means of the  hot iron.   In a patient
whose nasal canal  was entirely wanting, Dupuytren by means of a
drill, as recommended by Wathen, made  another in the direction of
the natural channel, then  kept it open by  placing a canula there per-
manently.
   8. Process of M. Laugier.—Briot having  noticed that M. P6cot
had, in spite  of himself,  penetrated in one instance into the antrum
highmorianum,  and having himself,  on another occasion, penetrated
through the os unguis into the  nasal passage, has furnished the proof
that fistula may be cured in this manner, since the affection did  not
reappear in the two patients whom he mentions.   This certainly is
better than nothing, but I doubt i£ notwithstanding the reasons, and
some facts mooted in its favor by M. Laugier, who,  transforming
this accident into a rule, has proposed to  penetrate, at the  very first,
into the maxillary sinus, and  to leave a canula there permanently,—I
doubt, I  say, if such a  method can ever have numerous partisans.
Nothing, in fact,  proves that the tears, having arrived in the sinus,
could  make their  egress from thence with facility, that they would
not produce  accidents, or- that it would be  easy to make an exit
for them by piercing the vault  of the palate.   The perforation of the
os unguis would have still fewer inconveniences.
   9. Process of Warner.—Warner, desirous at all hazards of obtain-
ing a permanent opening for the passage of  the tears into the nose,
destroyed  the  os  unguis extensively, whether carious or not.   In
union with the  extirpation of the sac, eulogized by Woolhouse,  and
which M. Jameson has again  proposed  in our times, the process of
Warner has been reproduced by M. Gerdy, since the principal object
of this surgeon is to destroy the entire inner wall of the nasal canal.
   10. Appreciation.—If, as I with so  many others have  had it in
 my power to testify, the  treatment of lachrymal tumor and fistula by
 setons, the canula  and caustics, will succeed in nine cases out often,
 the process of Woolhouse, already rejected as useless by Marchettis,
 Solingen, Maitre  Jan, and  especially by the Nannoni, would in our
 time  no longer be worthy of  consideration.  So long  as it is possi-
 ble to act on the natural  passages, we should, by this hypothesis, be
 censurable in  attempting  to create  a  new one;  in  the contrary
 case, it would be more rational to imitate the conduct of Wathen, or
 pierce through the  track of the nasal canal, like  Dupuytren, than confine
 ourselves to the perforation of the os unguis or sinus, as after the man-
 ner of Saint-Yves  or M. Laugier. Should there be necrosis, we ought
 then  to treat the fistula by one of the other methods, for the disease
 of the bone requires no other  care than it does when situated in any
 other part of the body.  The employment of the actual  cautery or
 chemical escharotics is  not without its danger, when they are  car-
 ried  so  near the  eye:  they  have, more than in one  instance,  pro-
 duced obliteration of the lachrymal ducts,  and  by this means an
 incurable epiphora.   What would  seem to deter still more from the
 method of Woolhouse is this, that the tears rarely acquire the habit 
230
NEW ELEMENTS OF OPERATIVE SURGERY.
of falling into the  nose, even though the passage which has been
opened for  them should remain free, (beante.)  " As to the mode
of cure," says  Guy  de Chauliac,  "by  piercing through the nasal
channels by means of an awl, it is not approved of by Heben Mesue,
and I have  not  found it effectual, for immediately afterwards the   [:
aperture through the bone fills up, and there is nothing which can
run through it or flow into the nose;" so that, besides the deformity
which it makes at the great angle of the eye, the patient is left with
an epiphora, (larmoiement, weeping  eye or delachrymation,) which
is, in most  instances, beyond the resources of art; but in my view
it is demonstrated, at the  present day, that we  have very often de-
ceived ourselves on this point, and that we are more than ever justi-
fied in still attempting new trials.
  F.  Closure  of the Canal.—In the  midst of this labyrinth of me-
thods or processes,  there is one, perhaps, which  has not been exam-
ined in a correct point of view;   I mean cauterization.  Everything
authorizes us to believe  that practitioners, like Severin, (Med. Effic.
Exopyrie, p. 656,) and Scultetus, (Arsenal de Chir., tab. 34, p.  190,
1712,) among others, who had  so  much confidence  in the red hot
iron and escharotics, rarely cured fistula lachrymalis but by obliter-
ating  the nasal  canal.  This  obliteration,  which was proposed by
L. Nannoni, was systematized into a method by Delpech,  and M.
Caffort  of Narbonne  has written to me that nine patienis who were
treated in this manner were all cured.  A piece  of  nitrate of silver,
as large as a bean, is deposited in the upper part of the canal, while
the sac is also cauterized at the embouchure of the lachrymal ducts.
The operation is repeated three or four times in the space of twelve
days,  after which we  make use of simple dressing.   A hard cord is
formed in place of the lachrymal  passages,  and no epiphora follows!
It appears also  that Bosche, who cauterized the lachrymal puncta
with the the view of shutting them up, had no apprehension from this
obliteration;  and that M.  Malgaigne, like Anel, Gunz, Petit,  and
Demours, has  seen instances where the lachrymal ducts were want-
ing, and where there was  no  epiphora produced.   If such were the
fact, a very simple method might be substituted for all those which
have  been in  vogue  up to the present time.   The excision of the
puncta lachrymalia would  be  all that would be necessary.  I have
performed it in two instances,  but I can a§ yet give no statement of
the result, except that the tears, notwithstanding, penetrate  into the
nasal  canal, and that I have  not been  enabled to obliterate in this
manner the  lachrymal ducts.  Cauterization, in the manner of Del-
pech  or  M.  Caffort, was not successful in the three cases in  which I
used it.  In  conclusion, I am of opinion that there remains at the bot-
tom of this subject, a question  of  physiology and therapeutics which i
has to be examined.
  G.  Anomalies.—However distended  the sac may be, it rarely
happens  that we are  obliged  to  follow  the precept of Boyer, and i  i ,
excise a portion of it,  or to have recourse to compression, as Guerin i  i ,
recommends.  Cauterization with the nitrate of silver, as advised by '  '
Scarpa, would evidently be preferable in the majority of cases.
  Excision, however, is a practice which we should be wrong in reject- ■  ■
ing absolutely.   If it is true  that we may  in reality dispense with it, it t  t 
LACHRYMAL PASSAGES.
231
is also true that it  may, in  some cases, abridge the period of cure.
I have, in four cases, deemed it advisable to recur to it, and have
been very well satisfied with it.   The tumor, which was half the size
of a nut, was of long standing, and with walls very much attenuated.
After having  laid it open freely from above downwards, and seized
one of its sides with the forceps, I removed from it, by one cut of the
scissors, an ellipse of four lines in breadth.   The cyst, which in these
cases is reflected as it were upon  the anterior  surface of the direct
tendon, is only in part formed by the lachrymal  sac; so also may
we remove a  large portion of it without wounding the tendon of  the
orbicularis muscle.  In place of opening into the  great angle of the
eye, the lachrymal tumor has sometimes made its way into the nostril
through the os unguis, an example of which is given by Heister.  In
internal fistulas, it is not the re-establishment of the course of tears
which is the important point, but the ulcerous affection which is to be
arrested or cured.  If there should exist a tumor,  though the lachrymal
ducts and puncta were closed, we should have no  other treatment to
oppose to them  than that of abscesses  or chronic inflammations.
Compression at first, or resolvents and astringents, and then a cut of
the bistoury into the cyst,  and the employment  of meches or deter-
gent injections, would be  all that there was  to be done, unless  we
should  incline to leave a canula remaining in  the nasal  canal.  In
certain persons the osseous canal is so small that we are obliged to
employ force, and even a very considerable degree of force, in order
to effect the entrance into  it either of a canula  or any foreign body
whatever.  The contraction which I have here reference to, is most
usually met with in adult  individuals  who  have  been affected with
lachrymal tumor or fistula from their infancy, and is not to be con-
founded with that which depends upon an exostosis, or a deviation
of the  bones, &c.; it is owing as I  think to this, that the  canal
ceasing to furnish a passage to the tears, no longer grows, and  un-
dergoes a suspension  in its development, which  prevents it, at a
later period,  from being in relation with  the  rest  of  the organ-
ization ; it is  in  fact  the  canal of a child  in the orbit of an  adult.
If the explanation which I give of this fact be correct, we  should
be prepared to meet  with still more difficulties for the insertion of
the canula in persons  affected  with fistula lachrymalis  from  child-
hood, than in others.  I  have operated  in five instances under
this condition of things.  A young man twenty-three years of age,
who had been affected with a double lachrymal tumor from the  age
of eight  years, and who died at the Hospital of  La  Pitie in  1834,
enabled me to ascertain, by dissection, the  existence of this species
of contraction.   Monro and M. Lenoir appear to have noticed similar
facts.  It is moreover quite natural, that not only  fistulas from  child-
hood, but also very old fistulas should, in general, be accompanied
with a contraction of the  osseous  canal, if it is true  that the tears
then cease to  flow  into  the nose.   Since the  alveoli,  like  other
osseous cavities, shrink (s'affaissent) when they have been deprived
of the bodies by which they were accustomed to be occupied, we
may without difficulty conceive that the nasal  canal would have a
tendency to contract, should it remain a long  time without giving
egress to the  tears.                 £ 
232
NEW ELEMENTS OF OPERATIVE SURGERY.
   In other persons I have found the nasal canal greatly dilated, and
 in  the form of a funnel  at its upper  part.  This result, which is
 owing to the  protracted distension of the sac properly so called,
 prevents the canula from remaining in  its place but with great diffi-
 culty, causes it to mount up towards the forehead, or to fall almost
 inevitably into the nasal passage, at the expiration of a few weeks,
   [The extirpation of the  lachrymal gland for the  cure of fistula
 lachrymalis, was performed with  partial success in 1843,  (Revue
 Med. de Paris, December,  1843,) by M.  P. Bernard; the weeping
 mqisture, however, continued.  This operation had been suggested
 for the disease in question by MM. Nannoni and  Biangini, and has
 also been performed  in extirpating the globe of the eye for cancer,
 (see Arch. Gen., Avril, 1844, pp. 501-503.)  M. Bernard found the
 gland hypertrophied.   T.]

                     Article  III.—Eyelids.

                        §  I.—Ectropion.

   Two causes may lead to the reversion of the eyelids outwards,
 the protrusion (boursouflement) of the conjunctiva and the narrow-
 ing (raccourcissement) of the skin.  This last condition, or ectropion,
 properly so called, is  the most serious.
   A. Ectropion from exuberance of the  conjunctiva.  This first case,
 which  is generally the  easiest  of cure  and the most rare that we
 meet with, presents itself under the acute stage or in the chronic
 form.
   I. If the malady is  recent, cauterization, which  had already been
 recommended by G.  de Salicet, by means  of a particular kind of
 cautery, will ordinarily suffice.   M. J.  Cloquet has in this manner
 effected the  cure of  an ectropion  of  the  conjunctiva, which had
 existed more than a year.  Saint-Yves and Scarpa particularly eulo-
 gize nitrate of silver in such cases.   A  good many of the dry col-
 lyria would produce the same effect.  Calomel and sugar, tutty, the
 white oxyde of bismuth finely pulverized, with an  equal part of
 sugar candy, especially, have enabled me to effect cures  that were
 truly surprising and exceedingly prompt,  by applying them in small
 quantities (par  pincees) morning and evening,  on  all the engorged
 parts.  Cauterization with nitrate of silver,  I have found to answer
 in many patients,  while the nitrate of mercury became indispensable
 in two others in 1837, at the hospital of  La Charite.
  II. Excision.—When these resources have been tried in vain, we
 may, in a  case of necessity, imitate Anel, by passing a noose of
 thread through the skin near the lids, and act  upon  it by drawing
 upon it  above, in  order to  readjust the diseased  lid to its normal
 position, and apply at the place where the  thread is, as recommended
 by J. Fabrice and Solingen, adhesive plasters, by which we  attach
its other extremity upon the  forehead for the lower lid, and upon the
face, on the contrary, for .the  upper; but besides that such means
would  scarcely ever  succeed, it is  infinitely more  simple, sure and
prompt to excise  the conjunctiva.   This also is the method adopted
by all the moderns, and tha  ojgp which Antylus had already recom- 
EYELIDS.
233
mended, and which Hippocrates himself advised though obscurely,
when the scarifications performed  by his ophthalmoxis did not suc-
ceed.  While an assistant keeps the eyelid turned back, the surgeon
with a good pair of dissecting forceps in his left hand, embraced a
fold of the diseased membrane sufficiently large to restore the eye-
lashes to their  normal direction, but not so much of it as to turn
them inwards;  excises this fold from the great angle towards the
smaller angle of the eye when he operates on the right eye, and in
an inverse  direction for  the  left eye; endeavors  to  include in his
incision the conjunctiva only, and to cut  rather in proximity to the
globe of the eye than to the  palpebral border; and,  moreover, for
the performance of this excision makes use of a straight pair of scis-
sors, or a pair  curved flatwise.   A very sharp bistoury or even a
good lancet would  also  attain our object, but the scissors  are the
most convenient.  The blood, which at  first flows out abundantly,
soon stops of its own accord.   The operation is now terminated, and
for the  subsequent treatment we  proceed  in  the same manner as
if the patient was affected  with  an  ordinary or traumatic  oph-
thalmia.
   In cicatrizing, the wound pushes  back the convex  border of the
tarsal cartilage towards  the  skin, and  thus  by shortening the inter-
nal surface of the eyelid, replaces  it in  its natural relations.   To
perform this excision, Paul of Egina in lieu of forceps passed a thread
transversely from one ocular angle to the other, in order to raise up the
conjunctiva.  This excision in ectropion, which is disconnected with
external cicatrices, is an operation so natural, that we have reason to
be surprised not  to  find  it  adopted by  all the ancient authors.
Though it be true that it was performed and  described formerly, by
a number of authors, it is nevertheless a fact that M. A. Severin is
the first, who after having obtained a great many cures by it, estab-
lished it as a fixed principle  in surgery.   The remarks of  Severin
(Medec efficace, part 2, chap. 33,) on excision of the conjunctiva,
were forgotten  like those of his  predecessors, when BordeHave
(Mem.  de VAcad. de  Chir., t. XIIL, p. 150,) proposed it  as a new
operation, and  endeavored to demonstrate  all its advantages.  It
must be evident to whoever  reflects a moment on this subject, that
the best mode of bringing into their proper line the internal  and ex-
ternal coverings of an everted (renversee) eyelid, must consist in
shortening that  which is too long, when we cannot or ought not to
elongate that which is too short.   Such was the reasoning of Borde-
nave, and since that time the  excision of the conjunctival protrusion
(bourrelet)  in ectropion,  has  been  adopted  as a general  process in
practice.  Some surgeons (see Carron du Villards, Guide  Pratique,
etc., t. I., p. 342,) under the impression that they could render this
process more efficacious, have suggested that it would be advisable
after the  excision is terminated, immediately to raise up the border
of the eyelid towards the eye, and to keep it adjusted  in this manner
by means of strips of adhesive plaster or bandages, in  order  to favor
the approximation of the two lips of the wound which has been es-
tablished upon the  conjunctiva.  Others,  as  Dzondi (Guthrie. Mala-
dies de VCEil,  1830; Carron du Villards, t. I., p. 343,)  especially,
have gone so far as to propose the excision of cutaneous cicatrices, 
234
NEW ELEMENTS OF  OPERATIVE SURGERY.
when any exist, or to make a semilunar incision upon the root (la
racine) of the eyelid, in order to enable the plasters or bandages to
straighten  with more facility the  ciliary border.   But it is evident
that such accessories would only tend  to complicate  the  operation,
and that they will not be retained.
   III.  The  only treatment in fact, therefore, that can  be advanta-
geous, when there exists no loss of substance, or organic alteration
in the tissue of the skin itself, consists in astringents and caustics, or
excision of the conjunctiva by the method of Bordenave.  The only
modification, perhaps, under such circumstances which might be pro-
posed with  advantage, would consist in cutting the flap (or fold) of
the  conjunctiva, in such  manner that its  anterior border might be
made to approximate as  near as  possible to  the free border of  the
lid, and then to  unite the two lips of the wound by a few points  of
the simple  suture.    It  is  probable that we  would  by this  means
abridge the time of the cure, by avoiding the inequalities of an  in-
ternal cicatrix.
   B. Ectropion from shortening  (raccourcissement) of the skin.—
Bridles and cicatrices, which are sometimes left as the consequence
of burns, wounds  and ulcers of the face, frequently produce  an  ec-
tropion much more  difficult to destroy than  the  preceding.   Desi-
cants and caustics applied upon the palpebral conjunctiva are then no
longer of any use; and it would be fruitless to attempt to re-adjust
the lids by means of threads or plasters.  Cauterization with the red-
hot iron, and excision of the relaxed surface itself, are usually insuf-
ficient.   Many practitioners,  even  among the  moderns, admit, that
the disease may then be considered as incurable.  It is in such cases
especially, that blepharoplasty may be called into  requisition.  [See
Vol. I., also our notes on this subject in that volume. T.]
   I. Method of Celsus.—Up to the  time  of Boerhaave and  Louis,
an  infinity  of processes were  practiced in order to elongate the ex-
ternal surface of the eyelid thus reversed.   Some with Demosthenes
of Marseilles, Celsus (Lib. VII., cap. 7,) and A. Pare,  proposed to
make upon  the  skin a semilunar incision, with  its horns turned  to-
wards  the opening of the eye ; others confined themselves to a trans-
verse incision, the lips of which they endeavored to keep apart, by
filling  the wound with  lint or any  other foreign  body; others, like
Paul of Egina, and Acrel, endeavored to destroy effectually all  the
bridles and  cicatrices, either by making simple incisions upon them,
excising them with the bistoury or scissors, or by strangulating them
by means of a ligature.   At present it is admitted, that these differ-
ent operations, far from  being advantageous, are almost always hurt-
ful, and that in spite of every precaution, the wounds which result
from them,  shorten the  integuments of the eyelid  in place of favor-
ing their elongation.
   Though it be true that the ancient method of Celsus is frequently
the most inefficient in cases of ectropion from alteration of the skin,
it  is, moreover, also  true, that it  may sometimes  succeed.  M. A.
Petit (Obs.  Chir.,  p. 175, obs.  94,) gives a curious instance of it;
there existed  a  breadth  of scarcely three lines between  the tarsal
cartilage and the eyebrow; the conjunctiva was incised without any
benefit;  when the external semilunar incision, and  in such manner as 
EYELIDS.                         235
to comprise only the skin, was then resorted to, and the lips of this
incision kept apart by lint.   The bottom of the wound by healing
up (par dessication,) was transformed into  a cicatrix  of three lines
in breadth, and the eyelid was thus enabled to cover the eye as in
health.  M. Malvani, (Journ. Gen. de Med., t.  108, p. 28,—or Arch.
Gen. de Med., t. XXL, p.  273,) and  Pellier de  Quingsy, (Obs. sur
I'ceil, p. 502, obs. 201,) moreover,  who relate  facts  borrowed from
Daviel and Marchand, equally prove  that this method does not de-
serve all the blame, which following the example  of Herlse, who
wrote  in  1668,  the  moderns have generally reproached  it with.
It is, however, to be considered that it is exceedingly uncertain, and
that it is scarcely worthy of being revived at the present day.
  II. Process of Antylus  and M. Adams.—In 1813, M. Adams, an
English oculist, proposed  for difficult cases  a process which he
supposed  he  had  invented,  but which M.  Martin (These, Paris,)
attributes  to  Physick and M. Bouchet, and which  is found in part
described  in  Aetius,  (Serm.  3, cap.  61,  62.)  A triangular flap or
V, whose  base corresponds to the eyelashes, is  cut out at the ex-
pense  of the affected eyelid.   The  two sides of  the  division are
then reunited by  means of suture.   The advice of M. Adams has
been  adopted in France  by Beclard, and  especially by M.  Roux.
I have seen it employed, and often employed  it myself successfully.
Antylus (Peirylhe) who made his incisions from the adherent to the
free border of the lids, was  careful in dividing only the  conjunctiva,
tarsal  cartilage  and  orbicularis muscle ; of leaving, in a word, the
skin  intact, which  manifestly distinguishes  his process from that of
the English surgeon.   M. Adams and M. Roux  first seize  the eye-
lid with a ligature forceps, then cut on each side through its whole
thickness, and in this manner circumscribe the triangle mentioned
above, by commencing at  its base.   The  blood  which immediately
runs out copiously, and which comes from the ciliary or palpebral
artery, soon  ceases of itself.  To reunite, M. Adams restricts him-
self to a single point of suture placed very near the eyelashes.   M.
Roux proceeds precisely as in hare-lip, that is to say, that with one
or two short, strong pins, or those little pins called minnikin pins,
(camions) he constructs the twisted suture.  In place of the  bistoury,
it would be as I think, more  convenient to employ a good pair of
scissors, as I have frequently done.   The  operation  is then more
prompt and certain, and the  section of the tissues neater and incom-
parably more easy.  Also,  I cannot see that there would be any
use in  giving more than two or three lines breadth to  the base of
the flap to be cut out, or to prolong its extent beyond the tarsal
cartilage.
  III.  Process of M.  Walther.—In a patient in whom the ectropion
occupied only the temporal half of the eye, M. Walther, (Bulletin de
Ferussac, t. XIII., p. 77,) after having extracted the eyelashes, seized
with a forceps the outer extremity of the lower lid,  which he divided
through its entire  thickness  as far as the temple, then did  the same
for the  upper lid, and  removed the flap  of soft parts  thus circum-
scribed.   The  two lips of  the wound  approximated  from  above
downwards, were  kept  in contact by two points of suture, and the
patient recovered  perfectly.  This process,  it is seen, is  no other 
236         NEW  ELEMENTS  OF OPERATIVE  SURGERY.

than that  of M. Adams, applied to the smaller  angle of the eyelids,
and cannot be applicable except in cases similar to that mentioned
by M. Walther.
   IV.  Process  of  M. Key.—In 1826,  M.  Key  had  to  treat an
ectropion, which MM. Travers, Tyrrell and Green had vainly endea-
vored to cure by the ordinary methods.  M.  Key, supposing that the
cause  of the reversion of the  lid in this man might have depended
upon  the  spasmodic contraction  of the orbicularis muscle,  made a
transverse incision  in  the skin, and  penetrated little by little as far
as to the convex side  of  the tarsal cartilage; directed  an assistant
to keep the two lips of the  wound  apart, and was then enabled to
seize with the forceps a bridle  of fleshy fibres, which he divided by
means of a very sharp pair of scissors.  The  operation was attended
with entire success.  I do not know if practitioners will  adopt the
views  of  M. Key ; I am not  aware that they have been precisely
stated ; what is certain is, that we cannot well conceive of the ex-
istence  of these supposed spasmodic contractions, nor  how the ex-
cision of a portion of the  orbicularis muscle  of  the  eyelids can
remedy ectropion ; nevertheless, as in surgery especially,  as soon
as  a fact is averred, whether  it is comprehended or not, prudence
recommends that it  should be admitted, I have not thought it proper
to pass by in silence the operation of the  English surgeon.
   V.  M. Brach, (Kleinert's  Repert., Fevrier, 1837, p. 22,)  who pro-
poses to circumscribe and then excise  a quadrilateral flap  of the in-
teguments, and to  have recourse afterwards to the suture, appears
to me to have intended to speak of, or to propose an improvement
for the treatment of entropion, rather than that of ectropion.  The
same remark I  think may be made of M. Jacob, (Dublin Hospital
Reports, vol. V., p.  390,) who  imagines the  operation  may be ren-
dered more sure, by confining  ourselves to the  division  of the tem-
poral  angle of the eyelids.
   VI. The process  of M. Dieffenbach, (Bulletin de Ferussac, torn.
XXVI., p. 97,)  consists in an incision on the base of the  eyelid, with
a view of penetrating in this manner to the internal surface of this
organ, and to draw its conjunctiva with  the  convex border of  the
tarsal cartilage  outside, in order to fix them by means of a suture in
a  fold  of the  skin.  This, however, is an operation which it ap-
pears  to me ought not to have the preference  but  in a very small
number of cases, and which would expose to a deformity nearly as
great  as that of the ectropion itself.
   VII.  Should  any of the processes of which I have hitherto
spoken, not appear  to be suitable, and should the  shortening of the
skin be considerable, we should have at our command the  resources
of blepharoplasty, such as I  have described it in another part of this
work.   In such cases I think satisfactory results might be hoped  foi
from the method of Jones, even more  than from the modification pro-
posed for blepharoplasty in general by M. Hysern of Madrid, (De la
Blepharoplastic temporo-faciale, Madrid, 1834,) though this moclifica-
tion, which I  had not  an  opportunity of speaking of at the  propei
time, and in favor of which the author  relates two successful exam-
ples, is in other respects very ingenious.   The method of Jones  has
the immense advantage of not  substituting a deformity in place of 
EYELIDS.
237
 that which we wish to destroy, and of being easy of execution and
 devoid of serious dangers.  I had  suggested it in 1834, and I still
 believed myself the inventor of it in 1837, when I learnt that M. A.
 Berard made a trial of it without success, and that  M. Jones had em-
 ployed it in two instances with advantage.  M. Sanson, who, accord-
 ing to M. Carron du Villards, (Maladies des Yeux, t. L, p. 347,) had
 also employed it, had no reason  to be satisfied with it,  since his pa-
 tient, who was soon seized with an erysipelas, ultimately died.  Hav-
 ing finally put it in practice in 1838,1 ascertained  that it was in reality
 easy and more prompt than any other, and that we should be wrong
 in not giving it  the preference in cases where all that would be re-
 quired to adjust the eyelid would be to elongate  the  skin to the ex-
 tent of some lines.  The young man whom I operated upon in this
 manner, had had almost the entire left cheek destroyed by a carbuncu-
 lous affection.   The lower eyelid was thus depressed as far  down as
 to a line with the suborbitar foramen, and the inferior half of the eye
 thus remained  entirely uncovered.  Having cut and dissected the
 flap, I first united the apex of the wound, to the extent  of  six  lines,
 by means of three points of suture.   Three  other points of suture
 outside, and as many on the inner side, afterwards  approximated the
 sides of the flap and the  borders of the solution of continuity that
 were still free.   An erysipelas  which made its appearance on the
 sixth day, did not prevent the agglutination of the parts from being
 accomplished, and the patient left the hospital at  the end of a month
 with his eyelid  raised up  to  the extent of four  lines, though  still a
 little reversed, and in  such manner as not to touch the upper lid ex-
 cept under the influence of a very strong contraction of the orbicu-
 laris muscle.  It would be necessary, morever, in order to derive all
 the advantage possible from this operation, to prolong to a very con-
 siderable distance  the incisions on the side of the base  of the orbit,
 and to dissect the flap nearly as far as the  root of the eyelashes, in
 order to separate its apex as much as possible from its point of de-
 parture.   It would  be moreover necessary to reunite the whole by
 numerous points of suture, and  to endeavor to place in  contact the
 borders of the wound to an extent of from four  to ten  lines below
 the point  of the V, which moreover would be  included by one  of
 the threads or one of the pins.  (See Blepharoplasty.) Should ectro-
 pion have been caused by any tumor whatever developed in the in-
 terior of the orbit, or in the substance of the eyelid itself, it  is unne-
 cessary to say that the surgeon should direct his  attention to this tu-
 mor, and not to the reversed eyelid.

                     §  Il.-r-Blepharoptosis.

  When the upper eyelid is kept depressed to such degree as to com-
 pletely conceal  the eye, and without the eyelashes being turned in-
 wards, whether such disease should  depend  upon the  inaction  of
 the levator muscle, or that it is owing to any other cause, if it is an-
 cient, and has not yielded to antiphlogistic or exciting  remedies, or
to local or general pharmaceutical means, we are necessarily obliged
to have recourse to the resources of surgery for this malady.  The
 process  ascribed  to M. Hunt,  (Carron du Villards, Oper. cit., t. I., 
238
NEW ELEMENTS OF OPERATIVE SURGERY.
p. 254,) and which I have described above under the name of M.
Brach, might in this case be useful.  Having excised his elliptical or
quadrilateral flap, the surgeon would attach the palpebral border to the
superciliary border of the wound, and would thus place the movement
of the eyelid under  the influence of the occipito-frontalis muscle;
we  should be wrong, however, to put  too  much confidence  in this
remedy.   The operation which the fall of the upper eyelid may re-
quire, and which is the  same nearly as for entropion  and trichiasis,
has moreover considerably varied.

                       § III.—Trichiasis.

  Hippocrates passed two nooses of thread through the skin, one
near the free border, the other towards the base of the eyelid, and
knotted them together in order to turn the eyelashes outwards.
  A.  Excision of the integuments.—But  it is  to  the excision of a
transverse  cutaneous flap, that  attention  has been  more especially
directed.  Already carefully described by Celsus and  G. de Salicet,
this excision is performed in various ways. Acrel, who also proposes
it, recommends that we  should give a rhomboidal form  to the flap.
As it  appeared to him that it would not always be attended with suc-
cess, he suggested the  idea  of incising the  integuments above the
eyebrow, and to remove therefrom  a segment of very considerable
size.  Celsus and Galen  traced out with ink the  limits of the  flap to
be removed, and afterwards reunited the  wound by means of a sin-
gle  point of suture.  Aetius advises  that  one of the incisions, the  su-
perior, should be semilunar, and that the inferior should  be straight.
In place of one point of suture he employed five.  Paul of Egina com-
menced by making upon the internal  surface of the eyelid, behind the
eyelashes, a transverse incision, extending from one angle of the eye
to the other.  This was associated  with  excision and  three points
of suture.  L'Habitant,  (Annuaire d'Evreux.—Jour.de Med., 1806,
t. XII., p. 368,) cured a  patient in five days.
  B.  Cauterization of the Skin.—Rhazes had already endeavored
to replace excision by  means of caustics.   Abul-Kasem made use
of the hot iron  or quick-lime.  Costasus  especially, and D. Scachi
have eulogized the actual cautery.  Ware incised before cauterizing.
M.  Heling (Bulletin de  Ferussac, t. II., art. 20) and M. Quadri have
bestowed warm  encomiums upon sulphuric acid.  The  professor of
Naples  commences  by causing the eyelids to be gently separated
apart and then washes,  wipes and carefully  dries them by means of
a fine piece  of linen or a sponge.  He then, by means of a small bit
of polished  wood,  applies the acid upon the  skin which  corresponds
to the border of the tarsal cartilage, and this to the extent of  four to
six  lines transversely;  waits some  seconds, in  order that the first
application of the acid may combine with the  tissues ; repeats it a
second, third and even a fourth time, until the eyelid is slightly crisp-
ed outwardly, and he adopts  moreover every precaution possible to
prevent the caustic from penetrating to the  eye.
  The excision and cauterization of the skin, whether with sulphuric
acid,  or with potash, as M.  Solera (Bulletin de Ferussac, t. II., p.
417) prescribes, evidently produce the same final result.   By both 
EYELIDS.
239
methods  there is  a loss  of substance.  In order that cicatrization
may be effected, the lips of the wound are obliged to approximate to-
wards each other.  The  result is always a shortening of the eyelid
and especially of  its outer surface.   After excision, to which more-
over we  should give a variable  extent, according to the degree of
retraction that we desire  to produce, should we, after the manner of
the first authors who have employed it, as De Beer and M. Langen-
beck, have recourse to the simple or quilled (emplumee) suture, or
should we, as Scarpa recommends,  confine ourselves to  a simple
dressing and  union by the second intention ?  This is a matter of
choice, and not of necessity.
   C.  Tearing out, (arrachement) of the Eyelashes.—One of the most
ancient methods of treating trichiasis,  and especially districhiasis, is
the extraction of  the deviated hairs, the first idea of which, accord-
ing to Galen, is to be attributed to Popius.  Nothing, in fact, seems
more natural, in order to destroy the pain and  inflammation  which
then exist in the front part of the eye, than to  remove their  cause.
•Unfortunately it is soon  perceived that this remedy is only a pallia-
tive, and only relieves but for the moment; and that, in growing out
again, the extirpated eyelashes almost constantly retake their morbid
direction.  Nevertheless  it is almost the only operation approved by
La Vauguyon, Maitrejan, De La Motte, and even Richter, when the
tarsus itself is not diseased.  In order to protect ourselves from such
an inconvenience, practitioners proposed to apply a caustic upon the
root of the hairs which have been extracted.  Sulphuric acid, butter
of antimony and  nitrate  of silver have in turn  been lauded for this
purpose.   If there are only two or three hairs that have  deviated,
then  mere extraction by means of a tweezers  (epilatoire)  very fre-
quently will be found quite sufficient.   In repeating it  as soon as the
eyelashes reappear, we ultimately either destroy their root or change
their direction.  It is, moreover, an operation too simple, and which
too constantly affords relief, not  to be  made trial of at the very be-
ginning.   I have  employed it three times with complete and perfect
success.   Excision with the extraction of the eyelashes, as  Forlenze
advises, (Annuaire d'Evreux, 1810, p. 68,) could have no  object.
   D. Cauterization of the Eyelashes.—Perceiving that  all these
remedies might fail, some surgeons made trial of the actual cautery,
after the  advice  of Rhazes.   In our times, also, some practitioners
have found no  better method of remedying trichiasis  than an im-
provement on  the mode  of cauterization employed by  so many
ancient authors, and especially by Celsus, who made use of a needle
heated to  a white heat.  The form of cauteries formerly employed
did not allow of carrying the caloric to a sufficient depth.  That of
M. Champesme (Revue Med., 1826) is terminated by  a point which
supports a large, smooth  dilated ball which approximates  it  a little to
the cautery called sparrow-head (tete de moineau). • Heated to a white
heat this point, though very small, maintains  the heat sufficiently to
form rapidly eschars on every part to which it is applied.  M. Cham-
pesme asserts that he has seen trichiasis several  times radically cured
by his instrument;  and we could not deny its  advantages  if, as A.
Pare sustains, cauterization of the  lashes ought to have the decided
preference.  M. Carron du Villards, (Op. cit., t. I., p.  307,) plunging 
240           NEW  ELEMENTS  OF OPERATIVE SURGERY.

in an insect pin to  the depth of a line and a half,  in following the
direction of the lash in each bulb, afterwards  unites together all the
pins  thus  implanted, by means of a silver thread, and then seizes
hold of them with a curling tongs (fer a papillottes) strongly heated.
The process of Celsus, Pare, or of M. Champesme, is by this means
rendered as simple  as it is easy.
   E.  Reversion of the Eyelashes outwards  (eversion).—A mode
less  severe, and which  appears to have  been attended with some
success, consists in  reversing  the  deviated eyelashes  upon the skin
of the eyelids.  Heraclides, who passes for the inventor of it,  kept
them there, as did  also Acton, by means of plasters.   I have  suc-
ceeded by this mode in a case which  had resisted excision of the
integuments.  Celsus and Galen say that in their time some persons
introduced through the skin  by means of a needle, a woman's  hair
doubled in such manner as to enable it to entangle the deviated  eye-
lashes in its noose.  According to Rhazes, we succeed full as  well
by crisping (frisant) them with a hot iron.

                       § IV.—Entropion.

   A.  Excision of the skin, so  strongly recommended by Bordenave,
Louis and Scarpa, and almost  all the moderns, as a remedy for en-
tropion, is  an  operation too simple and one that too frequently suc-
ceeds  not to  be made trial of at  first.   The  surgeon being placed
in front of the patient, seizes with an ordinary forceps or with his
fingers, or with the  crutch forceps  (pince en bequille) of Beer, a fold
of the integuments sufficiently  large to make the lashes turn upwards
and forwards.   If this fold should be too large, we  should incur the
risk of producing an ectropion ; if not sufficiently so, we should  only
obtain an imperfect cure.  It is to be excised moreover, in the same
manner and with the  same precautions as the  protrusion of the  con-
junctiva  in lagophthalmia or simple ectropion.   After the operation,
Scarpa recommends that the skin of the  face  for the lower eyelid,
and that of the eyebrows and forehead on the contrary for the upper
eyelid, should  be pushed back towards the orbit, and maintained and
gathered at this point by means of graduated compresses or adhesive
plasters extended from the cheek bone  to  the forehead.  " On the
following day," he remarks, " the patient may open his eye, and if
proud flesh or fungosities grow up at a subsequent period at the bot-
tom of the wound, they are repressed by nitrate  of silver.   It  is in
such cases especially that Beer and M. Langenbeck consider that the
suture ought to be employed, in order that the eye may cease as  soon
as possible  from being fatigued by the presence of the  lashes.   As
the skin divided is very thin and very pliant, and as nothing is more
easy than to perforate it with  a thread, and  as there would more-
over evidently be an advantage in immediate  reunion without gath-
ering the teguments together  like Scarpa, on  the side of the eye,  I
cannot see why we  should refuse to make use of the  simple  suture,
were it only for the space of twenty-four hours, as  is  recommended
by M. Langenbeck.
  B. Avenzoar speaks of practitioners  who  preferred  compressing
the flap of the integuments between two splints, and thus cause its morti- 
EYELIDS.
241
fication, rather than to excise it with a cutting instrument.   Bartisch
has reproduced this idea under another form,  by proposing to com-
press the skin between two plates of iron  united by a hinge.  Adri-
anson. according to Heister, invented another method.   By means
of an instrument almost similar to  that of Bartisch, and garnished
with holes, he pinched up a large flap of skin,  the  base  of which he
traversed by passing threads through the apertures of the instrument,
(pince.) then excised the upper border and left it to itself as well as
the threads, which required to be knotted  immediately, like  so many
ligatures.
  C. Excision of the Palpebral border.—In  obstinate cases, Dr.
Schreger removes, by means of curved scissors, a triangular flap from
the border  of the eyelid, including  in it  the  deviated eyelashes,
and even goes, according to M.  S.  Cooper, to the extent of recom-
mending the excision of the entire reversed portion of the tarsus; but
we cannot see for what reason this process, already lauded by Heister
and De Hayes-Gendron, ought to have the preference  over simple
excision of the palpebral integuments.
   D. Process of M. Crampton.—M. Crampton, after having perpen-
dicularly divided the free border of the eyelid  to the right  and left
of the point which  supports the deviated hairs, reunites the two ver-
tical wounds which he has made,  by a transverse  incision of the
conjunctiva, then brings the portion of the cartilage thus divided into
its natural position, and maintains it there by means of adhesive plas-
ter, or  a suspensory to the eyelid.  M. Travers, who partially adopts
the views of M. Crampton, thinks that in  certain cases  it would  be
still better to excise the little flap of the tarsus.  The physicians  of
Bimarestan, mentioned by Rhazes, and who, after having incised the
cartilage, traversed it with a thread,  in order to turn it outwards;
Richter, who in obstinate  efctr6pion advises that we should make a
transverse incision upon the tarsus, and Paul of Egina himself, who
recommends that we should incise the eyelid  transversely upon  its
deep-seated surface, are the sources,  as wre perceive, from whence
M. Crampton obtained the idea of his  process,  which has again been
recently attended with success in a case of ancient entropion, as em-
ployed by M.  Mackenzie,  (Gaz. Med., 1838, p. 775.)  At all events,
however, it is a remedy only to be made trial of as an exception in
cases where all other means fail.
   E. Process of Guthrie.—M. Guthrie also incises the  tarsus near
the ocular angles;  but in such manner as to go a little beyond their
convex border, afterwards he  reverses it with the finger, either to-
wards the forehead or face, according to the eyelid  affected.   If in
falling  upon the eye, the  cartilage continues to turn inwards, M.
Guthrie recommends that we should moreover  divide it transversely,
and that we should excise a portion of it at the same time with the
skin which covers  its external surface.  Without being important or
meriting any great degree  of confidence, this  process, nevertheless,
appears to be less objectionable than the preceding.
  F. Process of Saunders.—The most sure mode, says Saunders, is
to remove almost  the  entire diseased  organ.   A thin plate of lead
or silver curved like the eyelid, being  previously  introduced between
this curtain and the eye, the operator causes the parts to be stretched;
                               16 
242           NEW ELEMENTS OF  OPERATIVE  SURGERY.

divides the skin and the orbicularis muscle, behind the eyelashes, a lit-
tle beyond and in the direction of the tarsus, dissects the flap and ter-
minates by the extirpation of the cartilage.   The inconveniences of
such a method are too evident to make it necessary for me to expose
them.   There would be  more advantage in following the advice
given by M. Jaeger, then by M. Flarer, to excise the cutaneous por-
tion of the free border of the eyelid, respecting its ocular portion,
while at the same time removing the deviated eyelashes  and  their
roots.
  G.  Process of Vacca, (Journ. de Progres, t. III., p. 273;  Bull, de
Ferussac, t. VlL, p. 361.)—The conduct of Vacca appears to me to
be much more reasonable.   In one  of the  most obstinate cases of
trichiasis, this surgeon proposed to lay the roots of the eyelashes bare,
and to destroy them, either by means of a cutting instrument or nitric
acid.   A concave thin plate, having a transverse groove on its con-
vex surface, is first placed  in front of the globe of the eye.  An as-
sistant stretches  the  eyelid  and keeps  the  border  confined in the
groove of the plate.   By means of two vertical incisions  of a line
long united by a  transverse  incision, and comprising only the  skin,
the operator cuts out a little parallelogram,  which he  reverses to-
wards the side of the palpebral opening, thus  lays bare the cartilage,
seeks the bulbs of the diseased eyelashes with a forceps, excises them
with scissors and burns them, replaces the flap,  and makes use of
plasters, not the suture, to  keep the wound united.   The numerous
branches, furnished by the palpebral artery to the eyelashes, are cut
and bleed  freely.   Nevertheless, the hemorrhage  is never trouble-
some, and always stops of its own accord.
  Delpech, who also" eulogizes cauterization of the eyelashes, not ol
their  root, (tete,) but of their neck, counts chiefly on the establish-
ment  of an elastic cicatrix,  or an modular tissue,  and consequently
prefers union by the second intention.   Besides the processes already
described under the head  of trichiasis, viz. excision  of  a fold of the
skin, eulogized also by Dionis, Saint-Yves, Janin and Gleize, or the
the red hot iron, also recently lauded by M. Jobert, entropion has been
attacked by the process of  Guerin, that of M. Gensoul and that of
M. Segond.
  H.  Guerin, (Journ. de Montp.,  t. II., p. 281 ; Carrondu Villards,
t. I., p.  314,)  attributing the disease, without doubt, to a spasmodic
contraction of the fibres of the orbicularis muscle of the eyelids, pro-
posed to slit perpendicularly to the extent of several lines, the free, from
the adherent  border of the eyelid.   It is said that Physick, Beclard,
and M. Bouchet also had recourse  to this method for  entropion.  We
thus produce a coloboma,  or a sort of hare-lip of the eyelid, which
gives momentary relief, but which cannot effect a definitive cure but
at the expense of a very disagreeable deformity.  It is consequently
a method which should be rejected.
  I. The  process attributed  to M. Gensul (Carron du Villards,  1.1.,
p. 315, 326, Gaz. Med., 1832, p. 568,) would be less objectionable.  In
place of a transverse fold, this surgeon excises a vertical fold of the
teguments of the eyelid.  In the process of M. Segond, (Revue Medi-
cate, 1836,) there is excised  successively a vertical and a transverse
fold of the skin,  so as to unite the ancient method to the process of 
EYELIDS.
243
the surgeon of Lyons.  I do not doubt that we may succeed in this
manner in curing entropion in a number of cases;  but I scarcely
understand the necessity of this species of crucial  incision devised by
M. Segond and extolled byM. Carron du  Villards.  An examination
of a great number of cases of reversion of the eyelids also has never
enabled me to comprehend the utility of  the processes of Saunders,
Crampton, Flarer, &c, the excision in the  manner  of Bordenave
always having succeeded  and  appeared to answer with me.
   J. Process of the author.—To render excision as  simple and effec-
tual  as possible, whether by the ancient  method or  the method of
M. Gensoul, I adopt the following process :  If the palpebral border
is reversed inwards, rather towards its extremities than middle por-
tion, I prefer  the  excision of  a vertical fold ;  in the contrary case I
adopt  excision of the transverse fold.  In the first case I take care
that the wound  is larger at its lower  part  than above, and that it
represents a sort of oval.   In the second case I incise as near as pos-
sible to the ciliary border, and I am guarded in giving to the flap a
breadth so much  the greater  at its  middle, in  proportion  as  the
middle third  of the  eyelid is  found more completely  deviated  in-
wards. By means of these precautions,  the approximation of the
borders of the wound is effected entirely at the expense of the rever-
sion of the eyelashes, and  the least loss of  substance of the skin pro-
duces a decided effect upon the entropion.  When,  after excision of
the integuments, we  leave the wound to cicatrize by second inten-
tion, the cure may be long and incomplete.  To confine ourselves to
the employment of adhesive plaster, to approximate the sides of the
wound, is  very  uncertain, and the blood or the tears, which flow in
abundance, render the application of the suture quite difficult.  These
difficulties all disappear by my  method, which  may be adopted by any
body.  Having raised up, with the fingers or a good pair of forceps,
the vertical or transverse fold  to be excised,  I immediately traverse
its base with a needle, first at the middle and  then at each extremity,
in order to leave there three threads, each a foot long.   I then excise
this fold at a line in advance of the threads,  and there remains nothing
more for me to do than  to tie them into a knot, in order to complete
the suture and accurately unite the wound.  In this manner we avoid
all embarrassment caused by the blood ;  besides that it is infinitely
less difficult to traverse the tissues, and  that we cause less pain to
the patients than if it were necessary to pass successively afterwards
the threads through the  two lips of  the wound.  This process, made
trial  of already  in ten  to twelve patients, either  at  the hospital  of
La Charite or in  private practice, has appeared to me to be  of
such great simplicity, that I have no longer felt it  necessary to make
use of any other.
  K. Appreciation.—In simple blepharoptosis excision of the inte-
guments is almost always followed by success.  It is also the most
effectual remedy for ordinary entropion.  If it were  a paralysis of
the levator muscle, we  should have recourse to  the  process of M.
Brach.   In trichiasis and entropion, extirpation, extraction and rever-
sion of the eyelashes, in  the manner  of Heraclides, when their length
permits it, or even the  process of Hippocrates, might be first made
trial  of.  Then  come,  1st. Excision of  the integuments, which, 
244           NEW  ELEMENTS OF OPERATIVE  SURGERY.

as Phvsick recommends,  ought to be made very near the palpebral
border.   2d.  Cauterization of the skin by the method of Helling, M.
Quadri, M. Solera, or M. Carron, which  I  have tried  in three in-
stances with success.  3d.  Process of Vacca for the most severe cases.
And, finally, 4th. The excision of the cartilage, according to the views
of M. Guthrie, Schreger,  M. Travers, Saunders, and M. Crampton,
or even by the process of M. Adams, if no  other could succeed.

                  § V.—Tumors of the Eyelids.

  If the tumor which occupies either one of  the eyelids has not dis-
organized this curtain but  only  deformed it, we must destroy it with-
out encroaching on the natural  organ.
  A.  Encysted tumors come under this class; being a sort of hyda-
tid  productions  or  sebaceous cysts  or degenerate mucipares, they
scarcely ever disappear by resolution.
  I.  Extirpation.—When the  vinous solution of muriate of  ammo-
nia, recommended by Morgagni as well as  by Boyer do not succeed,
we ought, if  the patient is disposed to  be relieved propose the oper-
ation  properly so called.   In these cases the ligature, incision, cau-
terization, and extirpation  have been recommended.  The ligature
has been long since, and  very properly, abandoned.  Cauterization
is  equally rejected, unless it should be combined with incision.  A
needle fixed like a  seton  in the substance  of the  tumor, as  recom-
mended after a case or two by Demours, (Arch. Gen. de Med., t. XVI.
p. 107,) and by M. Jacquemin,  would not in my opinion succeed ex-
cept by chance.  So that  it is  to extirpation that attention has been
more especially directed.   In  order to perform it* it is  altogether
useless previously to pass  a  thread through the tumor whether laid
bare or not,  as Bartisch proposes, in order to act upon it with more
certainty.  When it is small and appears  to have its seat nearer to
the conjunctiva than to the skin, we must  seek for it upon the inter-
nal surface of the eyelid, because the operation then does not oblige
us to go through the tarsal cartilage.   The greater projection that it
makes externally even ought not always to deter us, for this promi-
nence depends much more upon the pressure  of the globe of the eye
than upon the precise seat of" the tumor.  When the skin is changed
and very much attenuated, when it is attended with too much diffi-
culty to reverse the eyelid,  or when the  tumor  exists outside the
tarsal cartilage, we are then under the necessity of dividing the in-
teguments.
  a. First Process.—With the thumb placed on the  inner side of the
tarsus and the  forefinger applied upon the skin, the surgeon seizes
the diseased  lid;  reverses it  outwardly ;  presses  upon  the tumor
with his finger in order to make it project in front of his thumb ; lays
it bare by means of a transverse  incision  ; seizes it with an erigne,
which is taken charge of by  an assistant; then immediately resumes
the bistoury,  dissects  the  tumor, and isolates it in such a manner as
to leave nothing of the cyst behind.  The  little wound which results
from this  operation requires  no particular care, and  the cicatrization
is effected in the course of a few days.  We might also, as  soon as
the tumor is  secured with a hook, and when it has but little  volume 
EYELIDS.
245
and may be  readily raised up, excise  it with one cut of the scissors
curved flatwise.   Nevertheless it is important to respect the conjunc-
tiva and subjacent  tissues, and to incise rather than  excise them,
seeing that their destruction would expose to the danger of entropion.
  b. Second Process.—When from  necessity or choice we wish to
attack  the  cyst  through the skin, the  forefinger takes the place of
the thumb, and vice versa.   In pushing the tumor the finger stretches
the whole eyelid, protects the eye and  answers a better purpose than
the little cup of lead or  silver formerly used, or the plate of gold or
leather still recommended by Chopart and Desault.  We afterwards
divide the integuments cautiously, in order not to open into the mor-
bid body.   As for the rest there is nothing particular, and the cure is
rarely  protracted beyond from three to four days, and without the
necessity of dressing.
   c  In both cases  we ought to be on our guard against perforating
the eyelid, and as much as possible of  wounding the tarsal cartilage,
because the cure would in most  cases be thereby  retarded,  and
that  there  might perhaps result  from it a sort of fistula or some
other deformity.  A good pair of forceps  may advantageously  be
substituted for the fingers in most cases.  Two forceps, one on each
side confided to  an assistant, gives still greater facility in stretching
the eyelid while the surgeon dissects and removes the tumor.  If the
operator is sure of his hand, he may moreover himself  fix the eyelid
upon the globe of the eye by means of his thumb and left forefinger,
while with the bistoury in his right hand he makes the  division of the
skin.   Having secured the  cyst with an erigne  he isolates it, and af-
terwards separates it  without danger.  A plate  of  horn  or shell
glided  between  the eye and  the eyelid,  and  which  allows of the
ciliary border being fixed on the  transverse groove   which exists
on its anterior surface,  by means of the nail of the left thumb, gives
still greater security and freedom.  A  man from the country who had
in each upper eyelid a  fibrous tumor as large  as a duck's egg, was
cured  by M. Fleury, (Bull, de la  Fac de Med., 1807, No. 2, p.  16,)
who, removing an ellipse of the integuments together with the tumor,
effected a cure without interfering with the  movements of the eyelid.
   II.  Modified Cauterization.—Maitrejan, Heuerman,  Nuck,  and
Loyseau, (Observat.  Chir.  &c,  p.  112,  1617,) before them com-
menced by largely  opening the tumor  in order to empty it, and after-
wards  to cauterize its  interior.   Chopart  and  Desault, who profess
the same  doctrine, use for the second stage of their  operation the
crayon of nitrate of silver.   In  adopting  this method,  Dupuytren
gives as the reason  that it is more easy, and in every respect as  cer-
tain as any other, that it ensures us against  the danger of perforating
the eyelid,  and that it is the only one that  can  be undertaken, when
in spite of every precaution, we have penetrated into  the  cyst while
endeavoring to lay  it bare.   Nothing  is  more easy than the manual.
The organ  is seized in the  same manner  as in the preceding case.
With one  stroke of the bistoury we divide the skin and small sac,
which  we empty, or is emptied immediately.  With a crayon of ni-
trate of silver, directed with a certain degree of force upon the  bot-
tom of the  wound, we cauterize its entire  surface.   The heteroge-
neous (coque) mass soon exfoliates, and the wound afterwards heals 
246
NEW ELEMENTS OF  OPERATIVE SURGERY.
 up very rapidly.   All other things being equal, excision is preferable;
 but the process of Dupuytren  is almost equally as good, and will be
 found applicable  in  intractable  subjects.   Only it is important that
 the whole cavity of the cyst should be accurately and very strongly
 touched by the caustic  ; it is probably from the want of this precau-
 tion that a return of the disease took place in the three patients men-
 tioned to me by M. Champion.   I have, moreover, employed  both
 modes with like success.
   B.  The Chalazion, the Grelon and Grando, which are so often
 confounded with palpebral cysts, are on the contrary small concrete
 tumors, occasionally fibrous, sometimes as it were caseous or tuber-
 culous, and at other times of a fungous or mucous aspect.   Under
 this last form they often show themselves near the conjunctiva, where
 I am  in the habit of excising them, and  afterwards cauterizing their
 root.,  It is evident that incision  and  cauterization would not be ap-
 plicable  to the others, and that  extirpation is the only resource which
 can succeed with  them.  Like M. Champion,  I have observed  that
 many of these tumors have no cysts,  and that in  order to  remove
 them, we are obliged to dissect them,  as for example,  we dissect tu-
 mors  of the breast.   I will remark that this small  operation is quite
 painful, and that in certain patients it causes a  manifest tendency to
 syncope.
  C.  Erectile Tumors.—The eyelids are subject also to other tumors.
 I have elsewhere given examples of the erectile tumors which are found
 here.   I will add here  that a tumor of this species which occupied
 the great angle of the eye, disappeared  unber  the  action of a com-
 pressing bandage and topical astringents, as proposed  by M. Carron
 du  Villards, (Malad. des Yeux,  t.  I., p.  353.)  Caustic potash appears
 also to have obtained a remarkable cure of this kind  (Ibid., p. 355)
 with the same practitioner, who also asserts that the hot iron proved
 very efficacious in the hands of M. Jules Cloquet.   It  would appear
 that it is to his father to whom  we are indebted for the treatment of
 erectile tumors by vaccination, and that a tumor of this kind which
 was situated upon  the right eyebrow, was cured in this  manner by
 himself in 1822.
  D.  Cancerous Tumors.—Experience  has  sufficiently proved  that
 cauterization  is an  objectionable mode  for destroying cancerous
 tubercles of the eyelids.  Though even it should be a tumor of a
 less alarming nature, it  is still with the cutting instrument that we
 ought to attack it, so often as the  degenerescence has extended to the
 natural tissues.  In this  part, as in other regions, it is much better to
 do nothing than to leave a portion of the disease behind  and  not to
 trench into the sound parts.
  I. When there  exists  only  a simple tubercle accurately circum-
 scribed, should it actually occupy only the border of  the tarsus, we
 must isolate it by two incisions  united in a V, remove it at the same
 time with the triangular  flap which includes it,  and have  recourse to
the twisted suture to unite the wound by first intention.   If the alte-
ration extends more in breadth  than in depth; if after its extirpation
we are of opinion that  we cannot approximate the  borders of the
wound, we excise  the  tumor  by a semilunar  incision more or less
elongated, or to a greater or less  depth, either with a very sharp bis- 
EYELIDS.
247
toury, or as M. Richerand prefers, with curved scissors, doing every-
thing in our  power not to wround the puncta or the lachrymal ducts.
The solution of continuity cicatrizes by second intention.   Gradually
the integuments approximate to the eye, and ultimately form a bor-
der which replaces in part the eyelid which has been destroyed.
  II. Cancerous  degenerations show  themselves,  moreover, in the
eyelids, as upon all other regions of the  body under various forms.
It does not follow, as has been supposed, because the cancerous tu-
mor  has extended as far as the  conjunctiva, that its extirpation be-
comes impossible, or that we are prevented from  having recourse to
this remedy.   M. Champion, who ventured to remove a large can-
cerous plate, and to perforate through and through the diseased eye-
lid, nevertheless  succeeded  perfectly  in the case which  he has  com-
municated to me.
   III. Again, the free border of the eyelid affected  with tylosis is
often transformed into a thick bourrelet, which in  ulcerating soon as-
sumes the aspect of cancer.  But this kind of granulous and ulcerated
border, which many  practitioners who denominate it noli me tangere,
prefer attacking by general medications rather than by active topical
means, is in  general  very readily removed under  the action of cau-
terization, by means of nitrate  acid of mercury.   Having reversed
the diseased eyelid outwards and protected the globe of the eye by
the usual means, I carefully  touch all the ulcerated surface, and even
the edges of the degenerated  border with a piece of lint, slightly
imbued with the caustic. These applications, renewed every four or
five days, for three weeks or a month, transform the cancerous into
a simple ulcer, and effect such a reduction in the surrounding tissues,
that  the wound  soon  cicatrizes and  permits  the eyelid to recover
almost all its pliancy.   I have, in this manner, cured  a number of
persons whom other  practitioners had  refused to treat otherwise than
by extirpation of the eyelid, and it is a method  which I cannot too
much recommend.
   IV.  If the case should be one of  a cancerous plate, of less thick-
ness than breadth, and  which did not extend to the  free border of
the eyelid, cauterization with the same acid or with the Vienna pow-
der,  or  better still with  the  zinc paste, would be preferable to the
knife ;  upon the condition, however, that upon the eyelids themselves,
there were no other than the teguments yet altered, and that  these
different caustics should be applied in such manner as to not compro-
mise the globe of the eye. I have often applied with entire success to
cancerous ulcers at the inner extremity of the upper or lower eyelid,
or solely and simply at the grand angle of the eye, a plate  or  thick
piece of zinc paste, according as it appeared desirable  to  cauterize
superficially or deeply,  and I am of  opinion that this caustic ought to
be substituted for the bistoury whenever the cancerous ulcer, plate or
tumor do not present well defined limits.

             § VI.—Ankyloblepharon, Symblepharon.

   A. The adhesions which  the  eyelids contract  with the eye  have
been observed at every epoch.   In order to destroy them, Heracli-
des, who employed the bistoury, lays down as a precept, that we 
248
NEW ELEMENTS OF OPERATIVE SURGERY.
should incline the edge of the  instrument  rather towards the  skin
than towards the eye, and in order to prevent the reproduction of
the adhesion should charge the patient frequently to move the organ
of vision in every direction.   When they are slight or but little ex-
tended, it is  sometimes practicable, as Alix says, to  tear them out
by means of a sound  or probe.  If they show themselves under the
aspect of bridles or lamella?, and we can succeed  in gliding under
them, upon the globe  of the eye, the blade of a canulated sound, we
may, according to  the direction of Maitrejan and Boyer, divide them
upon this instrument without any danger.   It is never allowable at
the present day, to raise up the eyelid by means of a thread while
we are dissecting it, as was the practice in the time of Bartisch.
Moreover, the important point is not the division of these adhesions,
but  to prevent  their reproduction.  The  movements of the eye,
recommended by  Heraclides, the  plates of lead,  gold,  or leather,
which  Solingen and others recommend to keep between the eye and
its connections, rarely attain  the object in view.  The porcelain or
glass eye recommended by Demours, and the plate of softened ivory
preferred  by M.  Carron, (Oper.  cit., t.  I., p. 264,) are scarcely any
better; inflammation  soon  renders the presence  of such  foreign
bodies  insupportable.   The most prudent course is to restrict our-
selves to  passing, from time to  time, a ring or the  head of a large
pin between the contiguous surfaces, in order that they may cicatrize
separately.  It is an operation after all, which, whatever M. A. Seve-
rin  (Med. Effic, part II., chap. 55, p. 215,) may say of it, ought not to
be attempted, except  in patients whose transparent cornea has con-
tinued  unaffected and  unchanged, at least opposite to the pupil.  The
case mentioned by this physician, who was  operated  upon twice by
A. Petit and Dussausoy, (Obs. Clin., art. 13, p. 181,) and afterwards
by a charlatan,  shows  all  the danger to be apprehended from an
opposite course.  Perhaps, however, we should then succeed if, after
having slit up the eyelid vertically,  as Guerin advises, (Soc Med. de
Montpellier, t. II.,  p. 285,)  we should keep  its flaps reversed up to
the period of the cicatrization of the bridles, and afterwards  reunite
them by  suture.
  B. Congenital or accidental union of the palpebral borders, always
a less  serious affection, may be complete or incomplete, and may
exist alone or at the same time with the preceding infirmity.   In the
first case, in place of acting with the bistoury from before backwards,
as the ancients  did,  upon the whole extent of the line  which the
natural division ought to occupy, we first make a small opening near
the temple, in order to introduce afterwards, through  this incision, a
canulated silver sound, which is a little concave on its back, in order
that it may accommodate itself to the convexity of  the  eye.  The
bistoury, guided by this director, would pass without danger from
one  palpebral commissure  to the other in following the  interline of
the eyelashes.  In the  second case the preparatory incision is not
necessary.   We insert the sound through the remains of the ancient
opening,  as was successfully done by Hevin,  (Pathol,  et  Therap.,
t. II., p. 135.)  In  a  patient operated on successfully by Quesnault,
(Lelong, These, No.  179, Paris,  1819,) there existed at the angle of
the eyelids a small opening, which partially allowed of vision through 
EYELIDS.                         249
it.  An opening existed also in the cases cited  by Botin and Seiler,
(Carron, Oper. cit., t. I., p. 257.)   Of the three brothers operated on
in this manner by G. Lagree, (Anc Journal de Med., 1760, t. XII.,
p. 157,) one died on the eighth day from marasmus.   After having
separated the eyelids, if ankyloblepharon should have  coexisted with
the disease, we must proceed to its destruction according to the rules
indicated above.   In  the  place of the bistoury  conducted upon a
sound, it would be practicable to employ scissors  bearing a ball of wax,
as J. Fabricius recommends, or a small button at the extremity of one
of its  blades, according to the  recommendation  of Scultetus.  But it
would be trifling to pass a noose of brass wire furnished withjcnots be-
hind the abnormal agglutination (soudure), as Duddell  did, and to ap-
proximate its two halves with the view of gradually dividing the bridle.
   Finally, no one at the present day would be so absurd as to imitate
F. de Hilden, by knotting  the two ends of this  noose and attaching
weights to it in order to drag it by degrees to the outside.  Inasmuch
as after every process  the disunited  borders retain, after the opera-
tion, a great tendency to become re-agglutinated,  the surgeon should
not neglect to place  between them, near the commissures,  some
strands  of  lint imbued with cerate, nor frequently to  separate them
apart by means of a metallic stem or ring.   To dissect  the conjunc-
tiva in  order  to unite it  afterwards  with the  skin by  means of a
suture, as M. Ammon  recommends, would often fail and presents too
many difficulties.   Three  points of simple suture  on each lip of, the
wound  near the commissure, would better attain our  object t and
would cause infinitely less embarrassment.
   C.  Simple phymosis, or  contraction (retredssement) of the eyelids,
should be treated like ankyloblepharon, and requires no other details.

     § VII.—Tumors.—Folds at the Great Angle of  the Eye.

   Two  kinds  of tumors, disconnected with the lachrymal passages,
have  been  noticed in the great angle of the eye ; one having the
caruncula lachrymalis  for their seat, the other placed between the in-
teguments and the direct tendon.  I know but one fact of this last kind,
and which belongs  to M. Besson.  The tumor, which existed on both
sides,  had the size and form of an almond: it was extirpated, and the
patient got  well.
  A.  The other kind is known under the name of  encanthis.   It
has been noticed by a great number of practitioners, and I myself
recently met with an example  of it in the month of December, 1837,
in a young girl of six years of age.  The disease may in these cases
assume the  character of different kinds of tumors, whether fibrous or
cancerous;   in general, however, it  presents itself under the aspect
of a small reddish granulated mass, slightly painful, and which seems
to prolong itself to  a greater or less distance in the orbit, and which
also protrudes more or less between the eyelids near the inner com-
missure.  Encanthis, unless it should be attacked at the beginning,
yields  neither to debilitating or resolvent means.  The ligature, em-
ployed in one instance by Purmann, would be suitable only to pedi-
culated encanthis.   It will be by  means of caustics or the bistoury
that we  shall succeed.   Among the first there are  scarcely any other 
250           NEW  ELEMENTS OF OPERATIVE  SURGERY.

than the nitrate of silver or the nitrate of mercury, which can be
applied  with  safety.  Potash, the butter of antimony, and the zinc
paste, would  in fact expose to too much danger of injuring the lachry-
mal  sac or the nasal extremity of  the eyelids.  Extirpation of the
tumor is in itself an operation  sufficiently delicate, inasmuch as it
would be easy to wound either the  puncta, the lachrymal ducts,  the
muscle  of Horner, the tendon of the orbicularis muscle, or in fine the
outer wall  of the lachrymal sac.  The patient ought to be laid on a
bed  of  sufficient  height, or seated  on  a chair;  an assistant placed
behind steadies the  head and attends to keeping the eyelids separate.
The surgeon, securing  the tumor with an erigne, which he immedi-
ately consigns to  a second assistant, isolates,  by means of a straight
bistoury, the  morbid mass, first below, then above, then inwardly, in
order finally  to dissect it from behind forwards, and from within out-
wards,  avoiding  with care the globe of the eye.  M. Fleury (Bull.
de la Fac  de Med., 1806,  p. 157,  or 1807, No. 2, 3 annee, p. 16,)
has  extirpated two  of them which were of the size of a large egg,
but  they were situated  upon the upper eyelid and not at the angle
of the eye.  M.  Carron du  Villards,  (Malad. des Yeux, etc., 1.1.,
p. 462,)  who says  that he has twice performed the operation of remov-
ing encanthis, perceiving that in one case it was a fungus and in  the
other a melanotic tumor, considered  it necessary to touch the bot-
tom  of  the wound with  the button cautery in his  first patient, and
with caustic  potash in  the second.  The palpebral artery,  which is
ordinarily divided by this operation, sometimes gives rise to a kind
of hemorrhage which is quite abundant, but which simple tamponing
generally arrests  without any difficulty.  The wound is then filled
with small balls  of lint,  after which a fine piece of linen perforated
with holes and imbued with cerate, and then a plumasseau of lint,
are placed above to cover the great angle.   After this nothing more
is required to keep on the dressing than to envelope the whole with a
compress and a  few turns of bandage in  the form of the monocle.
After the first dressing we reduce every day the size or the number
of the  small  balls of lint, and the wound generally cicatrizes in  the
space of from fifteen to twenty days.  It was in  this manner that
M. Marchettis succeeded in detaching a mehceromatous tumor which
extended  over even a  part  of  the transparent cornea,  but he had
recourse to the scissors to terminate his operation.
   B. Epicanthis.—Should the fold of integuments, which  from  the
root of the nose sometimes advances forward in the form of a crescent
upon each side, as  if for the  purpose  of covering the caruncula la-
chrymalis, have  too great an extension, patients might readily be
relieved by means  of an operation which MM. Ammon  and Car-
ron, who designate this deformity  under the name epicanthis, have
frequently  employed with success.   Raising  up the skin at the root
of the  nose,  a vertical  elliptical flap  is excised, of  such dimensions
that the approximation of the lips of the wound by suture will imme-
diately  cause the disappearance of the two angular crescents.   If
before excising it we should  pass  pins or threads through the base
of the cutaneous  fold, the operation would  be still more simple.
   [Mr.  Dalrymple, a surgeon of London, (Cormack's Journ., October,
1843, p. 952,) has had occasion  to  remove from the upper eyelid an 
ORBITAR CAVITY.
251
encysted tumor about the size of a pea, composed of closely agglu-
tinated epithelial  scales, containing granular earthy  molecules, in-
stead of being composed as is usual of thin transparent laminas, with
a central nucleus. T.]

                 Article IV.—Orbitar Cavity.

  Loupes, encephaloid masses, aneurisms, exostoses, &c, may be de-
veloped in the  interior  of the  orbit.   The  lachrymal gland itself
sometimes acquires a considerable volume in passing  into the con-
dition of schirrhus.  These different lesions, whose especial peculiar-
ity is to push the  eye forwards, and at  the  same time to incline it
towards the point opposite to that at  which they are situated, have
often given  occasion  for its  extirpation.  Nevertheless, so long as
the globe is not  itself implicated in the degeneration  it  may be saved.
This is indisputably demonstrated by an elegant operation of Acrel,
the case related  by M. Cantoni, (Journal des  Progres, t. XIII., p.
256,) that of M. Gerdy, (Archi.v.  Gen.  de Med., t.  VIII.,  p. 339, 2e
serie,)  and the  practice of Dupuytren, (Clin, des Hopit., t.  III., p.
196.)  An ancient memoir of Daviel and Guerin of Bordeaux proves,
on the other hand, that the lachrymal  gland has often been extir-
pated with success  by those  two surgeons.   M. D. Lasserve (Cas
de Chirurg., &c, p. 52,  fig. 15,) has extirpated from the  orbit of a
woman a cyst  which strongly protruded the eye outward, and  the
interior of which was cribbled with  hairs.   Even osseous tumors
may be removed  without injuring  the eye,  either by  the  chiseLand
mallet, or by tractions or well-directed movements, as is proved by
the case related by  M. Sultzer.   The  rules to be followed for extir-
pation, either1 of the lachrymal gland or of any other tumor situated
in the  orbit, will  have necessarily to vary according to the volume,
form, nature and seat  of the disease.   If, for example, it was only a
cyst  filled with matters  more or less liquid,  nothing more might be
required than to plunge a bistoury into it, and to keep its cavity open
by means of a  meche of lint.  MM. Schmidt  and Rutdhorffer, in
fact, who have often met with cases of this kind, consider that punc-
ture with a trochar would be sufficient.  Ware (Mai. des Yeux, p. 188,
1805,)  cured his patient of a serous cyst, which he  had in the orbit,
by means of sixty-three  punctures.  Guerin  of Bordeaux,  supposing
that he was  to extirpate the lachrymal gland or a cancer, perceived,
after he had passed through the eyelid,  that  he had  fallen upon
a tumor filled with semi-liquid matters ; he  opened and emptied it,
and introduced  a tent into it, after which  the  cyst  exfoliated  on
the  twenty-first day.  Spry, who fell into  the same error in 1755,
would have probably preserved the sight of his patient if, instead of
going on to extirpate the eye,  he had had the prudence of Guerin.
The  liquid humors  mentioned by St. Yves,  (Mai. des  Yeux, p. 188,
1805,) Pellier, (Obs. sur  VCEil, &c,  p. 40,) and  M. Graefe, (Archiv.
Gen. de Med., t.  VIII., 2 serie,) the collection of hydatids described by
M. Lawrence, (S. Cooper, Diet,  de  Chir.,  &c.,) and M. Travers,
(Synopsis, &c,  p. 229, 235, 1821,) the meliceroma, steatoma, glairy
cysts, and purulent collections, indicated by St. Yves (Oper. cit.)
and MM. Lawrence, Richerand, Guthrie, (Mai. des Yeux, p. 147,148,) 
252
NEW ELEMENTS OF  OPERATIVE SURGERY.
and  Travers,  (Oper. cit,  p.  229,) are  to  be treated  in the same
manner.
                              § II.

  In respect to solid tumors, there are two modes of removing them.
Whether they are osseous or osteo-fibrous tumors, as in the cases of
Baillie, MM. A. Cooper, Crampton, (Mackenzie, p. 56,) and Travers,
(Loc. cit.) fibrous, adipose,  or cartilaginous tumors, like those men-
tioned by M. Mackenzie, (Ibid.;) or even exostoses, properly so called,
examples of which are given by Sue,  J. L. Petit, (Mai. des Os, t. II.,
p. 303,) and Brossaut, (Mackenzie, Op. cit.,  p. 48, 1830,) they are
notwithstanding to be extirpated.
  A. Process  of AcreL—The  whole thickness of the eyelids is to be
divided in the natural direction of their curvature, near their root, and
upon the point corresponding to the most prominent part of  the tu-
mor.   An assistant then separates apart the lips of the wound.  The
surgeon, by means of a narrow bistoury, guided by the forefinger of
one of his hands, isolates the tumor from the orbit, secures it with an
erigne, dissects its inner surface, in order to separate it from the eye,
either by the finger or the cutting instrument, and makes an effort to
remove it from its apex to its base.  It was in this manner that Daviel
and Guerin proceeded, and none of their patients  died.   Although in
one of their cases the tumor had, on its inner side, a groove adapted
to the  optic nerve, and that in  another  there supervened an enor-
mous tumefaction of the eyelids with severe fever, all preserved their
faculty of vision.   It might at first have been doubted if the lachrymal
gland itself had  actually been  extracted;  but Guerin  dissected it
after the operation,  and made even  a model  of it in  plaster;  the
original of which, preserved by him in alcohol, he exhibited to the
Academy of Surgery.   It  is moreover  an operation which,  at the
present day, is  perfectly well understood.  MM. Todd, Lawrence and
O'Beirne have performed it in England  with  no  less  success than
Daviel, Guerin and M.  Duval in France.   The treatise of M. Mack-
enzie gives two other instances of it, and Warner, as well  as M.
Travers, had already had  recourse to it.  I have seen  a woman in
whom M. J. Cloquet performed this operation, so effectually that there
was  no longer any flow of tears on this side.
  B. Process of the Author.—In my view, we could attain our object
better than by the process  of  Acre!, if we  were to  commence by
prolonging the external commissure towards the temple in such man-
ner as  to be able to reverse the eyelids.  Different trials have satis-
fied me that by acting in this manner we  may readily lay bare the
two outer thirds of the  orbital circumference.   This being done, the
surgeon separates the tumor he is about to remove from the  osseous
cavity  which contains it, by dividing the cellular tissue  from  its ex-
ternal surface; dissects it down to its greatest depth, isolates it with
every  possible precaution,  either from the  muscles, optic nerve, or
globe of the eye itself, and draws it to the  outside by means  of the
finger or an erigne.  For more facility, it would  be well perhaps to
circumscribe it also by a semilunar incision on the side towards the
transparent cornea.
  It must undoubtedly have been through inadvertence that an ob- 
ORBITAR CAVITY.
253
lection has been made to this process of incurring too great a risk
of wounding the ducts of the lachrymal gland, (Archiv. Gen. de Med.,
t. VIII., p. 354, 2e  serie ;) for if  they required the attention, this
process would enable us to  respect them still better than that which
consists in penetrating into the orbit through the upper eyelid.
  C. Sequela.—After the operation there sometimes succeeds such
an extensive swelling that it is not unusual to see the eye at  the end
of three or four days make as  striking  a projection as it did before.
But this condition of things soon subsides.   In the space  of from
ten to thirty days everything returns to its normal condition, and the
cure usually takes place.  Immediate reunion ought not be attempted
in either process, since  the cavity which is left in  the orbit, cannot
immediately be filled up, and  that the  tissues, lacerated rather than
divided  are obliged to suppurate.   In a  patient whose wound closed
up too rapidly, Guerin  saw supervene  symptoms so formidable that
he found himself obliged  to break the cicatrix with a sound.  All
that is necessary then, is to  dress with a meche or tent imbued with
cerate, to approximate  the wound at the palpebral angle, if it has
been found necessary  to divide it, and to cover  the whole with
plumasseaux, and then by some compresses, which are kept in place by
the bandage called the monocle.  When the suppuration is established
the dressing should be renewed every day.   Injections often  become
necessary, and we do all in  our power to.enable the solution  of con-
tinuity to close up from the  bottom to the exterior.   If by traversing
the eyelids we  should render the  operation more easy, even though
the deformity which it involves  would necessarily have to be  greater,
we ought to give the preference to this manner of proceeding; but
unless the  tumor  should have acquired  an  enormous volume this  is
not the case.   The incision  of the outer  palpebral angle  will always
enable us to procure a  sufficient degree of separation, even though
there  should have been alteration of the bones, to enable us to re-
move the tumor as well as the necrosed  splinters, as was the case  in
one of the patients of Guerin.   In a case of M.  Hope, the tumor,
which had existed for seven years, had so elongated the optic nerve,
that it became  necessary to push back the eye  with the hand, and  to
keep it fixed there by means of a bandage ; the cure, nevertheless, was
complete.   In  a  young woman whose indocility was uncontrollable,
M.  Wardrop bled her to the  amount  of fifty ounces of blood,  in
order to produce syncope, which enabled him to perform the opera-
tion with so much ease and success, that the patient coming to  her-
self, could scarcely  believe it.  In a case of pancreatoid sarcoma
mentioned by Bouttate of Moscow, (Abernethy, Mel. de Chir.  etrang.,
t. II., p.  453,) the tumor, which was seven inches in length, and three
and a half in  circumference, weighed  two pounds and a half.   It
was intimately united with the conjunctiva, which it pressed upon ;
but it was  not difficult to isolate its base from the cornea, which had
preserved  its transparency.   After the ablation, the patient recovered
his sight. 
254           NEW  ELEMENTS OF OPERATIVE  SURGERY.
                Article  V.—Globe of the Eye.

                      § I.—Foreign Bodies.

  Numerous and various kinds of foreign bodies may become fixed
on the eyelids or on the  front part  of the eye, in the same way as
between the eyelids and the eye.   Besides  the ordinary signs which
reveal their existence, I have  ascertained, like Andrieu, (^liu's. au
Citoyens, &c, p. 19, 1780,) that pungent and fixed pain correspond-
ing to the middle  of  the upper eyelid, indicates the presence of a
foreign body upon the  cornea ;  in  the same manner  as those which
are concealed in the  oculo-palpebral  fold  of  the conjunctiva, are
announced by a  dull pain,  which corresponds to the upper border
of the tarsal cartilage.
  A.  The ciliary border of the eyelids is sometimes invaded by in-
sects.  A young  peasant girl who had this part of the coverings of the
eye transformed into  a brownish  colored border, and who  suffered
from it to a considerable degree, carried there so great a number of
pediculi pubis that M. Champion, who was then consulted, could have
never believed it possible that so many of them could have attached
themselves upon so narrow a space.  In such cases, all that is neces-
sary is, to cause  the parts to be rubbed with mercurial ointment, that
of white precipitate, or the pomade of  Desault, and no operation is
to be attempted.  There  have been seen, moreover, different sorts
of worms  either in the  ulcerated  border  of an eyelid,  or at the
bottom of the oculo-palpebral groove.  We have already an example
of this kind in the Ephemerides of the Curiosa Naturae, and  we owe
to M. J. Cloquet the  history of a  man,  who had the eye and the
orbit deeply excavated by a species of worm known under the name
of asticot.   I  have also met with  a patient, who being  habitually
uncleanly, and for  a long time tormented by a ciliary blepharitis,
had six enormous asticots at the great angle of the eye, between the
inner extremity  of the upper eyelid and  the caruncula lachrymalis.
The mode of destroying  them, moreover, is the same as for the
pediculus pubis,  and other insects.   It is also probable that camphor,
so  much  praised by M. Raspail, (Gaz.  des Hopits, Novembre et
Decembre, 1838,) if it  were associated with mercurial topics, would
give them still greater  efficacy.
  B.  Foreign bodies of a certain  size may also sometimes remain
implanted  for a  considerable length of time in  the eyelids or front
part of the eye without  being  perceived  there.   A young man
entered the hospital of La Charite, in 1837,  with a sub-acute ophthal-
mia.   The cornea preserved its transparency ; a grayish colored che-
mosis with an erysipelatous tumefaction  of the upper  eyelid, which
phenomenon was more marked in the direction of the temple than
towards the nose,  immediately struck  my attention.  The young
man, who suffered  but little, did not know to what to attribute his
malady, which had existed for the  space  of fifteen days.   By dint
of researches, I finally discovered  in the  superior  oculo-palpebral
groove, the yellow  extremity of a body which  I immediately  seized
with a forceps, and which  was nearly an inch in length and a line and 
GLOBE OF  THE EYE.
255
a half in diameter.  It was a piece of hay-stalk, which had penetrated
into the orbit while the patient was asleep upon a  cart loaded with
hay.   Borichius (Collect. Acad.,  partie etrangere,  t.  VII.,  p.  321)
speaks of a thorn  which in, this  manner remained  for  a  period  of
thirty years in the inner angle of the  eye before it occasioned any
pain, and which ultimately  produced  a violent inflammation.   A
stem which was more than an inch long, and which entered the orbit
through the eyelid, remained there also, says  Willius, (Collect. Acad.,
t. VI., p. 248,)  a very long time without being recognized, though it
produced very serious accidents, with delirium and convulsions.
  C. Fragments of whalebone of a  line or two in length have, in the
same manner, become lost under the conjunctiva in a patient men-
tioned by St. Yves, (Mai. des Yeux, p. 210, art.  12.)  Bidloo, Schar-
schmidt and Percy (Chirurg. d'Armee, p. 112, 113,) give similar in-
stances of pieces of wood, glass and pipe-stem.   M. Maunoir (Corps
etrang., 1812, p. 212)  speaks even of portions of chesnut shells which
have thus become fixed on the front part of the globe of the eye; and
M. Champion  has noticed the  same thing.   There  haye also  been
seen hairs that had grown from the caruncula lachrymalis, as in the
case cited by Albinus, and become incurvated outwardly so as to give
momentary irritation  to the eye.   Demours (Seance de l'Academie de
Med., 22d May, 1828) speaks of a  barb of a barley ear which had
introduced  itself into the lachrymal punctum in such manner as to
project outside, but  to a very small extent.  A case  also has  been
mentioned which was noticed by Dupuytren (Archiv. Gen. de Med.,
t. XVII., p. 126),  and in which  an eyelash  had, by  curving back-
wards, become entangled in one of the lachrymal puncta.   I will
add that a woman who thought she had a small tumor on the sclero-
tica, at the  outer angle of the  eye, and who had carried this pre-
tended tumor  for the space of nineteen months, had there nothing
more than a particle  of millet seed, which had  come  out of a  bird-
cage, and  which appeared  to  have been kept  in its place  merely
by atmospheric pressure.  I have  seen the  same thing on various
other points of the globe of the eye, and even on the cornea.  In
all cases, the little cup  reposed  by its concavity on the eye, and
seemed to have  embedded itself into  the conjunctiva.  I have also
found on  the cornea small scales, either of cinder or copper or iron,
which had retained their position in the same manner for the space
of several weeks  without occasioning serious accidents.  A patient
whom I exhibited at the clinique of La Charite, in 1837, had one of
these scales in the front part of  the cornea for the space of fifteen
months, and had paid so little  attention to it that it was for another
disease that he was  induced to  come to the hospital.
  D.  A gold or silver ring, the head of a long pin, a small roll of
paper, an earpicker, or any other smooth and round substance, will
answer for removing the different solid  foreign bodies which continue
movable  between the eyelids;  but it is not always the same with
particles  of metal, stone, wood,  &c, which  having been projected
upon the organ of vision, become fixed and retained there.   In such
cases, when we are not afraid of breaking them, the point pf a pen,
cut  in the  manner of a  toothpick, or any other similar instrument  *
glided upon the front part of the cornea often succeeds in detaching 
256
NEW ELEMENTS OF OPERATIVE SURGERY.
  them.  At other times we cannot  do this except with the point of a
  lancet, and in some cases even only by making use of a small pair of
  forceps skillfully managed.   It is only under very rare circumstances,
  and when the ferruginous corpuscle is scarcely adherent, that the load-
  stone, as recommended by F. de Hilden, (Bonet, Corps de Med., p. 393,)
  (who boasts much of the successes thus obtained by his wife,) could
  be usefully employed.   The same remark would apply to the roll of
  Spanish wax employed by Deshayes Gendron,or to a piece of amber
  to attract to the outside particles  of straw.   When we decide upon
  the operation an assistant is  charged  with holding the eyelids apart.
  The operator directs the point of a lancet or of a very sharp-pointed
  bistoury  to the circumference of the  foreign  body, which he  isolates
  down to  a certain depth in  the substance of  the cornea, then seizes
  hold of it with  a very  fine and well adjusted  forceps, draws it while
  moving it gently for fear of breaking it, and  afterwards  pursues the
  same treatment as  in  a patient having an  ordinary ulceration or
  simple ophthalmia.   This operation moreover does  not in itself pre-
  sent any  difficulty ;  it merely exacts address and great precision in
  the movements.  Moreover, when the body to be extracted projects
  beyond the level of the eye, if it is solid and does not penetrate into the
  chambers, we almost always succeed  in detaching it by scraping it
  with the  border or the side of the point of a lancet or cataract needle.
     E.  If, as I have seen in different patients, grains of powder, or lead,
  or fragments of percussion-caps, glass, metal, or of a watch-spring for
  example,  should  happen to  penetrate  into the eye, we should, sup-
  posing that they could be perceived, not hesitate  to cut into either the
  cornea or sclerotica in order to search for and extract them with an
  ocular forceps,  or cause their expulsion in any manner whatever.

                 § II.—Various kinds  of Vegetations.

     A.  Pterygion.—When, by means of resolvents  judiciously em-
  ployed, we have not been able to disperse the pterygion, and that it
  advances upon the cornea to such extent as  to  make us  apprehend
  the loss of the sight, it must be removed by means of the bistoury or
  the scissors.  The section of the vessels which  go to it, and which
  Beer still recommends, its strangulation by means of a thread passed
  between  the conjunctiva and sclerotica, as  preferred by La Vau-
  guyon, and also cauterization, have succeeded in  more than  one
  instance ; but as all  these means are uncertain and more difficult of
  execution than excision, they have generally been  abandoned.   In
  order to  remove the pterygion we seize hold  of  it with a good pair
  of forceps in one hand, at one or two lines from its point; we draw
  upon it a little towards ourselves as if to detach it; and soon perceive
  a  slight  crackling sound  similar to that  of unrolling  parchment.
  Then it becomes easy to isolate it either from its apex to its base, or
  vice versa, as  M. Flarer recommends, (These  de  Lefebvre, Paris,
  1829,) by means of  the bistoury or a good pair  of scissors.   As the
  cornea rarely resumes its primitive transparency opposite the wound,
  Boyer recommends with reason, as I think,  when  the point of the
•  pterygion has approximated very near the pupil, not to prolong the
  dissection as far as that, but to excise only  the  posterior four-fifths 
GLOBE  OF THE  EYE.
257
of it.  Emollient lotions during some days, and afterwards resolvent
applications, as in all chronic phlegmasias of the conjunctiva, consti-
tute its consecutive treatment.   I have operated for pterygion by this
process, in  patients who had two, three, four, and even five of them
on the same eye ;  I have never found any serious difficulty in it, and I
cannot comprehend either the dangers which M. F. Cunier (Bulletin
Med. Beige, t. I., p. 296)  charges it with, or the importance of the
methods which have been proposed to be substituted for it.  When
the  pterygion is not  very thick,  Scarpa  is of opinion that in the
greater  number of cases it is sufficient  to  excise a  semilunar  flap
from it opposite the point of union of the sclerotica with the cornea,
and that in other cases we may destroy it entirely; that in order to
prevent a cicatrix raised up in the form of a border, we should first
detach the  apex, then the base, and finally terminate with its middle
portion.   I do not, however, conceive that this  last  precaution  can
be of any great moment, and partial excision, which I have tried in
three instances, has not succeeded with me.   In all cases it is pru-
dent to  follow the advice of Boyer, and to apprize the patient  that,
notwithstanding  the  operation,  he may not  be perfectly cured,
because of the species of spot which is too frequently the result of it.
  B. Pannus.—The  periphery of the cornea  is sometimes covered
by a grey  or reddish  flattened vegetation, granulated like the back
of the tongue, indolent, from a quarter to a half a line in thickness,
and advancing more or less, in the manner of a ring, on the transpa-
rent portion of the eye.   In certain  cases, however, this variety of
pannus  forms only the  segment  of a circle, while in others there
appear to be  detached from it semilunar or triangular plates, which
prolong themselves a little farther than the rest  upon the cornea.
M.  Graefe (Revue Med., Mars, 1818, p. 464)  gives an instance of
one which  entirely covered both eyes.  Nothing but complete excis-
ion or cauterization can remove this disease.  If the pannus has but
little thickness and is entirely circular, the nitrate of silver answers,
and should have the  preference.   When  it ]£  more solid  and forms
somewhat  large plates,  excision  by means  of a lancet or  cataract
needle held flatwise, (portee en dedolant,) followed immediately after
by  cauterization,  is  more  appropriate.   A  vegetation of the same
kind may  be developed  upon the  cornea and remain  completely
independent of the conjunctiva.  I saw a remarkable example of this
kind in a forgeman, forty-five years of age.  The plate, which was
half a line thick, more than three lines long, and a line and a half in
breadth, placed transversely and slightly concave above, was situated
below the pupil, and left a very perceptible and perfectly sound strip
of cornea between its lower border and the sclerotica.  I destroyed
it three  times with the nitrate of silver, and three times the patient,
who was very anxious to resume his occupations, left the hospital
before being absolutely cured, and at the moment when there was the
best reason to hope for a perfect cure.
  C. Horny Plates.—M. Mirault speaks of a production which is much
more singular still.  The cornea of a man affected with trichiasis from his
infancy, was covered with a kind of dirty white dry, and as it were, scaly
skin. It was probably a xerophthalmia. Similar productions, or such as
                                17 
258
NEW ELEMENTS OF OPERATIVE SURGERY.
were horny, have also been encountered on the front part of the eye
in certain individuals  affected with ichthyosis.
  D. The cornea is also liable to other excrescences. Guerin makes
mention  of a young person of Macon, who had a fleshy tubercle as
large as a pea on the  front part of the pupil, and which  he cured by
one  cut of the scissors.   Some of them may be compared to navus.
M. Wardrop gives  examples of them.   In one case, the tumor was
granulated,  of a brownish  color, and  but little  vascular.  It  was
softer, of a reddish color,  and placed half on the cornea and half on
the sclerotica, in another patient.  In a third case, three long hairs
proceeded from it, and protruded like  a  pencil from  between the
eyelids.   The same  author quotes  a case similar to this last, in the
Baron of Gloucester,  and remarks that Gazelli  had also seen  hairs
growing from the cornea.
  E. Among these  tumors, there are some of them that are analo-
gous to vegetations from the mucous  membranes.   These are a sort
of fungus.   M.  Wardrop has seen  two examples ; one  irregular,
granulated,  and partially  on  the  sclerotica; the  other darker and
more solid.   In  a case cited by Voigtel, a cartilaginous point was
found in the centre.   Sometimes also the tumor  derives  its  origin
from an ancient  ulcer.  Maitrejan gives an example of this;  but it
appears that in his patient, the fungus came rather from the interior
of the eye, than from the  cornea properly so called.  These  differ-
ent projections can only be cured by excising them completely; also,
we must take  care to cauterize the bottom  of  the wound immedi-
ately, if we expect to  prevent all  return; it is in this manner that
Pellier succeeded in a patient who had a tumor of this kind caused
by a burn from gunpowder.

                        § III.—Cataract.

  Although Galen and the Arabs had already pointed out the nature
of cataract, centuries passed away before it was generally understood.
The pellicle which constitutes the disease  is situated,  according to
Culsus, between the uvea and  the crystalline ; on the  contrary, ac-
cording to Guy  de Chauliac and G. de Salicet,  between the iris and
the transparent cornea.  What contributed most to give prevalence
to such  errors,  was  the  idea  that  the  crystalline  was the seat of
vision.   Therefore, as soon as Kepler had demonstrated in  1604, that
the  lens of the eye was no other than a refracting body, an actual
surgical revolution was promptly brought about on this  subject. Gas-
sendi, who wrote in 1660, as well as  Palfin and Marriotte, attribute
to R. Lasnier or F. Quare, the honor of  having  first  sustained the
idea that cataract does  not depend  upon an accidental pellicle, but
on  an opacity of the crystalline.   Schelhamer, who imparted it to
Rolfink, had taken the idea from a surgeon of the  Hotel Dieu.   Bris-
seau, Mery, P. du Petit, Borel,  Tozzi, Geoffroy, Albinus, Bonnet, and
Freytag, had  also without doubt derived  it from  the  same source.
But it is to Maitrejan to whom we are indebted for having placed the
fact beyond all dispute.   In going from one error they were upon
the  point of falling into another ; in place of never seeing cataract
in the crystalline, it was now  maintained that  it was always there. 
GLOBE  OF THE EYE.
259
Ph. de  la Hire, Freytag, and Morgagni, did not succeed without
difficulty in establishing  the  fact, that this malady may also be pro-
duced by the opacity of  the capsular membrane.  It was S. Muralt,
Didier, Heister, and  Chapuzeau, for whom it was  reserved  to de-
monstrate, without rejoinder, that cataract is produced by  opacity of
the crystalline, that of its capsule, or of the matter in which it floats,
and not always that of one part only.
  A. Cure without an operation.—Though since the time of Celsus,
who was the first that has spoken lucidly on this subject, it has been
acknowledged  that confirmed cataract is rarely  cured except by the
operation, properly so called, we should nevertheless be wrong in de-
nying absolutely, the efficacy of any other treatment.
  The  cataract which is seen in scrofulous, scorbutic and syphylitic
subjects, or in consequence of an inflammation  or any other disease
in the neighborhood of the eye, has disappeared in more than one in-
stance, either spontaneously with the constitutional disease, or under
the influence of general or local  treatment judiciously directed.
Maitrejan, Callisen,  Alberti,  Gendron, Murray, Richter, Ware, and
many others, have  given examples of this kind.  Hyoscyamus ap-
plied to the eye according to M. Nostier, or a simple seton to the nape
in the  opinion  of M. Champesme, (Arch. Gen. de  Med., 1.1., p. 290,)
have succeeded in curing cataracts of very long standing.  M. Die-
trich recommends that we should arrest its development by repeated
punctures  to the eye, and M. Schwartz (Revue Med., 1828, t.  III.,
p. 126) has cured  three cases by means of  revulsives, &c.  With
MM. Rennes,  (Archiv.  Gen. de Med., t.  XXII., p. 206), P.  Delmas
and Manoury (Biblioth  Med., 1827, t. IV., p.  185), I have seen it
disappear spontaneously. M. Janson (Hotel Dieu de Lyons, Compte
Rendu, 1824, p.  83) also gives two  examples of this kind.   MM.
Larrey and Gondret affirm, moreover, that they have obtained simi-
lar results by means of moxas, the actual cautery, or the ammbniacal
pomade applied upon different points of the  head,  especially to the
sinciput.   Without admitting as certain with M. de Blainville (Nouv.
Bull, de Sc. Med.,  Fevrier,  1835, p. 31,) that  the crystalline  may be
formed by its capsule; without conceding also with  M. Campaignac,
that  cataract is  only a symptom of disease of the  envelope of the
crystalline, it must at least be admitted that the cataract which re-
sults quite  frequently from  wounds  of the eye, is to be ascribed as
M. Watson  (Arch. Gen. de Med., t. XII., p. 610) asserts to inflam-
mation of the neighboring lamellae.   The repeated experiments of M.
Neuner (Journ. de Prog.,t. VIII., p. 117;  Bull, de Ferussac, t. XIV.,
p. 194) have since  shown with what facility opacity of the crystal-
line may be produced, by means  of certain  liquids  introduced  into
the eye.  The experiments  and observations still more varied of M.
Dietrich, (Bull, de Fer., t. VI., p. 84 ; Arch. Gen. de  Med., t. XII., p.
295,) Tartra, Beer, and Szen, though contradicted by those of M.
Watson, exhibit the decided influence of  wounds and certain acids in
the formation of some  cataracts.   A cataract from  infancy  was
cured  by the evacuation of a brown matter, by means  of a small
puncture into the capsule.   The crystalline, which was sound, re-
mained, it is said, (Gaz. Salut., No.  5, 1783,  p. IV) in its  place in
both eyes, and the sight was reestablished !!   From hence, without 
260           NEW ELEMENTS OF  OPERATIVE SURGERY.

doubt, came the new method of M. Jungken, (Arch. Gen. de Med.,
2e serie, t. X., p. 93.)   It is doubtless  difficult to believe that the
crystalline, which is an inert body and the actual product of an exu-
dation, and which receives  neither vessels  nor nerves, can recover
its transparency after having actually lost it; but pus and other pro-
ducts which may be deposited in front of it, as in the three, examples
related by M. Boudant, (Arch. Gen. de Med., t. XXIII., p. 429,) being
in more direct relation with the iris or ciliary circle, would be more or
less  influenced by the  particular  state of the eye and the genera]
constitution of the individual.  It  is  also well established at the pres-
ent  time, that  traumatic  cataract very frequently gets well without
an  operation.  The  case of cataract caused by a  blow on the eye
from the branch of a tree, as mentioned by M. Mondiere, (Arch. Gen.,
third series,  t. II., p. 352,) ultimately disappeared spontaneously.  I
saw a similar case at the Hospital  of La Charite in  1836.
  A young peasant, of fifteen years of age, was struck upon the eye
by the free extremity of a  small  green twig of a tree.   A cataract
was thereby immediately produced, which was  perfect when first
brought under my notice, at  the expiration of fifteen days.  In order
to reduce the inflammation which  existed in the eye, and also to faci-
litate the cure of the cataract, I had  recourse to bleeding at the arm,
a few leeches to the temple,  frictions around the orbit with the mer-
curial pomade combined with  belladonna, and afterwards to a large
temporary blister over the cutaneous surface of the eyelids.  After hav-
ing become broken up into many fragments, which successively passed
into  the  anterior chamber,  the crystalline  ultimately became com-
pletely dissolved, so much so, that the boy, after having been in the
hospital two months, left there almost  perfectly cured, and with a
pupil which presented only one single small opaque point.   I saw a
similar result in 1837, in a young lady wrho wounded her eye with a
pair of scissors.  Another example  occurred at La Charite in 1838.
Some of the  observations also related by M. Convers, (Gaz. Med.,
1838, p. 513,) fully corroborate this fact.  In a child of five years of
age, mentioned by M. Gerson, (Arch. Gen. de Med., 2d series, t. VIII.,
p. 224,) the cornea having been  wounded  by the  point  of a  knife,
a cataract was thereby produced,  which  got well spontaneously.
Nevertheless, if on changing its color, the crystalline evidently un-
dergoes a molecular action subject to the laws of chemistry, and if
spontaneous  cataract is not  the product of either an electric action,
or of that species  of oxydation suggested by MM. Richerand and
Leroy,  it would be still more difficult to refer it constantly, with M.
Campaignac, to alterations in the secretion of its capsule.   Such being
supposed to be the case, we cannot see why, by a contrary combina-
tion, it might not sometimes be possible for*it to return to its primitive
condition.  M. Luzzato (Encyclogr. des Sc. Med., 1836, p. 405,) speaks
of a patient who, after having been a long  time afflicted with cata-
ract, was cured of it by a violent ophthalmia.   On the other hand, the
crystalline capsule may be torn and place the lens which it contains
in contact with the humors  of the eye, which in their  turn effect its
solution  or  favor its  absorption, facts of which description we have
on  record.   The crystalline having passed into  the anterior cham-
ber, in a patient of Ansiaux, (Clin. Chir., 2d edit., p. 161,) ultimately 
GLOBE  OF THE  EYE.
261
became  dissolved there.   This body disappeared in the same man-
ner in the case cited by M. Bobillier,  (Rec. de Mem. de Med.  Chir. et
Pharm.  Mi lit., t. XVI.,  p. 240,  1825,)  and I  have seen the same
thing occur in three instances.
  B.  Surgical  Treatment.—Surgeons, moreover, have attempted,
from the remotest antiquity, to destroy cataract by means of particu-
lar instruments.   Celsus  in fact leaves it to be inferred, that among
the physicians of Alexandria there were many, especially a certain
Phyloxenes, who had  acquired  in  this respect a  very great degree
of skill.
  Conditions.—I. If the cataract be  simple, if it  has its seat in the
crystalline  or has not contracted  any unnatural  adhesion with the
surrounding parts, if the iris retains its power of contracting and
dilating  alternately, if the patient still  distinguishes light from dark-
ness ; if no inflammation exists either in the eye or in the periphery
of the orbit;  if there be  present neither  cephalalgia,  nor a catarrhal
affection, nor any general disturbance;  if the  eyes  are neither too
projecting or  too much sunken in their socket; if the  patient is not
too much advanced in  age, and if he is sufficiently tractable to sub-
mit to all the necessary treatment, the chances  of  success are as nu-
merous  as could be desired.  When, on the contrary, the patient is
enfeebled by age, that spots exist upon the cornea, that the  pupil re-
mains immovable, that a greenish tint is observed at the bottom  of
the eye, that deep-seated  pains  are  felt or continue to exist in the
orbit, that a chronic ophthalmia or any other malady tedious  and dif-
ficult to cure, and more or less serious in its character, exists in the
neighborhood of the  eye, we cannot count on success.  In other
words, so often  as the crystalline and its capsule alone are diseased,
that apart from  the cataract the organ is in a natural  state, and that
there is nothing in the orbit that  prevents  the reestablishment  of
vision, then, whether the cataract be  true or false, formed by plastic
exudation,  (Simmeon,  Bull,  de  Fer., t. X.)  or  by a return of the
crystalline to its embryo condition, (Grandclaude, Journ. Comp. des
Sc. Med., t. XXXI.)  whether the cataract be lenticular, capsular, or
capsulo-lenticular,  anterior membranous or  posterior membranous,
hard or  soft, milky or gypseous, barred, oscillating, stellated, pearly,
with three branches or central, purulent, putrid, spotted or trellis-like,
marbled, dry or husky,  sanguineous, dendritical, yellow,  grey  or
black, the operation should  be recommended.   In other cases, and
especially  if it  is complicated with  infiltration of  pus (Dujardin,
These, Paris, 1830) or blood into the little receptacles of the vitre-
ous humor, it should  not be undertaken but as a dernier resource,
when every thing had failed, and not until after having forewarned
the patient  of the slight chances that  exist of a cure.  Nevertheless
we must not allow ourselves to be deterred by appearances.
  The immobility of the pupil  is not  a  certain sign of  amauro-
sis.  Wenzel, Richter, MM.  Larrey,  Watson, S. Cooper, &c, have
shown, as I have often myself seen, that adhesions of the iris or con-
tractions of its opening after an  iritis may also produce it, and also
that it will dilate and contract itself though the retina be paralyzed.
I  have many times seen  dilatation with immobility  of  the pupil, in
patients affected with  cataract without  complication of amaurosis. 
262
NEW ELEMENTS OF OPERATIVE  SURGERY.
 Others nave remained with a movable, narrow and very regularly
 formed pupil, without  recovering their vision.   Some patients  who
 could not in any manner distinguish day from night have, after  hav-
 ing been  operated on, been more fortunate.
   II. Black cataract, (cataracte noire,) which had already been noticed
 by Guy de Chauliac, Morgagni, Rolfinck and Freytag, and of which
 Maitrejan,  Janin, Pellier, Arrachard, Wenzel,  A. Petit, Edwards,
 Coze, (Dujardin, These, Paris, 1830,) and MM. J.  Cloquet, Riobe,
 Luzardi and Sanson, (Journ. Univ. des Sciences Md., Juillet, 1819,)
 have related examples, is too rare to arrest the attention of an intelli-
 gent  operator, even in supposing, which is not demonstrated, that it
 may  exist without changing  of the color of the pupil.  A young girl
 twenty-six years of  age, blind in the usual way that patients affected
 with  cataracts are, had nevertheless the pupils almost perfect.  The
 crystalline was  first extracted from  one of the  eyes and then from
 the other, and the operation, which was performed by M. Roux, (Diet.
 de Med. et de Chir. Prat., t. II., p. 108,)  was  perfectly  successful.
 M. Carron du Villards, (Pasquet, Lancette Franc, t. XII., p. 524,) and
 M. Robert (Carron du Villards, t. II., p. 271,) have observed similar
 examples:  I also have noticed  two  cases.  Moreover, when  no
 organic lesion nor any serious symptoms render the operation formi-
 dable, I do  not see why,  when the  patient is completely blind,  we
 should refuse to undertake  it.  In such cases the patient can lose
 nothing, while on the other hand, should there be only one chance in
 a thousand, it would be uncharitable not to let him have the benefit
 of it.   We  must nevertheless  absolutely desist  from it as soon as
 there  is a  certainty of a deep-seated alteration in the eye.
  III. Tremulus  Iridis.—Should  the  crystalline  or  the humors  be
 movable,  or offer the  slightest  appearance of tremulus  iridis, we
 should at least be careful not to operate by extraction.   The case of
 a crystalline thickened, and  spontaneously depressed, as mentioned
 by  Turquet de Mayerne, was  it not in fact complicated with tremu-
 lus  iridis 1 (Prat, de Med., p. 90.)  In -a man who was in this con-
 dition, and  to whose solicitation I finally yielded,  the crystalline
 gently issued out of itself  enveloped with its capsule a few moments
 after  opening into the  cornea, and the vitreous humor  was  in so
 limpid a condition  that it would have escaped like water, if I had
not immediately made pressure on the fore part of the eyes by means
of lint.  Cerebral accidents supervened and were sufficiently serious
 during some days, to give  me  the  greatest degree  of uneasiness.
 The left eye suppurated, and the right, although perfectly clear, re-
 mained altogether insensible to light.   This is a state of things which
 I have often since met with, and which is imputable to a liquefaction
of the vitreous humor.  Depression alone may be attempted in such
 cases, if it  is thought prudent to attack the cataract;  the opera-
 tion then produces scarcely any reaction  in the eye.   It has at least
 the advantage of causing the disappearance of a deformity by again
giving to the pupil all its regularity, and this result is not to be dis-
dained when there  is only one of the eyes in a state of cataract.
 The  mobility of the crystalline  is sometimes hereditary.   Portal
 (Malad. Heredit., p. 87, 3rd  edit.) gives an instance of two brothers
who were thus affected, and whose father had the same peculiarity. 
GLOBE  OF THE EYE.
263
The crystalline rested in part in the anterior chamber, as in the two
patients noted by me.
  IV. Anomalies.—False cataracts, which  are almost always com-
plicated with affections of the iris, or some other membrane of the eye,
are not generally so easy to destroy as the true cataracts.   All other
things being equal, the crystalline cataract is of a less serious charac-
ter than the capsular, or that  of the humor of Morgagni.  I have
seen  patients completely blind, though their  crystalline was  only
slightly opaque.  In others, the cataract appeared so advanced that
nothing more was  required for its maturity, and nevertheless they
could still see very well.   A dealer in grain in the environs of Paris
furnished me a very  fine example of this  species in ]838, at La
Charite.  Arrived at the Hospital  from  his own residence without a
guide, he could count his fingers and  distinguish faces, though to ap-
pearance his two cataracts were as complete as possible.   I have
had occasion to remark, that, persons who could see in spite of their
cataract, had  an opacity of the crystalline only,  or of the posterior
capsule, and that in them there existed a certain free space between
the iris and the lenticular apparatus.
   V. A light which is made to pass in front of the eye of a patient
who  does not see, will, provided there  be no opacity in front of the
vitreous humor, produce  three images, one anterior, regular, (nette,)
and straight, one deep-seated, large, diffused, and also straight, and.a
third in the middle small, pale, and  reversed.  The anterior image
alone will remain  in the case  of  complete  cataract.  But it is the
deep-seated image only which is effaced when the opacity is concen-
trated upon the posterior layers of the crystalline or its membrane.
This method, which I have often tried, and the use of which has been
sanctioned by  M. Janson, (Pasquet,  These, Paris, 1837,) has how-
ever appeared to me  to afford very little reliance.  It is useless in
ordinary cases, and I do not think it would be sufficient in doubtful
cases.
   VI. Ages.—In children, the operation, though difficult  to be per-
formed, succeeds better than in adult  age, and  so much  the better
after that, as the patient approaches nearer to the middle period of
life.  The table arranged by M.  Drache (These, No. 180, Paris, 1837,)
shows what are  the influences of age and Other personal conditions
on the formation of cataract.  Almost all authors agree with Sabatier,
that  we ought  not to recur to the  operation except in persons who
are old enough to know the benefit  of it; that it ought not for exam-
ple to be employed before the tenth or fifteenth year.
   a.  The intractability of children, the little  anxiety they have about
obtaining their sight, and the dangers we should have to incur in en-
deavoring to operate upon them in  spite of their wishes, and the diffi-
culty of subjecting them to the necessary precautions, are the principal
motives upon which this precept is  established.  But if in the tender
age the operation is more delicate and more hazardous, and the mem-
branes of the eye from being more tender, thinner,  and less dense, are
more easily penetrated;  the eye  is less movable, the pupil more
large, and such patients, dreading  only the  pain,  are in nowise-con-
cerned about the consequences  of  the operation.   As this operation
is  rarely accompanied  with severe- pain, I  cannot see how in such 
264
NEW ELEMENTS OF OPERATIVE SURGERY.
cases it can have any thing in it of a very formidable character.  It is,
moreover, always practicable to confine even the youngest subjects,
and to  keep their eyelids separated apart.   The eye is an organ es-
sential  to the development of intelligence, and the source of the great-
est number of our ideas.   If its functions should be found abolished
at birth, its  development ordinarily remains incomplete ; it acquires
gradually an excessive degree of mobility, which renders the opera-
tion much more delicate, and diminishes the chances of success.
  In conclusion, when we reflect upon the importance of the educa-
tion of children, it would be really difficult not to admit with Ware,
Lucas, Saunders, Travers,  Beer,  &c, the advantage of relieving
them as speedily as  possible of cataract.  Nevertheless, I am not of
opinion that we ought, in such cases, to select the age of two years,
as Farre recommends, or the period of six weeks, with M. Lawrence,
rather  than the the first or third year.
  b.  In old men, the disease being almost a natural consequence of
old age, the operation is inadmissible, except they earnestly desire it,
and are moreover found in the best conditions possible.  I have per-
formed it, however, in a man of eighty years of age, and in a woman
of eighty-five, with a successful result, which is far from being always
obtained  in young subjects.
  VII. The five hundred cases of cataract which I have noted up to
the present time have not enabled me to assert that males are more
frequently affected with it than females.  We see by the researches
made by M. Maunoir, (These, No. 345, Paris, 1833, p. 13,) that out
of one  hundred and  twenty-one cases of cataract observed at La
Charite there were  sixty-one men  and sixty women; while at the
Hotel Dieu, out of two hundred and seven patients, there were  only
seventy-two women, while there were one  hundred and thirty-five
men.   Before the age of thirty years, acquired as well as congenital
cataract is almost always soft or capsular.   After sixty, it is almost
constantly solid and lenticular.   The period from forty to sixty years
is that  which is most liable to it.   Between  fifteen and  forty years,
we must  be on  our guard, for it often  indicates a more profound dis-
ease of the eye.  Although out of seventy-two cataracts examined un-
der this point of view by M. Maunoir. (Lancette Franc, t. I., p. 392,)
thirty-five only had commenced in the right eye ; this eye, according
to my observation, is more frequently affected the first than the left.
I have  met with five  patients who, from different causes, had  been
suddenly seized with  it, like the peasant mentioned by M. Wendel-
strum,  (These citee,  p. 29.)   In  twenty cases out of two hundred it
has appeared to me  to be hereditary.   A man whose two elder bro-
thers, a sister, his grandfather, and great grandfather had  had the
same misfortume, was seized with cataract at the age of forty-two
years.  M. Maunoir (These citee, p. 21) states that out of thirty-nine
cases of cataract he found ten that were  hereditary.  In the same
family  at Argentan,  (Duval, These, Paris, 1830,)  four of the daugh-
ters and the father and mother were attacked with this disease.  But
all this should not prevent us from recurring to the operation.
  VIII. Single or double.—When the cataract occupies one eye only,
there are physicians who proscribe the operation.  With one eye, say
they, we can see sufficiently well  to  get  along,  distinguish  objects, 
GLOBE  OF THE EYE.
265
read, and,  in fine, fulfil all the duties  required of us by our social
wants.   The operation may produce an acute inflammation, render
the sound eye itself diseased, as M. J. Cloquet has seen, and produce
a complete blindness.  Even upon the  supposition that it does suc-
ceed, the focus of luminous rays being  no longer the same in both
eyes, there necessarily results  from it  a discordance, followed with
confusion of vision, &c.   To this reasoning it may be objected that
if the sound eye is sometimes destroyed after the operation, this acci-
dent rarely happens; that we see undisputably better with two eyes
than with  one only,  and that the presence of one cataract appears to
be good grounds for supposing that another may supervene upon the
opposite side.  As to the difference which it is supposed will take place
in the field of vision after the displacement or extraction of the crys-
talline, experience  has now demonstrated that it  is not  the fact.
Maitrejan, St. Yves, Wenzel,&c, relate cases in which no mention
is made of it, although the patients had  been operated on in one eye
only.   I have published some facts of this kind, collected at the Hos-
pital of Perfectionnement.  M.  Luzardi writes me that he possesses
a great number of similar instances, and I could myself, at the  pres-
ent day, add near fifty cases to those  which I announced in 1826.
Nor, finally, has M.  Roux, who has very often extracted the cataract,
found,  though it existed on one side  only, that it was necessary for
the patients afterwards to wear glasses of different forms for the two
eyes.   Therefore, if the patient is young and of good constitution, if
he desires or earnestly requests to be cured, we ought to  subject him
to the operation, even though one of his eyes may be wholly sound.
  IX.  Maturity  of the Cataract.—Formerly it was supposed that
cataract passed  through  different degrees of consistence ; that soft
and diffluent in the  beginning, it becomes gradually firm and  solid;
in a word, that it may be ripe  or not ripe.  At the present day sci-
ence is under the empire  of more correct opinions.  It is now known
that cataract may be very solid at the commencement, and become
almost liquid after a long  lapse of years.  It is nevertheless true, that
the contrary is very frequently  observed, and that the  idea of ma-
turity and immaturity is not altogether destitute of foundation.  Cat-
aract  being  almost  constantly the  result of a morbid  action from
some internal  cause, is not in  reality perfected until at the  moment
when this cause ceases to act on the eye, and when the opaque body
is no other than a necrosed portion of the  organism, and an  actual
foreign body.  It is not, therefore, because it is too  soft  or too hard,
that we ought to wait for its complete development; but because its
progress not being  limited, there are then evidently less  chances of
success than at  a more  advanced  epoch,  and when its  separation
(coction) has been perfectly effected.
  X.  The two Eyes.—Scarpa, Dupuytren, and many other skillful
surgeons have maintained that it is better when the cataract exists in
both eyes, to perform the operation first on one side, and not to have
recourse to the other until after the  cure of the first.  If  it succeeds,
the patient may rest satisfied with it, so long as the eye is not too
much  enfeebled.  If it fails in its results, there still remains at least
one more resource.  The patient bears the second operation with
more courage and less alarm than the  first.  When we operate  on 
266           NEW ELEMENTS OF OPERATIVE SURGERY.

both eyes at the same time, the inflammation may be communicated
from one to the other, the reaction must be more acute and the danger
of accidents supervening  greater than when we operate on one eye
only.  Boyer and Dupuytren have remarked on this subject, that double
ophthalmia when  once developed, rarely fails of arresting itself defini-
tively on one eye only, which takes upon itself, so to speak, the  onus
of the  disease  of both, and  in most cases ultimately  becomes de-
stroyed.   The whole of this is questionable ; and  as the simple ope-
ration, even in the most fortunate cases, only imperfectly reestablishes
the sight;  as  patients much rather prefer to sustain the two opera-
tions consecutively, than after a certain interval of time ; as the ope-
ration on one  side sometimes causes inflammation of the  sound as
well as diseased eye ;  and as the double operation presents numerous
favorable chances for one of the two eyes at least, if not  for both,
I conclude, with  Wenzel, Demours, Forlenzi, Boyer, &c, that all
other things besides being equal, it is better to adopt this last course.
  XL The  preparations  that the ancients caused their patients to
submit to, are almost wholly laid aside by the moderns. At the pres-
ent day, we limit  ourselves to the employment of a regimen more or
less rigid during the space of several days ; bleeding, some laxatives
or a gentle  purgative ; diluent drinks or antispasmodic and anodyne
preparations, according as the patient exhibits certain indications of
plethora, obstruction in the alimentary passages, or too great a degree
of nervous irritability.  As a preventive means of inflammation, there
are some who apply a blister.  Scarpa places it upon the nape fifteen
days beforehand, and  M.  Roux only the  evening  before.   Forlenzi
prefers placing it upon the arm.  I am not certain that this applica-
tion is not more dangereus than useful.  Many practitioners dispense
with its use, and  do not appear to have had cause to  regret it.   If
adopted  as  a general precept, it must frequently do harm.   During
the first days, it sometimes produces a heat in the skin, and an irrita-
tion which may react  in an  unfavorable  manner upon the eyes.   If
we confine ourselves  to placing  it upon the neck, it would then be
better to follow the rule of Scarpa, or of Dupuytren, who, when he
thought proper to make use of it, left it  on fifteen days before  pro-
ceeding to the  operation.   On the arm it is evident that the patients
can receive no disadvantage from it; nor can we perceive that it
can have the least degree  of efficacy.  For myself, I use it  only after
the operation, upon the supposition that special accidents require  its
employment, and I have not found that there were  any objections to
be made against  this mode  of proceeding.
  XII. Seasons.—Spring and autumn, which are more favorable than
winter or summer for the success of all operations, have been selected
also for those of cataract.   We  cannot undoubtedly refuse to those
two seasons some advantage to the patients, in consequence of the
temperature, which is  usually more  mild and uniform then than at
other periods of the year  ; nevertheless, as these conditions may be
obtained or found at any time, cataract may in fact be  operated upon
at any season.  We ought not, however, to  decide upon it  without
caution, if an epidemic of a somewhat grave character should be pre-
valent, especially those which more  particularly affect  the  mucous
membranes.  When there are prevailing catarrhal affections, dothin- 
GLOBE  OF THE  EYE.
267
enteric fevers,  ophthalmias, measles, or even erysipelas, prudence
requires that we should refrain from it.
  C. Operation for Cataract by Depression.—In some cases we
confine ourselves to displacing the  crystalline, or placing it  under
such circumstances, that it may disappear under the influence of the
action of the organism ; in  other cases, on the contrary, we expel
the cataract from the eye, in endeavoring to remove the opaque body
in its totality, which  constitutes two general methods,  that of de-
pression and that of extraction.   The first, still knowrn under the title
of the method  by depression, comprises, moreover, the  method by
reclination (reclinaison), or reversion, or that by discision  (discision),
or breaking  up (broiement),  and is  performed in different ways;  it
takes the name of scleroticonyxis  for  example, when in order to
reach the crystalline the needle is directed upon the sclerotica, be-
tween the uvea and  the vitreous  humor, or when  we purposely
penetrate through the hyaloid substance ; and it is called keratonyxis
when we reach  the eye in  its anterior  chamber, through the trans-
parent cornea.
   I.  Preceding steps.—The  evening before the operation, the patient,
who should have taken only light soups, ought to have administered
to him an injection, if his bowels are not already free.  An  aqueous
solution of the extract of belladonna applied  between the eyelids an
hour or two beforehand, forces the pupil to  dilate itself  largely,
enables  us  to follow  with  the  greatest  degree  of certainty all the
movements of  the needle, to avoid  the iris with  greater facility, and
more readily to compel certain portions of the cataract  to pass into
the anterior chamber, should that be judged necessary.  The irrita-
tion which such an application produces, is too trivial to be worthy of
consideration.  The momentary mydriasis which results  from  it
soon disappears, and alters in no respect the  functions of the organ.
The advantages which it gives are in reality of the highest degree
of importance, and should not be sacrificed to idle fears.  In  irritable
and timid  persons, in whom the eye is very movable, it is well  in
order to accustom this organ  to the contact of foreign bodies,  to
touch it several times during the space of some  days, with the blunt
extremity of  any instrument whatever, or even with the finger.
   a. The  articles comprise two needles at  least, in order that  if
one should fail, we may continue the operation with the other ; a cap
or serre-tete, which should accurately embrace the cranium ;  a long
compress to  cover the sound  eye while we are operating on the
other; small  oval pieces  of fine linen,  perforated with  holes, and
which are to be placed in  front of the  orbit after the operation, in
order to prevent the lint from coming directly in contact with the
lids; a bandage of linen folded double, sufficiently long to go  round
the head, four to five fingers' breadth in width, and presenting at its
middle portion, near its free border, the division of a j^ reversed, to
lodge the nose ; finally, a band of black taffeta designed for covering
the preceding ; lastly, a fine sponge, hot water and pins.
   b. Needles.—As it is  more especially for extraction that the specu-
lum, elevators  and opthalmostats  have  been proposed, I shall say
nothing of them in  this place.
   As to the needle, we have an infinite  variety of them.  The one 
268           XEW  ELEMENTS  OF OPERATIVE SURGERY.

that Celsus recommends was spear-shaped, straight, and two inches
long; at a subsequent period, it was found more convenient to make
use of those that are round ;  since then the triangular needle has been
revived.  At the present time, every oculist, so to speak, has his own.
That  which Scarpa succeeded  in  rendering popular, slender, and
only eighteen  lines  long, is terminated by a point slightly widened,
curved  into the shape of an arc,  flat on its  convexity, and cut into a
ridge on its concavity, and like all the others, mounted upon  a han-
dle of flat sides and bearing a mark of a different color on its back.
Dupuytren rejects the kind of crest which  is found on the concave
surface  of the needle of Scarpa; his, on the contrary, is somewhat
more  flat on this side than on the back, in order more accurately to
embrace the crystalline, and to expose it less to be divided when we
endeavor to depress this into  the bottom of the eye.  He also re-
commends that it should have less breadth, and that its body, slight-
ly conical, should completely fill  up  the track traced by  the point, in
order that the humors cannot in any degree flow out during the ope-
ration.   The point  of that which is  adopted  by M. Bretonneau, is
shorter  and also as broad as in the  needle of Scarpa.  Its  body,
which i& of melted steel, finer  and almost cylindrical, passes freely
and without the least  effort through the opening into the sclerotica.
It is an  advantage which the instrument of Dupuytren does not pos-
sess, but one  which exposes the eye to be partially emptied  of its
aqueous humor.  The needle of Beer, which many German oculists
make use of, is straight and spear-shaped, and differs from that of M.
Bretonneau only in  having its  body conical and thicker.  Hey pro-
posed one which has only ten to  twelve lines in length,  and  which
in its form approaches much nearer  to a chisel than that of a needle;
being a  simple modification  of that of Hilmer, which is conical, its
free extremity, which is flattened and  terminated  in a half moon, is
its only  cutting portion ; the edges,  which are straight and rounded,
and its  want of a point, make it difficult  to wound  the iris  when
we are directing it towards the pupil,  while its form of that of a small
palette  renders the  depression of the  crystalline less  embarrassing.
With  an instrument Of this kind, it would be almost impossible to de-
stroy  a membranous cataract, or even to  open conveniently the an-
terior capsule  in lenticular cataract, and  inasmuch as the  breaking
up of the lens  to which the author specially designed it,  can be per-
fectly well accomplished  with  any other  needle, there is no  reason
why it should have the preference.   MM. Graefe, Langenbeck, Him-
by, Schmidt, Spitzac, (Fascicul. d'Obs., &c, p. 22, Pans,  1829,) Mid-
dlemore, &c, have  also each in  their particular way modified the
cataract needle.   But the difficulty does not lie here.   In the  hands
of a skilful operator, all these instruments are good.   In this respect
those  of Scarpa, Dupuytren,  and  M. Bretonneau are quite as good as
any of the others.  The needle  designed by Guerbois, (Journ. des
Conn. Med., t. I., p. 250,) with a double rest on its concavity, does
not present sufficient  advantages to be  retained.  M. Bergeon has
proposed one  which two  lines in breadth, and  hollowed out in the
form of  a small spoon, would  in my  opinion be of dangerous em-
ployment ; although it renders  the displacement  of the crystalline
sufficiently easy.  If the needle which M. Charriere has shown me, 
GLOBE  OF THE EYE.
269
and which when once in the eye opens itself in the manner of a lith-
otome of F. Come, did not expose us to the danger of wounding the
iris, and of entangling itself in the neighboring tissues, it  might pos-
sess some advantages.   The one which I  prefer is  somewhat more
incurvated  and more flattened, without being less in length or much
broader than that of Dupuytren.
  II. Scleroticonyxis.—Up to the eighteenth century, they  caused
the patient  to be seated astride a bench.  Barth  and Arnemann pre-
fer that he should be  standing.  Poyet, A. Petit, and Dupuytren, ad-
vise that he should be operated on in bed.   In France, the patient is
generally placed upon a solid chair of moderate height.  Beer recom-
mends  a stool, and Richter a chair with a perpendicular back, while in
England they give the preference to a music stool.   In  this respect
there can be nothing  fixed.  Though the seated position is evidently
the best, the others  may also be  adopted  without serious  incon-
venience.
  a.  Ordinary process.—The surgeon places himself in front, either
on the  same bench with the patient, whose knees he holds between
his thighs, as in the time of Celsus, with a small cushion to  support his
elbow, as recommended by J. Fabricius; or he stands up, as Dupuytren
and a great number of others advise ; or he seats himself on a chair
somewhat elevated, in such a manner as to be able to place his foot
upon a stool, and to support his elbow upon a cushion on his knee, as
directed by  Scarpa.  When seated, there is more fixity in his move-
ments,  since the elbow is supported ; wThen  standing up  he  is more
free  and more at his  ease.  Some surgeons  separate  the eyelids
themselves,  and  dispense with  assistants.  Barth  never operated
otherwise.   In this respect  there has  been much praise bestowed
upon the skill of  M. Alexandre, who again, it is said, is surpassed by
Dr. Joeger in Germany.   The thing doubtless is possible, but exhibi-
tions of force cannot  be taken as a rule, and there is no operation in
surgery which more requires an intelligent assistant, than cataract.
It is necessary that he should have a light hand, that he should per-
fectly comprehend every stage of the operation, and all the movements
of the operator, and that  he should be as practically  conversant with
it as possible.  Being placed behind the  patient, he embraces  the
head, and holds  it against his chest with one  hand, while with  the
other he elevates the  upper  eyelid.   Should we desire  to have re-
course  to any instrument to open the eye, the  double erigne  of Be-
renger, or  the blunt hook of some others,  could evidently  be  re-
placed  by Pellier's elevator of silver wire.   In general the finger is
preferable, whether with  Scarpa, we make use of it to  raise and to
keep up the  free  border of the upper eyelid against the supra-orbitar
arch, without  touching the eye ; or whether  after the manner of
Boyer,  we push it (l'enfonce) against the posterior surface of the su-
perciliary border, while incurvating its last phalanx in the manner of
a hook.   By this  last mode, the eyelid  is found  to  be  more firmly
fixed ;  but the angle  formed by the phalangeal articulations,  causes
more inconvenience to  the operator, and the eye runs more risk of
being compressed. Forlenze was in the habit of causing the entire
tegumentary covering of the eyelid to be drawn towards the eye-
brow, as  if  for the purpose of folding it or forming a border with it 
270           NEW ELEMENTS OF OPERATIVE SURGERY.

there.   In  this manner  the ciliary border, or  tarsal cartilage, is
raised as high as possible, and the pulp of the finger leaves  less fa-
cility for the skin to escape.  The most certain means of  preventing
our loosing our hold before it is time, cons'sts in placing a piece of
dry linen between the finger and the  integuments, in order to  pre-
vent them  slipping over  each other.   If the patient is in bed, the
surgeon places himself on the right  for the left eye, and  on the left
for the right eye ; adjusts the cap and fixes  it with the  bandage ;
covers one of the  eyes, whether it is diseased or not, with a small
piece of coarse lint, and a long compress  passed obliquely  round the
head.  The assistant, free or raised on a chair at the head of the  bed,
prepares for elevating the eyelid.
  First stage.—With the forefinger corresponding to the diseased
side, the operator depresses  the  lower lid and fixes the eye.  With
the other hand he seizes the  needle in  the  manner  of a writing-pen,
directs its point perpendicularly upon the  sclerotica, at one  or  two
lines from the transparent cornea, a little  below its transverse diam-
eter ; turns its  concavity downwards,  one of  the  cutting  edges to-
wards the cornea,  and the other  towards  the orbit, in order that he
may penetrate, rather by separating apart, than by dividing through,
the fibres of the coats of the eye ;  first inclines the handle of the instru-
ment with  a  considerable deal  of force  downwards, then raises it
gradually in an opposite direction in proportion as he enters into the
posterior chamber, and makes use of his two last fingers in order to
procure a point d'appui, between the parotid and the cheek bone.
  Second stage.—Before plunging it  in farther, he turns the instru-
ment upon its axis, in order that its concavity may face backwards,
and that he may be enabled to pass without danger below, then in
front of the crystalline, while penetrating  from without inwards  and
slightly from  behind forwards, without touching the iris or lenticular
capsule, if he  possibly  can, as  far  as into the pupil  and anterior
chamber.   He  then passes its point circularly several times around
the anterior circumference of the lenticular body, the  envelope of
which is in this manner lacerated as completely as possible.
  Third stage.—This being accomplished, the  surgeon applies the
arc of the needle directly upon the front part of the cataract, which
he then draws by an  oscillating movement downwards,  outwards.
and backwards, into the bottom of the eye, below the pupil and the
vitreous humor, where he  holds it fixed for the space of* a minute, in
order that it may not become disengaged.
  Fourth stage.—The instrument is then drawn back without  sha-
king it, by small movements of  rotation;   it is brought back to  the
horizontal  position; we again turn its convexity upwards, and re-
move it from the eye, by making it pass  through the same track it
had taken in entering.
  Remarks on the preceding different stages.—Many points in  this
operation require particular attention.
  1.  To make  use of the right hand, for the right as well  as the left
eye  could be of use only to those surgeons who are not ambidexter,
and  it is not often that these latter venture to perform operations on
the eyes.
  2. If the needle were directed  above the transverse diameter of the 
GLOBE  OF THE EYE.
271
sclerotica, as some  practitioners,  and among them M. Pilson, have
recommended, it  would become  almost impossible  to  depress  the
crystalline completely, or to avoid leaving it more or less near the
centre of the eye.  In applying it exactly upon the external extre-
mity of this diameter, we should be certain to wound the long ciliary
artery, and to produce an internal hemorrhage.   It is below it there-
fore that we must apply it.   When its convexity is turned forward, as
Scarpa recommends,, the fibres of the sclerotica, as well as some  of
the ciliary nerves and vessels, are necessarily divided, whereas no-
thing like this takes  place if we conform to the precept which I have
laid down.
  3. J.  Fabricius laid  it down as a rule that the needle ought to be
plunged in at the union of the sclerotica and cornea.  Others, with
Purmann, say at half a line from this last;  some at a line and a half;
several at two lines, two lines and  a half, and even three lines ; there
are those who say the breadth of  the nail or of the stalk of a straw,
the middle of the white of the eye, &c, and those who are in favor
of going as distant  as  possible from it, are influenced by the fear of
wounding the ciliary circle  or processes.   Among others, there are
those who,  like Platner, apprehend the lesion of the tendinous por-
tion  of the rectus externus  muscle  or  the nerve  of the sixth pair.
Fabricius, in  approximating the cornea, specially designed thereby
to reach more  directly in front of the cataract, while the majority
look only to avoiding with greater certainty the retina.  As to the fact
itself, two things  appear to me indisputable: it is that the puncture
of the fibrous expansion of the rectus muscle involves not the slightest
inconvenience,  and  that that of the retina is unavoidable when we
penetrate through the sclerotica, at whatever distance it may be from
the cornea;  from whence it follows,  as a  general rule, that there is
no danger in receding from, while there would be in approximating
too near to the ciliary body.
  4. In turning the back  of the  needle forward, when we wish  to
pass it below and then in front of the cataract, and to conduct it in
this  manner in the anterior chamber through the pupil, our object is
to protect, with as much certainty as possible, the retina and the iris
from the action of its point or cutting edges.  If we work with it in
the anterior chamber, it is in order to be more certain that it may not
work between the lens and its envelope.  The laceration of this last is
a more delicate and important operation than is generally supposed ; it
is upon its circumference that we must commence.   If we pierced it
first at the centre, it would be very difficult afterwards to detach the
flaps from it, and to prevent the formation of a secondary  cataract.
The best  mode undoubtedly would  be to depress at once both the
crystalline and  its capsule, without breaking  them, as some authors
have recommended; but by what mode could we force a membrane
so delicate to the bottom of the eye without dividing it, provided that
its adhesions have retained some degree of firmness ?
  5. It is not sufficient, in order to depress the opaque body, to seize
it with the point  of the needle.  The concavity of the instrument
ought moreover to embrace exactly and flatwise its anterior surface
at its middle portion, from the inner side of the pupil as far as to its
outer portion ; otherwise it would be reversed upon the slightest de- 
272          NEW ELEMENTS  OF OPERATIVE  SURGERY.

gree of pressure, either from above downwards or from below up-
wards.  The depression having  once commenced, the  needle repre-
sents  a lever of the  first kind, which finds its point  d'appui in the
opening of the sclerotica, and which, in order to make resistance out-
wards, backwards and downwards, should have the concavity of its
point  slightly inclined upwards, while  we  give to  it the oscillatory
movement mentioned.
  6. When the cataract is depressed, it is recommended to the patient
to look upwards and inwards without moving the  head, supposing by
that, but erroneously,  that the crystalline would be made to descend
lower down.  In not  withdrawing  the needle until at  the  end of
some  seconds, time is given to the depressed cells of the vitreous
humor to resume their natural position, and to imprison,  so to speak,
the cataract, which would almost mount upwards if we left it imme-
diately.  The small movements of rotation which the  instrument is
made to perform before disengaging it from  the eye, have evidently
for  their object to disturb the crystalline as little as possible, and to
be more certain of leaving it in its new locality.
  7. If, notwithstanding all these precautions, the cataract  mounts
upwards again as soon as we  cease to keep it depressed, we must
seize it a second time and depress it farther  down, and  continue  in
this manner Until it rises up  no longer.
  8. When it  is soft  the  instrument  ruptures  it, and  we rarely
succeed in entirely depressing it below the pupil; in such cases, if it
is not practicable to displace its fragments backwards, we endeavor
to break it down into small particles, which are to  be pushed forward
into the anterior chamber, in order that their  solution by the aqueous
humor may  prepare them for absorption.  It is  also to this place that
we  must direct every  opaque particle which may be found to remain
in the  centre of the  eye after the displacement of the  crystalline.
The foreign corpuscles are in this manner easily  pushed  forward  in
front of the  pupil, provided they  are completely liberated.  Unfortu-
nately the case, is not  the same, when our design is to place there the
flaps from the crystalline envelope.  In this case  we must  have skill
and address to  transfix, so  to speak, each flap in succession, from
before  backwards or  behind forwards, with  the  point of the needle
near the centre of their base, and to detach them while rolling them
up upon themselves, or by drawing them on the side near their apex.
If the capsule adheres to the uvea we ought, before  all other things,
to effect its  separation, and  in doing this avoid the iris as much  as
possible.  Upon the supposition that some circumstance may occur
to prevent this disunion, we  should necessarily be obliged to displace
the crystalline at first, and act afterwards upon the anterior layer of
the capsule, as has been described above.
  9. Crystalline in the Anterior Chamber.—The cataract, at the
moment of  the operation,  may, in  comsequence of  some  sudden
movement of the patient or the operator, escape  through the pupil
and fall into the anterior chamber.  This  may also happen  sponta-
neously from various causes, as blows,  falls, sudden strokes, and any-
thing which may concuss the head of the individual, or in any man-
ner bring about  the  rupture of the lenticular cyst.  This circum-
stance does  not necessarily oblige us, as has been supposed, to resort 
GLOBE  OF THE EYE.
273
to  the extraction  of the displaced disc.   Inasmuch  as  it has gone
through  the  pupil, in order to place itself in front, it could traverse
it again  to get behind, and  it will always be found more  agreea-
ble, both for the  patient and the  surgeon, to terminate the opera-
tion while the needle is in the eye, than to withdraw it again in ordei
to  incise the  cornea.   In the cases even where nothing yet has been
attempted, it is  no  obstacle to  depression, provided the pupil re-
mains dilatable and  that there is but very little degree of inflamma-
tion.  Dupuytren and M.  Luzardi, who, under such circumstances,
have made use of the ordinary needle, have plunged it  through  the
sclerotica and pupil into the anterior chamber, in such manner, as to
seize hold of the  lens, whether opaque or not, and which they have
afterwards succeeded in conducting into the bottom of the posterior
chamber.  I have frequently noticed this  accident, but  it never has
appeared to me of serious character at the moment of the operation.
There are, moreover, some singular facts in relation  to  this  subject.
In a patient of M. Monod the crystalline remained  in  the anterior
chamber.  This woman, having left the Hospital of Cochin, came to
the clinique two months afterwards.  I then noticed that the crys-
talline occupied its usual place in the posterior chamber.
   Having left my service at the expiration of six weeks,, the patient
came back again three  months  subsequently, when the crystalline
was again found  in the anterior chamber, having vessels which ap-
peared to have penetrated into it, and where, being now reduced to
a  third of its volume, it appears to constitute  a part of  the cornea!
In another case the crystalline having passed into the anterior cham-
ber several  months after depression,  repassed into the posterior
chamber while Pellier (Gaz. Salut., No. 50, p. 4, col. 2, 1760,) was
dividing the  cornea in order to extract it.
   10. In milky cataract, if as almost  always  happens,  the  capsule
itself is  affected,  it is almost indispensible  to carry the instrument as
far as to the centre of the pupil without dividing anything, otherwise
the opaque  liquid  diffuses itself into  the  eye, renders  the  humors
turbid, and prevents us from  any longer seeing what we are doing.
Nevertheless should this accident happen, and whether the  needle
was or was not in the anterior chamber, we ought before withdraw-
ing it, to simulate as accurately and with  as much caution as possi-
ble, the manipulations necessary to break down whatever it  might
be necessary to destroy.
   11. Purulent cataract, of which I have  seen two very marked ex-
amples, would require no additional attentions, as its absorption is
also speedily accomplished.
   12. If, as  I have often seen, the cataract should, on the contrary,
be very hard, stony, cretaceous, or like tupha, (tophacee,) which is
recognized by its unequal,  ridgy, and white  or yellow calcareous
color, we should treat it in the same manner precisely as an ordinary
crystalline, except that its capsule being folded and retracted, and, as
it  were, parched up, cannot be isolated from  the rest, and must be
depressed with the  same stroke.   Should the cornea, (Darcet, These
citee) the crystalline, (Kulm, Chir. des  Hopit., t. III., p. 397,) or
vitreous humor  (Middlemore, Revue Med., 1838, t. III., p. 269,) be
ossified, any operation doubtless would be useless.
                              18 
274
NEW ELEMENTS OF  OPERATIVE SURGERY.
  b. Other Processes.—1. Process of Petit.—At the commencement
of the last century, some  authors sustained, contrary to Hecquet, de
la Hire, &c, that the seat of the cataract was always in the crystal-
line.  Petit, adopting this  hypothesis, proposed  to  accomplish the
depression of  the opaque body without touching  the anterior layer
of the capsule.   After having plunged  the needle into the posterior
chamber, he inclines  one of its cutting edges  outwards  and  back-
wards ; opens  into the vitreous humor in this direction ;  brings the
needle back to the outer, lower, and posterior part of the capsule, which
he ruptures, secures the crystalline by hooking into it, and passes it
into the substance itself of the hyaloid body, while conforming in other
respects to the general rules  for depression.   This modification, re-
vived some years subsequently by Ferrein,  who declared himself the
inventor of it, was afterwards supported by Henkel, Gunz, Gentil,
Walsborr, &c.  In allowing the anterior capsule to remain intact, it
was to leestablish the vision  more completely than by the ordinary
process.   It was maintained that in falling upon a convex membrane
the luminous rays would scarcely feel the loss of the crystalline: that
the concordance of the focus of vision would be preserved; and that we
should not in fact be under the necessity of using spectacles after the
operation.   To these  reasons, practitioners  objected that the capsule
is frequently itself the seat of cataract, either alone or conjointly with
the crystalline;  that more often still  it becomes opaque afterwards,
and produces  a secondary  membranous cataract, should we fail to
destroy it at the time of the operation ; that consequently, so far from
preserving it, we ought to endeavor to  break it up as thoroughly as
possible ; finally, that in depositing the crystalline exclusively in the
vitreous humor, in  place  of simply depressing it  into the posterior
chamber, we should run the risk of producing serious accidents.
  2. Process  of the author.—The last objection raised by the  ad-
versaries of Petit is the only one destitute of foundation.  If the lace-
ration of the vitreous body were dangerous, the  operation for cata-
ract by  depression would scarcely ever succeed,  for it is almost
impossible to be avoided.   Should not the crystalline  enter, to some
extent, in spite  of  the operator, into the vitreous humor, can  it be
supposed that it would ever remain depressed,  pushed back as it
continually would be by  the  natural elasticity of the hyaloid mem-
brane ?   Moreover, in  causing it to glide between  the  coats and
humors of the  eye, how could we avoid lacerating the retina ?  Pro-
ceeding upon  this idea, M. Bretonneau has deemed it advisable to
adopt the process of Petit by modifying it;  that is to say, that in
place of opening the  capsule  posteriorly, this surgeon, after having
traced out a passage for the crystalline into the vitreous humor, pro-
ceeds to the rupture of the  capsule in  front as by the ordinary pro-
cess.  Being a witness  of the successes obtained by this  process at
the  Hospital of Tours, in 1818 and 1819, I have adopted  it without
having had any  reason to  regret it.   I perform it in the following
manner: the needle is directed as if to pass behind  the cataract;
when it has arrived at about four lines of depth, before changing its
position,  we incline it downwards,  backwards,  and  outwards, in
order to open  into the anterior cells of the vitreous humor; immedi-
ately afterwards, we turn its back towards  the iris; then while  ele- 
GLOBE  OF THE EYE.
275
vating its handle, we cause its point to pass under the lower border
of the  crystalline,  that  it may afterwards  be conducted  into the
pupil; then lacerate  the anterior  layer  of  the  capsule;  seize the
opaque body, and push it by a well regulated  vibratory movement,
in the direction  of  a line which would extend  from the great angle
of the eye to the mastoid process on the same  side.   We thus avoid
wounding the iris ;  the elasticity of the vitreous humor, though some-
times quite considerable, cannot however offer the least degree of
resistance, and enables the cells of  its membrane, while immediately
closing the passage, to become an obstacle to the reascension of the
crystalline.
  3. Another process.—I have often also employed another  pro-
cess which has appeared to me to be very convenient.  In  place of
inclining the needle downwards, I  direct it  upwards, and from be-
hind forwards, in order to bring it above and in front of the crystal-
line, and into the pupil.   By this means we more completely detach
the cataract, and nothing is more  easy afterwards  than to  force it
backwards and downwards.
   4. An itinerant oculist, M. Bowen, has  published a method which
he  calls  hyalonyxis, and which appears  to him  preferable  to every
other.   His  object is to traverse the vitreous humor from behind
forwards, then to lay open the posterior layer of the capsule, and to
detach the crystalline after the method of Petit or  Ferrein, without
interfering with its anterior envelope.   For that  purpose M. Bowen
pierces the sclerotica at four lines from the cornea.  The results of
his practice are all in favor of hyalonyxis, for he scarcely counts two
failures out  of twenty  operations.   From this therefore we may at
least conclude, that the wounding of the retina and  the vitreous hu-
mor is  a matter of very little consequence.   I  do not see, moreover,
any advantage  in going so far from the cornea, and there  is no ne-
cessity of recalling the  inconveniences to which we are exposed in
not destroying the  anterior layer of the capsule.  Nothing moreover
would  prevent our avoiding it, if we desired  to do so, by the process
which  I have adopted.
   5. M. Ruete, (Gaz. Med., 1838, p. 677,) in causing his needle  to
penetrate at the side of the capsule  on a line with the pupil, then
turning the point of his  instrument  forwards, in order to rupture the
envelope of the crystalline, and proceeding afterwards to the depres-
sion of the cataract, has in this process done nothing more than what
often happens to other surgeons without their being aware of it.
   6. M. Goyrand plunges his  needle into the  vitreous humor from
behind forwards like M. Bowen, and immediately causes it to per-
form a circular movement upon the whole circumference of the crys-
talline, which latter he  transfixes in order to  drag it into the vitreous
humor, without  paying any attention to the anterior  capsule. I have
seen him operate in this manner with great rapidity.
   7. M. Gensoul  formerly  made  use  of a  process, which  he  soon
after abandoned, but which  M. Roux has since thought  proper to
make trial of at Paris, and the idea of which seems to belong  to  B.
Bell or to M. Giorgi.  A small incision is first made behind the iris,
at the union of the sclerotica with the cornea.  The surgeon intro-
duces  through  this opening, a sort of scoop to  the fore part of the 
276           NEW ELEMENTS OF OPERATIVE SURGERY.

crystalline, which he pushes down or depresses, and the operation is
thus terminated.   The only advantage  from so large an opening of
the  sclerotica, would  be in giving relief  more  easily  than  by a
simple puncture to the too great degree of fullness of the eye, (trop
plein de l'ceil.)   But the division of the ciliary body,  the possible
escape of the humors, and the impossibility of carrying the cataract
sufficiently far backwards, would  of themselves suffice on the face
of them to cause this process to be forever  proscribed, though even
the trials of its inventors and of M. Roux, did not come to our assist-
to demonstrate its inconveniences and dangers.
   8. Reversion or  Reclination.—Since the  time of Pott,  some
authors, among others Willbourg and Schifferli, have maintained that
in place of depressing the crystalline, it would be better to effect its
reversion.   We cannot  deny that this modification would render the
operative process both more  simple and  more  easy.   When the
needle has lacerated the anterior capsule,  all that  is necessary is to
apply it a little nearer to its superior  than  to its inferior border, in
order that by pressing upon it, the reversion of the lens may be
effected at the moment by an oscillatory movement, which places its
anterior surface above,  and  its superior border behind.  If we de-
sired, moreover, to drag the cataract into the substance, or  below
the vitreous humor, as  Beer, Weller, and others recommend, rever-
sion evidently becomes the usual mode  of depression, whereas, if
we should abandon it in the posterior chamber, below the centre of
the pupil, it is clear  that it will in  most cases reascend, or that its
presence would irritate  the iris and the rest of the eye to such a
degree  as to  give  rise to  accidents.  Reversion  then, is  only a
dernier resource, and never a process of election.
   9. Discision or breaking up.—Pott, after  having endeavored to
demonstrate that the crystalline, when it is once placed  in immediate
contact with  the  aqueous humor, is dissolved, and ultimately dis-
appears, wished also to  prove that it is not indispensable to depress
it below the axis of vision; that it  is sufficient, as Warner had ad-
vanced, to reduce it into fragments ;  that in fact, as Ware pretends, a
cure  may be  effected  by rupturing  its  capsule.   Experience has
occasionally confirmed this opinion, for the examples of solution and
absorbtion of  the crystalline, whether it was left entire  or broken up
into  fragments, are not uncommon.   As on the other hand, the break-
ing up of the  crystalline relieves us of the most difficult point of the
operation,  it  is very natural that  M. Cappuri,  (Paccini, Bull, de
Ferussac, t. XIV., p. 192,)  as well as many other  oculists, should
have adopted  the opinion of M.  Adams, who  recommends that it
should be made use of  in all cases.  Nevertheless, I will say of this
the same thing that I would of reversion.   It is a process which is to
be adopted when the cataract is soft or too difficult to be displaced,
but it is one which, notwithstanding  the eulogiums bestowed upon it
by M. Parmi, is less certain  than depression properly so called.  If
it is true that the fragments of the crystalline are sometimes dissolved
with sufficient rapidity, it  is also  true that very frequently they re-
main there for months, and even to an indefinite period, and in such
way as to prevent the re-establishment of vision.  If the wounding of
the vitreous humor is thereby less difficult to be avoided, that ofthe 
GLOBE  OF THE EYE.                    277
iris is ordinarily more so.  Upon the supposition that there might be
some advantages in  leaving  the cataract to be gradually absorbed,
they  will be found more than counterbalanced by  the anxiety of the
patient, and the loss of  time  which must elapse between the moment
of the operation and the period when the pupil  is again restored.
I. am still  less capable  of comprehending  M. Lowenhardt,  (Gaz.
Med., 1838, p. 812,) who has had the temerity to pass a seton through
the crystalline in order to cure  the  cataract, and  who  declares that
he succeeded !  All  the  needles  are  good for effecting  discision.
That of Beer, or M.  Lusardi's small needle, in the form of a sickle,
seem more convenient, however, than those  of  Hey and Dupuy-
tren, and even than those of Scarpa  and M. Bretonneau.  Although
we may break'  up the crystalline by  attacking it on its posterior
surface, it is, nevertheless, preferable to act upon its opposite surface,
in order that  we may  be  better  enabled to see what we are doing,
and  to be more certain of avoiding the iris.  In this mode, when
the instrument has once  arrived in  the pupil, and that the capsule
has been properly ruptured, we  direct  its point and one  of  its
cutting edges upon the middle of the  cataract, which latter is di-
vided at first  into two parts, in order to return upon each fragment
separately, in  order  that they may be  reduced into  as small parti-
cles  as possible, after which we  endeavor to push  the  largest  of
them into the anterior  chamber,  by  means  of  the back  of the
needle.  When  we  operate  from behind forwards, and employ the
straight needle,  the  breaking up of  the  lens is in  reality more
easy, so long as the anterior layer of the capsule  remains entire,
because the crystalline  being then shut up as it were in a sac, and
unable  to  escape, is  compelled constantly to present itself to the
action of the instrument; but the vitreous humor suffers much more
than by the other process, and it is very rare, moreover, that the lens
and its envelope are not pierced through  and through at the very
first movements.
   III. Keratonyxis.—Depression, reversion, and  broiement, which
are generally  performed, as we have just seen, by  scleroticonyxis or
by sclerotico-hyalonyxis, are also accomplished by keratonyxis, that
is to  say, by penetrating through the transparent cornea.  This pro-
cess, whose invention has been disputed by many moderns,  is far from
being new.  Avicenna  speaks of practitioners who  first opened the
cornea  and penetrated  by that means to the crystalline, which they
afterwards depressed by means of a needle that  they denominated
al-mokadachet.  Abu'l-Kasem asserts positively that  he adopted this
method, and that wrhen  the  needle  is plunged into the crystalline,
some gentle movements  are  required to be made upon it in order to
depress  the cataract.   M. Herbeer  (Carron du Villard, Oper. de la
Cat. &c., p. 11,239,) affirms that this has been the  practice in Egypt
from  immemorial  time,  and M. Souty, (Ibid., p. 241, 1834,) makes
the same remark of the medicastres of India.  Manget also relates
the case of an English woman, who cured cataract  by piercing the
cornea.  In the collection of Haller, we find a thesis supported  by
Col. de Vilars, under the presidency of Le  Hoc, in which this oper-
ative process is much extolled.
  It  is  in this manner, says the author, that  birds recover their vi- 
278
NEW ELEMENTS OF OPERATIVE SURGERY.
sion by plunging  a thorn into  the  eye, and it is thus, according to
Galen, that goats have pointed out to man the manner of operating
for cataract.   In  the  18th century, Smith had already revived the
process of the Arabs.   Dudell, the disciple of Woolhouse, consider-
ing cataract  almost always membranous, proposes  that we should
penetrate the cornea to reach the anterior capsule, and to remove
from  it a circular  disc  by means of the needle,  in  such manner
as to form there a sort of window  to give passage to the rays of
light.  The famous Taylor and Richter  frequently performed kera-
tonyxis in cases  of milky  cataract.   Gleize in France, and Conradi
in Germany,  made  it known in the year 1786.  In 1785, Beer had
performed it  twenty nine times.  Demours had performed it in 1803,
the epoch at  which Reil had endeavored in his lectures to call atten-
tion to it, and when he gave it  the name which it bears.   But it has
required no less than the united efforts of Buckhorn in 1806 and 1811;
Langenbeck,  in 1811 and 1815 ; Dupuytren, Guille,  and Walther in
1812; Wernecke, in  1823; and Textor  and Pugin in 1825, to as-
sign it a place among regular operations.
   a.  Operative Process.—The  patient and the assistants are placed
in the same manner as for scleroticonyxis; the surgeon directs the
point  of a curved  needle, that of M. Bretonneau, for example, or that
of M. Langenbeck, which, though more pointed, has a cutting edge of
less extent, at about a line from  the sclerotica; supports the back of it
upon  the finger which depresses the lower eyelid ; causes it to pene-
trate into  the anterior chamber  at  the lower or external part of the
cornea; arrives  in the pupil; then turns downward the concavity
of his instrument, which up to this  moment he had held in an oppo-
site direction  in order to avoid the anterior surface of the iris ; freely
lays open the capsule;  detaches  the crystalline ;  hooks  its upper
border; depresses and reverses it;  endeavors even to push it below
the pupil into the vitreous humor, or  what is  better, comminutes it,
and' breaks it  up and depresses its principal fragments when he  can-
not bring  them into the anterior chamber; and afterwards turns the
back of his needle downwards again,  and withdraws it by making it
pass through the same track in an opposite direction to that by which
it was introduced.
   b. Appreciation.—Keratonyxis should not be attempted until we
have  previously produced ' a sufficiently extensive  dilatation of the
pupil, the  borders of which nevertheless it is very difficult in spite of
this precaution, to avoid  wounding severely, when we are endeavor-
ing to depress the crystalline.  It  is  to obviate this inconvenience,
and especially in order not to puncture the iris, that straight needles
among us have generally been proscribed, and that we penetrate at
some  distance from the sclerotica, taking care  at the same time not
to approximate too  near  the centre of the cornea.   The pyramidal
needle of  Beer, the shoulder that M.  Graefe has caused to be added
to the stem of the ordinary needle to prevent its penetrating too deep,
the needle of Himly, and that of  Schmidt,  &c,  do not in reality
present any advantage  over those which  are used  in  France, and
require no further description in this place.   In animals this process
is  preferable to all others, for reasons  which it is unnecessary for me
to point out.   Though in  the human species it may in fact be em- 
GLOBE OF  THE EYE.
279
ployed wherever depression is practicable, it is not advisable to make
choice of it except for milky  cataract, and in children and intracta-
ble subjects, and where the eyes are very movable and irritable or
deeply depressed.  The same hand will  answer  for both eyes;  no
nerve or vessel incurs any risk of being  wounded.  The retina re-
mains intact; nor is  the iris  in more danger than by the posterior
method.  The  tissues that are traversed have  scarcely any sensi-
bility, nor does the membrane of the aqueous  humor, which  MM.
Wardrop,  Langenbeck and Chelius appear  to have so much dread
of wounding, possess any more than a very slight degree  of vitality.
The operation then resolves itself definitively into a simple puncture,
and may be repeated a certain number of times without any serious
inconvenience.  But to these advantages no less numerous objections
may be opposed.   The adhesions of the capsule,  the contraction
of the pupil, the narrowness  and  flattened  form of the cornea, the
projection  of  the iris, and  hard gypseous  or stony cataracts, do not
appear to be adapted to it.  Properly understood, it is for the break-
ing up and reversion of the lens only that we may sometimes  have
recourse to keratonyxis.   Though it has succeeded  in seven times
out of eight with M. Textor;  that in many hundreds of patients, M.
Smalz, according  to M. Eccard, has never seen it produce suppura-
tion of the eye; that out of 345 cases of  M. Walther, he  failed only
in twenty-six ;  Dupuytren, in  one out of six; and M. Langenbeck,
in four only out of 112, this process nevertheless has been  abandoned
as a general method, by even  its warmest partisans themselves.  M.
Wedmeyer, who has performed it fifty-three times, rejects keratonyxis
as well as  M.  Langenbeck, and M. Schindler, (Bull, de Fir., t. X.,
p. 352-354,) who prefers in this operation to  pass through the centre
ofthe cornea, will not succeed in giving it any great degree of popu-
larity.  Nor do I think that M. Pauli, (Arch. Gen. de Med., 1838, t.
III., p. 352,) who, penetrating  at the cornea, then divides the vitreous
humor above the crystalline in order afterwards to perforate through
this opening through the entire body of the  lens, will ever succeed
in causing his method to  be adopted.   Nor  can I comprehend any
better the  superiority of what M.  Quadri (Gaz.  Med., 1833,  p. 643)
calls  his mixed method.   How is  it  possible that a sort of forceps-
needle introduced through  the cornea in order to extract the capsule
of the crystalline, while the cataract is being depressed  by means of
an ordinary needle passed through the sclerotica, could render the ope-
ration more  simple, more sure and  less dangerous ?  I conclude
therefore that keratonyxis cannot  be substituted for scleroticonyxis,
which alone enables us to push  the crystalline wthout  extracting
it, outside of the visual axis, and to  fix it there  securely, promptly
and permanently ; and that in fact it only deserves a place in books
of surgery under the character of an exceptional method.
  c As to the simple puncture of the cornea, as formerly practiced
by Lehoc, and more recently  by M. Wernecke with the view of pro-
moting the solution or absorption of the cataract, it has not yet suffi-
cient proofs in its favor to authorize its being formally recommended.
If nevertheless, as cannot be doubted, the decomposition ofthe crys-
talline  separated from  its membrane, is  a phenomenon much more
chemical than vital, we cannot see why the evacuation of the aque- 
280           NEW ELEMENTS OF  OPERATIVE SURGERY.

ous humor, when once impregnated with the foreign substance, might
not favor the dispersion of the  cataract, in permitting  the liquids
with which it is  surrounded to be renewed.
  IV.  Operation for Cataract in  Children.—In the early period of
life, we can scarcely have recourse  to  the method  of  extraction.
We should rarely  succeed in accomplishing it without emptying the
eye.   As is demonstrated by the observations of Scarpa, Ware,
Saunders, Gibson, M. Lusardi, and M. Lawrence, who has seen it
in four brothers, &c, congenital cataract and accidental  cataract in
young persons are almost constantly liquid and membranous. There
is consequently but little to do with depression or extraction.  The
object to be attained is to lacerate as completely as possible, the an-
terior  disc of the  capsule, and to empty it of  the matters that it
contains.  In  such cases  it is a matter of indifference whether we
operate by keratonyxis or scleroticonyxis, at least when the pupil is
very large, a condition which ordinarily exists.   The most difficult
point  is to  restrain the little patient.   Ware  confines  himself  to
placing him upon a table, raising his head by means of pillows, keep-
ing him held  down  by assistants, and holding  the eye steadily by
means of the fingers, while another  assistant raises the  upper lid
with  the elevator of Pellier.   Gibson, who  first gives an  anodyne
potion to blunt the sensibility, causes the most intractable to be im-
prisoned in a sort of  sack, open at both ends, and which  is confined
above the shoulders and below the feet by means of a running string.
Finally, M. Lusardi finds it more  commodious to seat the  child  upon
the angle of a prepared table, after having fastened his arms around
his  trunk  and placed his  legs between the thighs of the operator.
Whether we penetrate through the  cornea or the  sclerotica, it is
always important  to effect a complete loss of substance at the  ante-
rior disc  of the capsule, and  not to confine  ourselves to  its simple
rupture, unless we wish to incur the risk of seeing a secondary cata-
ract supervene soon after.   If the crystalline .should still retain  some
degree of resistance, and if it should  appear that the capsule itself
ought to be broken up into fragments, it would become necessary, as
in an adult, instead of leaving them in their place, to force them into
the vitreous humor or push them  forward into the anterior chamber.
If at the expiration of fifteen or twenty days, any fragments should
remain at the place of  the crystalline, Ware recommends that we
should repeat the operation, without waiting any longer, and states
that he has performed it four or five times successfully in this  man-
ner on the same child.  Such a course of procedure ought not  to be
imitated, unless we have satisfied ourselves that the fragments ofthe
cataract have absolutely ceased to diminish in volume.  This perhaps
would be an occasion for making trial of the process of  Wernecke,
and of evacuating the aqueous humor  by a puncture in the cornea.
  V.  Subsequent Treatment.—When everything is finished after the
operation for cataract by depression, the patients are recommended
to keep the  eyelids  gently closed.  The practice of placing before
the patient some object to ascertain the result of  the operation should
be abandoned by all  practitioners.  The light arriving in full  force
and  suddenly into the bottom of the eye, irritates the retina too se-
verely, and such  a  test in every respect can only  be intended to 
GLOBE  OF THE EYE.
281
gratify an idle curiosity.  After the employment of the needle espe-
cially, it must completely fail in its object, since the disturbance we have
just produced in the chambers of the eye may render the sight very
confused at first, though it is to be completely reestablished afterwards.
Nobody at the present day would  venture to follow the recommen-
dation of Purmann, by applying over the puncture of the sclerotica,
a small piece of gold-leaf, with the view of preventing the escape
of the aqueous humor or the vitreous body.
  Brandy and the white of an egg, employed by the  ancients, and a
thousand other  topical applications lauded without any foundation,
are also proscribed.   We confine ourselves to wiping out the eyelids
with a sponge or a fine compress, then placing in front of them the
oval  piece of linen perforated with  holes, dry or imbued with cerate,
and over these a soft compress of lint, and a bandage  of linen, which
is arrested under the nose by the bridle formed by its notch, and which
is fixed behind  to the cap by means of some pins; finally, the band
of taffeta which is to cover the whole.   It is important that none of
these portions of dressing should be drawn so tight as to compress
the parts contained in the  orbit.   For myself I  confine myself in
most cases to the employment of a  simple bandeau, which bridles the
nose, and which I attach to the cap behind by means of pins.  The
patient operated  upon should make no effort nor any movement.
Being carried back to his bed he is to be laid upon his back, with the
shoulders and head elevated by means of pillows.  The habit of sur-
rounding him with thick and colored curtains, and of allowing but
little light to penetrate into his chamber, has appeared  to  me  to be
more hurtful than  useful.  During the space of three or four days we
allow him only bouillon or light soups.  If the stools are not regular,
emollient clysters or  even  laxatives are to be administered.  We
may give him also, for example, a drink of a  more or less relaxing
character, such  as whey, barley-water  sweetened, syrup of prunes,
veal  broth, or decoction of tamarinds.   However little cephalalgia,
heat of skin or febrile movements, may supervene, bleeding is not to
be omitted.   When nausea and vomiting should at the same time be
present, laudanum by injection, as  Scarpa recommends, is  indicated
and  produces very good effects.  In ordinary cases the usual drink
to be employed is  infusion of linden, violet or wild poppy, sweetened
with some syrup.  Loss of  sleep and restlessness are to be relieved
by-an ounce of syrup of white poppy or diacodium made into a julep,
which is to be taken  by teaspoons  full.   When no serious accident
supervenes we do  not uncover the eyes until the third or fourth day;
while everything goes on well it is perfectly useless to examine them
before that time.  Should any accident occur we should be apprised
of it  by the state of the pulse, the cephalalgia, the pain in  the orbit, the
running of the tears and  the  saturation of the dressing by a yellow
discharge.  To  perform the dressing-the patient must be first seated.
The  different portions being  removed, a basin with warm water  is
placed under his chin, and by means of a sponge he himself moistens
and  separates his eyelids,  which  he immediately opens  after the
operator has wiped them.  At this time the curtains are to be closed.
Even though the  pupil should appear to be regular, it is scarcely
yet prudent  to undertake to ascertain the extent  to which the sight 
282           NEW  ELEMENTS OF OPERATIVE SURGERY.
is re-established.  The dressing is to be reapplied and renewed every
day, and we proceed in the same manner as in cases of simple
ophthalmia, while the eyes retain their redness.   If everything goes
on well we allow at every dressing a little more light to fall  upon
them, in such manner that at the expiration of twelve to fifteen days
they may be left uncovered and protected  only by a simple shade of
dark taffeta.  Nor is there  any longer any necessity of the diet being
very rigid, and the patient may get up in  the course of the second
week, resuming by  degrees his  customary  regimen.   I have  fre-
quenty  even made  them  or allowed  them to get up at  the be-
beginning of the fourth day.  Under a contrary state  of things, we
must look to the kind of symptoms which are developed, in order
to employ  in  good  season, antiphlogistics, general  or  local, purga-
tives, revulsives, and collyria, of this or that description, in the same
way as we would do in  a disease of the same kind produced by any
other cause, not forgetting at the same  time  that iritis, retinitis, and *.
choroiditis are  under these circumstances the accidents that we are
especially to endeavor to prevent or to combat.
  D.  Operation for Cataract by Extraction.—Cataract was still but
very imperfectly known, both  in respect to its seat and its nature,
when it was already proposed to extract it.  Antylus,  according to
Sprengel, opened the cornea by means of a needle, and proceeded to
seize hold ofthe opaque pellicle through the pupil, in order to extract
it.  Lathyrus  operated  in  the same  manner.  It appears also that
Galen practised incision of the cornea in front of the membranes, in
order to extract the cataract.  Ali Abbas and Avicenna speak of
extraction as  a common method.   Abu  '1  Kasem states  that he
learned from an inhabitant of Irack, that  in that country the prac-
tice was to  introduce a short  needle into the anterior chamber in
order to void  the cataract.  Avenzoar and Isa Ebn-Ali, who reject
it, state that in their time  it was in general use in Persia.  G. de
Chauliac himself has not forgotten it;  and Galeatius, who extols it
greatly, gives himself out as its author.   Entirely forgotten, however,
or laid aside, by the authors of the middle ages, the operation for cata-
ract by extraction does not appear  to have been revived in practice
until about the end  of  the'seventeenth century and the commence-
ment of the eighteenth.  In 1694,  Freytag  laid  open the cornea in
the manner  of the  Arabs, and succeeded afterwards  in extracting
from the eye  an opaque membrane, which doubtless was no other
than the anterior layer of the capsule  of the crystalline.   Woolhouse
passed through the anterior chamber with a needle arranged in such
manner as to be susceptible of being transformed at pleasure into a
forceps, and which enabled him afterwards to seize hold of the opaque
body in order  to effect its  extraction.   Petit,  effecting, in the pre-
sence of Mery, the extraction of a cataract which had fallen into the
anterior chamber, surprised many of the  assistants by showing to
them an opaque crystalline in place ofthe pellicle they had expected
to see.   St. Yves  also  decided upon extracting the crystalline lens,
but without success, which induced him, but we do not see for  what
reason, to maintain  more  strenuously than ever that cataract does
not have its seat in the body of the lens.  These different attempts had
then scarcely attracted any attention when Daviel, in 1748, submitted 
GLOBE  OF THE EYE.
283
his method to the judgment of the Academy.  By means of a large
instrument shaped like the tongue of a carp he opened into the lower
part of the cornea;  the wound in which he afterwards  enlarged by
means of a second instrument  narrower than the first, or by  small
curved scissors.  A gold  spatula to keep the lips of the wound open ;
a needle of  the  same metal, which was flat and  triangular, for the
purpose of opening the capsule, and a scoop to favor the issue of the
crystalline or its connections,  were also necessary to this  surgeon.
A crystalline which  had fallen into the anterior chamber, had obliged
him to put  his process in practice  for the first time in 1745.   One
hundred and twenty-two cures  out of two hundred and six opera-
tions,  as announced by him, made a vivid impression on the public
mind; and although the Caque of Reims had mentioned only seven-
teen  successful results out of thirty-four operations,  every body,
nevertheless, was anxious to repeat his essays.  Pallucci, who pro-
fessed, in 1752, to have performed extraction before Daviel, opened
the cornea from the  small to the great angle of the eye by means of
a knife,  the apex of which being very much elongated, resembled a
kind of needle.   Poyet devised a narrow instrument, pierced near its
point in order to  pass through this eye a noose or thread, which would
be capable of supporting this organ while the flap  of the cornea was
being made  from above  downwards.   La Faye proposed to substi-
tute for all  these instruments of Daviel, a knife in form of  a lancet,
somewhat narrow,  slightly convex  on one of its sides, and  the back
of which was blunt up to  near  its point.  To these he added a cysto-
tome, a  sort of triangular lance,  supported by  a  padded spring,
(ressort en  boudin,) and  enclosed  in  a sheath which was dilated in
its middle in such  manner  as to resemble the body of a syringe.
Beranger soon after modified the keratotome of  La Faye, gave it
more breadth, rendered it flat on one side, convex on the other, and
much thicker,  especially  on its  back.  Sigerist  gave  still greater
length to the point of Palluci's knife, in order to  open into the capsule
by traversing through the anterior chamber.  But Jung has remarked,
with great propriety, that a cataract needle is much better than any
particular kind of cystotome for this last stage of  the operation. It
was during  this  state of  things that Richter, who appeared in Ger-
many, Wenzel in France, and Ware in England,  definitively estab-
lished the rules  for the method by extraction.  Two" methods have
been proposed for extracting  cataract.   One,  but little known in
France, bears the name of scleroticotomy ;  the other, almost the only
one in use, is called keratotomy.   The same preparatory steps are
applicable to them.   The  pieces of  dressing  are similar  to  those
which are required for depression.  Nevertheless  the position of the
patient,  assistants and operator, require still more exact precautions
than in this last method.
  It is for extraction especially that Richter and  Beer urge the ne-
cessity of a chair with a solid and vertical back, against which  they
assert it will always be more  easy to keep the  head  of the patient
immovable, than  by supporting it against the chest  of  an assistant.
The  horizontal  position proposed by some, and  extolled by Rowley
and Pamard, is nevertheless but  rarely adopted  ;  doubtless, because
it is a little inconvenient for the surgeon.  I  have  often  made use of 
284
NEW ELEMENTS OF OPERATIVE SURGERY.
it, and do so daily, and I confess I never have been able to compre-
hend why it is not more frequently had  recourse to.  In that case, it
is necessary for  the surgeon to place himself upon the side of the
eye affected.  Should it not, however, be adopted, and that it should
be thought preferable to place the patient on a chair, it is, if not in-
dispensable, at least more convenient for the  surgeon to stand up
than to be seated before him.   The speculum devised by F. Aqua-
pendente, still employed by Sharp, and modified  by Heister, the in-
strument of Van Wy (Arrachard, Dissert., &c, p. 69, 106, Paris, 1805,)
the ring of Bell or Assalini, which M.  Lusardi  has  placed  upon a
handle and reproduced under a new form ; the erignes of Sommer,
and all the other instruments invented to  separate  apart, elevate or de-
press the eyelids, which are useful when we  have not a sufficient
number of expert assistants, are advantageously replaced by the fin-
gers.   Almost all of them incur the risk of compressing or of emp-
tying the eye.  The same remark may be made of ophthalmostats,
among which are to be mentioned the forceps of Ten-haaf, the pique,
the stem of which Casamata caused to be curved into an S,  in order
that it might be better accommodated to the form of the nose, which
Rumpelt attached to a sewing  thimble,  in order  to use the middle
finger while  the  forefinger of the same hand depresses the lower
eyelid, and to which Demours wished to add another modification by
mounting it upon a thimble open at its two ends.   The trefoil (trefie)
of Pamard, such as the son-in-law of the inventor made known in
1825, is liable to nearly the same  objections.   I find it less danger-
ous, however, than to apply the two first fingers of the assistant and
the operator in the great angle,  as is recommended by Ware, to pre-
vent the eye from inclining inwards, and  to  compress it up to the
moment at which the knife terminates the flap of the  cornea.  The
species of elevator, the kystotome forceps, the  double keratotome of
M. Martin, the instrument contrived by M. Bonnefin (These, No. 41,
Paris, 1837), are doubtless constructed with sufficient ingenuity, but
may be too easily dispensed  with to  make their utility a matter of
importance  with surgeons.   The  ophthalmostat of  M. Fardeau
(Journ. Hebd., 1835, t. IV., p. 117,) differs from that of M. Lusardi in
this, that in place of a prominent arc, it  carries on its ring a kind of
large concave and blunt nail  (ongle).  That which 1 have proposed,
(Estevenet, Journ.  Hebd., 1836, t. II.,  p. 147,)  has some  analogy
with the ancient probe of Segwart; resembling in its handle the or-
dinary keratotome, it is composed of  a  small plate of  shell, slightly
curved on its flat side, and which, moreover, represents the scoop <if
Daviel.   Being perfectly blunt  and destitute  of any kind of rough-
ness, this plate irritates the parts in no respect whatever.  As soon
as the point of the knife has passed through the cornea at the side of
the great angle  I glide this instrument below and  between it and the
sclerotica, in such manner, that by holding the  eye immovable in
that position, I render it  impossible for it  to  become  displaced in-
wards, giving at the same time a point d'appui  to the keratotome,
which allows me every liberty desirable for completing the section
of the cornea.
  I.  Scleroticotomy.—B. Bell, after making some  trials upon the dead
body, averred that it was full as  easy to extract the cataract by the 
GLOBE  OF THE EYE.
285
sclerotica as through the cornea.   This idea, the first application of
which upon living man was made by Earle, and which was revived
by D. Lebel  and M.  Giorgi, has been definitively adopted by M.
Quadri, of Naples, who founds upon it his new method or that of scle-
roticotomy.  An incision of about three lines in length is first made
by any keratotome whatever, upon the  sclerotica at two lines  from
the  cornea.   The crystalline and its envelope  are then seized hold
of by means  of a  small  pair of forceps, and  the  whole extracted
through the outer angle of the eye.   In proceeding in this manner,
M. Quadri affirms that he failed but in four  instances out of twenty-
five operations.   The first stage of the operation is less difficult, and
exposes perhaps to fewer immediate  accidents than the  ordinary
method, nor can it be very difficult to seize hold  of the cataract;
but how can it be embraced with sufficient firmness to enable us to
bring it through  the opening of the sclerotica without  emptying the
eye 1  How can it be  believed that so  large an incision through the
three  principal coats of the eye, will not, in a majority of instances, be
accompanied  by an internal hemorrhage, wounds of the ciliary nerves
or vessels, and followed by accidents a hundred times more serious
than those which take place  after the opening  through the  transpa-
rent cornea ?
  II.  Keratotomy.—Extraction, properly so called,  is composed of
three  different  stages:  the incision  of the cornea,  the  opening
into the capsule, and the  expulsion or  extraction of the crystalline
through the incision whether made upon the inferior or superior  half
of the eve.   The instruments  employed to effect, this have varied
considerably, and are  far from  being the same with  all operators.
In France, they freely employ the knife of Wenzel, the inventor of
which, Richter, (Bibl. Chir.  du Nord, p. 212,)  has  so severely  cen-
sured, and which differs from that of  La Faye only in this, that nei-
ther of its sides is more convex than that of the other.  Some prac-
titioners  however prefer the keratotome of Richter, the  blade of
which, which is  very pointed, expands from the point towards  the
handle in such a manner that it may divide one half of the segment
(limbe) ofthe cornea while traversing the anterior chamber.   That
of A.  Pamard resembles half a myrtle leaf,  and has, upon  its upper
border, which is straight and blunt, a small rib, in  order to  increase
its force.   Ware's knife, which is generally  employed in England, is
almost in every respect similar totfiat of Richter, and the instrument
of Beer, so much praised in Germany, differs  from it  only by the
shortness of its point, and in having a little less degree of length in its
blade, which latter, moreover, is somewhat  broader.  Beranger  has
proposed one which is convex on one  side, flat on the other, and
somewhat broader that than of La Faye.   Lobeinstein gives  it  still
greater breadth, and slightly elongates  its point.  Under this  form,
its  convex  side, turned backwards, protects the iris, while  its plain
surface glides behind  the  cornea.  This knife, slightly modified by
B. Bell, has since been improved by Jung, one of the most skillful
cotemporaries of Beer.  According to  Sprengel, the keratotome of
Jung, which is convex on both sides, and cutting on both its edges, is
very short and somewhat  broader than is necessary to divide with
one stroke half the circle ofthe cornea.  According to M. Harel, on 
286
NEW ELEMENTS OF  OPERATIVE SURGERY.
the contrary, tne knife should be like that  of Lobstein, convex only
on its posterior side, and should resemble  a  kind  of guillotine.  Fi-
nally, that of Barth is distinguished from the  preceding by the small
notch which is found near its back on one  of its  sides.   The impor-
tant point in the midst of so great a number,  is to choose an instru-
ment whose form and dimensions will enable us to divide completely
the half of the cornea,  in traversing the anterior chamber, without
giving egress  to the aqueous  humor while the knife remains in the
wound.   To effect this object, its blade, being of a triangular form, ten
lines in length, at least three lines in breadth near its heel, and slightly
convex on both its sides, ought to be somewhat thicker at its back
than near its cutting edge, and should gradually increase in thickness
from the point to the handle.  In this respect, Richter's knife, some-
what shortened as Beer has recommended, appears to me to deserve
the preference over all the others.  I have had constructed a carp's
tongue, four lines broad at its heel, six lines long, terminated by a point
somewhat tapered, and  which is more convenient for laying open the
cornea than the lance of Daviel.  An instrument which is longer, of
less breadth, and with a point more projecting, has been proposed
by M.  Furnari for the same object.   It is however perfectly under-
stood that we may, if necessary, make  use  of a  simple  lancet, the
little sickle-shaped  knife  of Sharp,  a  very  sharp-pointed bistoury,
or,  in  fact,  any cutting instrument whatever.   The  point under
these circumstances is, which is the best, and not what is of absolute
necessity.
  The second  stage has also attracted much attention from surgeons.
The needle of Thuraud, the lancet of Tenon, those of Hellmann and
Grandjean, Mursinna's probe, and the kystotome of La Faye himself,
with or without the modification of M. Rey or M. Bancal, are gene-
rally abandoned.   The  serpette of Boyer would have also fallen into
disuse, if the scoop of Daviel, which Dusaussoy (Gaz. Salut. 1786,
No.  29,  p. 3,) considers  that he  has improved,  and which is still
sometimes made  use of, was not mounted upon  the same handle.
Small  and straight forceps,  having a small hook at their extremity,
like those of Reisenger; the erigne forceps of Blaemer, or the tooth
forceps of Beer ; in fine, an  ocular forceps,  such as  are found at
every cutler's  ; a hook-needle; a small  spatula or gold scoop, and
Anel's  syringe in case  of necessity, and which are useful, either for
detaching or  afterwards removing  any fragments  of capsule, of
membrane or  of crystalline ; ought  also to be placed by the side of
the  knife on the  operating  table.  In a woman on whom I operated
for a black cataract at  the  Hospital of La Pitie, the capsule was so
thick and so firm, that it resembled in almost every respect the cor-
nea, causing me  a vast deal  of  trouble to open into and to extract
it, for which cases the instruments could not  be too sharp.   An ossi-
fied crystalline, as in  the case cited by M.  Middlemore, (Transac-
tions ofthe Prov. Assoc, vol. VI.; Revue. Med. 1838, t. III., p. 269,)
would  not be more difficult of expulsion  than any other.  It is prob-
able, however, that if the  cornea or vitreous humor were indurated,
as in the  patients of M.  Wardrop and Kulm, the operation for cata-
ract would hardly be thought proper.
  a. Inferior  Keratotomy.—1.  Ordinary  Process.—First Stage.— 
GLOBE  OF THE  EYE.
287
The patient and the assistants being  properly arranged, the surgeon
depresses the lower lid with the forefinger, which he  at  the same
time  presses against the caruncula  lachrymalis, in order to support
the globe of the eye on the inside; seizes the cataract knife with the
other hand ; directs its point at  a line or half a line in front of the
sclerotica, while  taking with his little finger a  point d'appui on the
temple ; then plunges the instrument immediately into  the anterior
ehamber perpendicularly to  the  axis of the cornea, a little above its
transverse diameter, and at  the  side of the outer angle of the eye;
immediately inclines backwards the handle of the knife, whose point
without this precaution would not fail to wound the iris ;  then pushes
it horizontally with firmness, and without any  shaking, to a point
diametrically opposite of the cornea, which he again pierces, but
from the interior to the exterior; makes  it advance  upon this line
without pressing upon its cutting edge ; takes care never to  withdraw
it towards the outside, and that one of its sides should be exactly pa-
rallel  to  the  anterior surface of the iris,  while the other looks to-
wards the front part of the eye, until in the progress of its track it
has entirely divided the inferior semicircle of the cornea, as near as
possible to the sclerotica, that is to say, at a line or half a line from
the greater circumference of the iris. It is at the moment when the
keratotome terminates this section, that  the slightest pressure would
be particularly dangerous,  and  which  it is important therefore to
avoid, as far as it is  in our power to do so.  At the same instant,
therefore, the assistant is to let go his hold upon the eyelid,  which the
patient, to whom some few moments  are accorded to recover himself
from his emotion, gently closes.
  Second stage.—After having  carefully wiped out  the vicinity of
the orbit, the surgeon raises up the eyelid or causes it to be raised a
second time, taking particular care not to touch the globe of the eye;
presents with the other hand the back of the kystotome at the most
depending  point  of the wound ; penetrates in this manner to above
the pupil, whose superior semicircle  he  passes around by preference
from one side to the other, and in such manner as freely to  divide the
crystalline  envelope with the  point of the instrument whose con-
cavity is to be turned  downwards.  When the two eyes are to be
operated upon successively, the surgeon rests  here  for the first, in
order not to return to it, until  after having opened the cornea and
capsule of the second.
   Third stage.—If the cataract does not of itself pass  into the an-
terior chamber, its expulsion is  to  be  favored  by means of gentle
pressure properly applied.   The operator pushes the left  forefinger
against the lower part of the eye.   With his right hand he places the
handle of the keratotome or the back of Daviel's ccoop, transversely,
upon the upper eyelid, in order to  execute while making pressure,
slight movements backwards and forwards, upon a level with the cili-
ary circle, in the direction of a line which would reach from this point
to the union of the two anterior thirds with the postero-inferor third
of the sclerotica, in passing from above downwards between the crys-
talline and the vitreous humor.   Immediately the lens is seen to pass
through the pupil, and to present itself by its border, at the  wound of
the cornea, which it escapes from, or  from which we force it to escape 
288          NEW ELEMENTS OF  OPERATIVE SURGERY.

by gradually directing upon it the pressure from above.  We then
remove it with the scoop, needle, or point of the knife, when the opera-
tion is usually found to be terminated.
   Fourth stage.—If opaque fragments of the capsule, of such large
size as to compromise the success of the operation, should  be found
to be left behind, they are to be seized hold of and extracted with
the forceps.  Any other fragment should be removed  in the same
manner, should the spatula or the scoop prove insufficient.  As to
those which become arrested in  the anterior  chamber, unless they
should be of a certain volume, it would be much better to abandon
them to the dissolving action of the  humors, than  to irritate  by re-
peated  trials with Daviel's scoop,  the  posterior surface of the cor-
nea.  The same remark may be applied to the diffluent layer which
is sufficiently often detached from the crystalline, when it escapes
into the anterior chamber, and  remains adherent  to  the environs of
the wound.  Whether the contact of the instrument with the mem-
brane of the aqueous humor inflames this lamella, as Sommer has
asserted, or whether it is detrimental in any other way, certain it is,
that a manoeuvre of this kind is frequently followed by a complete and
speedy opacity of the cornea.   Warm water injected into the cham-
bers of the eye with Anel's syringe, as Forlenze was  in the habit
of doing, would evidently be much preferable.   As  to  the dangers
of air, which according to M. Maunoir, (Carron  du  Villards, Oper.
de la Catar., p. 156, 216,) gets  into  the eye in place of the crystal-
line, making it necessary to  fill the anterior chamber with distilled
wrater to drive out this gas, I must differ in opinion  from the skilful
surgeon of Geneva.
   2.  Remarks.—In place of commencing  the incision exactly at
the extremity, or a little above  the transverse  diameter of the eye,
Wenzel recommends that the knife should be directed upon the mid-
dle of the outer and upper fourth  of the cornea, and that it  should
be made to come out at the same point on its lower and inner fourth.
His reason is, that by this mode the  root of the nose runs less risk
of being wounded,  and  that the wound  being oblique, the  eyelids
forced in closing to conceal its two extremities, cannot either of
them become entangled between its  edges.   This  precept, which
is generally recognized  in France, is far from having  attracted as
much attention in other countries.  In Germany, for example, it is
so little known, that Weller, who advises it, appears desirous of ap-
propriating the mode to  himself.  We  should be wrong, perhaps, not
to adopt it when the eye is large and projecting, because under such
circumstances, the lower palpebral border in fact might have a con-
tinual tendency to open  the lips  of the wound ;  but in other cases,
the advantages which are attributed to it, certainly originate much
more from theoretical ideas than from practical facts.  The puncture
of the inner angle of the eye is a matter of too little consequence to
be  regarded, and the natural  pressure made  by the upper eyelid
usually suffices to prevent the separation of the edges of the  wound,
whether it be transverse or oblique.  Then again, the projection1
which usually exists in most persons in the outer orbitar process, and
that of the superior maxillary bone near the ascending process, cannot
but have the effect to impede the march of the  instrument, and of in- 
GLOBE  OF THE EYE.
289
curring the risk of making such tractions upon the eye, as to endan-
ger the expulsion  of the vitreous humor.  Between the two angles
of the eye, nothing similar  is encountered.   When judged neces-
sary, it is generally under such circumstances practicable even to in-
cline the handle of the keratotome  towards the  temple  beyond the
transverse axis, without making severe tractions on the eye.   In in-
cising at less than  half a line from the cornea, it would  be with dif-
ficulty that we could avoid the iris  ; at more  than a line we should
have to  apprehend that after the  cure, the  opacity of the  cicatrix
would be brought too near the centre of the pupil.  A stage which
students have  most difficulty in comprehending  or executing pro-
perly, is that which consists in  falling perpendicularly on the eye.
It is, however, a point of the highest degree of importance.  If we
approach more to the  horizontal line, the point of the  instrument,
almost always  becoming entangled  between the laminae  of the cor-
nea, works itself obliquely through them,  and sometimes does not
reach into the anterior chamber, but at a line and a half  from its en-
trance, making in  reality but a small aperture, though in appearance
the wound is very large.
  To attain the object desired, the surgeon must not lose sight of the
position of the eye, and that  according as  this organ is more or less
turned inwards, he must always present the instrument to it from before
backwards, and from without inwards, but more or less inclined to-
wards the temple or towards the face.  We should also at the same
time recollect that the cornea being curved upon a cord shorter than
the sclerotica,  there must exist in  front of the union of these two
membranes a slight circular  excavation,  which causes  its  perpen-
dicular to be a little less inclined forwards  as compared with the di-
ameters of the body of the individual, and the perforation more easy.
As soon as the knife has entered into the  anterior chamber, its cut-
ting edge must be  kept downwards  as accurately asTjossible, in-order
to avoid the ciliary circle and iris  behind, or  having a cicatrix too
near the  centre,  should it  be inclined forward.   At the  moment
when its point is about to emerge at the side of the caruncula lachry-
malis, it would, should it  not  be directed a little towards the anterior
plane, bear too much upon the sclerotica, and might  again wound
the cornea.  As soon as we have commenced inserting it,  it is im-
portant not to give it any  retrograde movement until  it has com-
pletely traversed the eye.   The gradual increase of its thickness and
breadth, enables it to fill up the  wound exactly, from whence it fol-
lows that the aqueous humor does not flow out till at the end.  How-
ever little it may be withdrawn, on the contrary, it leaves necessarily
a void from whence this liquid immediately escapes.  The iris then
protrudes forward, and may be easily wounded.  The rule is, that
we  should  detach  the half of the circle of the  cornea.   A  smaller
wound wouid render the expulsion  of the  crystalline difficult, espe-
cially should it be  of a large  size, and would  necessitate dangerous
pressure.   Should the wound be greater, there  could be but little
inconvenience in it.  Ware extended it to two-thirds of the cornea;
but though in such cases gangrene of the flap, dreaded by Maunoir,
can scarcely be apprehended, it is nevertheless unnecessary to  go so
far. Should it be necessary to enlarge the incision of the cornea, the
                              19 
290
NEW ELEMENTS OF  OPERATIVE SURGERY.
 instrument in form of a double lithotome, devised by M. Carron du
 Villards, (Marini, Bull, de  Therap., t. VI., p. 282,)  might be service-
 able, and would readily enable us to  attain our object.   When the
 eye obstinately  continues at the vault of the orbit, the trefoil  of Pa-
 mard may  be required to render the process of extraction practica-
 ble ; if it is concealed at the great angle of the eye, we may some-
 times bring it out by means of the finger  directed upon the  carun-
 cula lachrymalis;  and better still, with the scoop (curette d'ecaille)
 which I am generally in the habit of using.  It could be fixed with-
 out difficulty and even without danger, between the middle and fore-
 finger of the assistant and the operator,  if we could feel perfectly
 sure that  we  could suspend all kind of pressure  the moment the
 knife had penetrated through and through the cornea, that is, a little be-
 fore the definitive formation of the flap.   At least I do not  see any
 risk in proceeding in this manner, until the point of the knife arrives
 in the great angle.  Then we are masters of the organ, and no ob-
 stacle prevents  our bringing it forward, provided, however, the bkide
 of the instrument is not displaced.   In place of the sound or flexible
 probe, which were used by  Pellier and  Siegerist, we might, when
 the pulp of the finger did not appear to  be capable of effecting our
 object, use  advantageously the nail of the forefinger, or even of the
 little finger, to  aid the knife in terminating the flap  of the cornea.
 The extremity of the finger is then directed upon the great angle, in
 such manner that its pulp falls  perpendicularly upon the  inner side
 of  the eye, at  the  same time that its back faces  forwards  and to-
 wards the median line.  As soon as the keratotome presents itself, its
 cutting edge is placed at a right angle on the free border of the nail,
 as  if to support  it; after which, while making it pass from the ex-
 ternal to the internal angle  of the eye, the nail fixes the  cornea by
 making a slight effort, as if for the purpose of gliding outwardly to-
 wards the  heel  of the instrument, until  the incision is  completed.
 The shell scoop which  I am now in the habit of employing, substi-
 tuted in  place of the  nail,  renders this  stage of the operation still
 more simple and easy.
  In spite of all these precautions the iris will sometimes presenl
 itself under the  cutting edge  of the knife.  Gentle frictions  on the
 front part of the eye, through the upper lid, often oblige it to withdraw
 itself backwards, either because we in this manner favor its contrac-
 tions and its narrowing, or,  as appears to me more  probable,  because
 the pressure that we must  almost necessarily make upon the cornea,
 restores  it to its natural position, by forcing the  liquid  which is in
 front of the keratotome from the anterior into the posterior chamber,
 or perhaps because we straighten its  folds by flattening the vitreous
 membrane.   Certain it is  that we never succeed better than when
 we apply the finger naked upon the eyelid, and moderately compress
 it.  After all, the worst that  can  result  from it is a second pupil;
 which accident  has happened  to  Wenzel, M. Roux, and Forlenze;
 numerous examples of it are to be found in the works  of  authors.
 It has happened many times with myself, and. I  have  not found that
the  re-establishment of the  sight  has been thereby interfered with.
1 am therefore  of opinion that it  is less  dangerous to incur the risk
of this accident, than to withdraw  the knife to finish the incision with 
GLOBE  OF THE  EYE.
291
the  scissors, and that prudence,  moreover, allows us  to  dispense
with it, if in order to avoid it we expose the eye  to fatiguing mani-
pulations.   The elasticity of the sclerotica, and perhaps also the action
of the recti muscles, may quite frequently be found sufficient to ex-
pel  the  crystalline, which then  immediately presents itself at  the
wound, as soon as the instrument is withdrawn, or a short time after.
It is indeed  owing to this fact that many practitioners have suggested
the idea of opening the capsule at first, and not to return to the ex-
pulsion of the cataract until after having  proceeded in the operation
to the  same extent upon the other eye.  Bell, and after him, Jung,
from fear of breaking up the crystalline, have proposed to scrape the
capsule rather than incise it.   After having cut through the cornea,
M. Jiingken (Jour, de Kleinert, Juin,  1836, p. 76s) considers that the
chances of  success would  be augmented by removing  the capsule
before extracting the crystalline.   It is  a practice which  is decidedly
pernicious,  and which nothing but the  extreme skill of  the German
oculist  has  rendered  somewhat  popular.   Pellier,  Siegerist,  and
especially Wenzel, have  considered that it would  be better to open
this  membrane with  the  keratotome  while passing  through  the
anterior chamber, than to  return  to  it afterwards.  It was an easy
thing for Wenzel, who reached its  anterior layer by  inclining
slightly backward the point of his knife, when it was passing in front
of the pupil.  For operators who are less experienced, it would be
an exhibition of force, and  an act of imprudence which might be
attended with danger.   The operation would be  uselessly complica-
ted  by raising the flap of the cornea  with a spatula, while another
instrument  was being directed  towards  the  pupil.  The  cataract
knife is rarely employed for this incision, because  the iris might
thereby be easily wounded.  Hey's needle, the little  myrtle-leaf of
Morenheim, and the spear-shaped instrument of Beer,  are special
instruments which are replaced by the ordinary curved needle, or the
serpette of Boyer, which, however, in consequence of its convex and
rounded border, is much better adapted for going through the wound
than lacerating the crystalline envelope.  I would  say the same of the
instruments of M. Furnari, which,  nevertheless, are  constructed
with considerable ingenuity.  This surgeon after having incised the
cornea with his lance-shaped knife, the  point of which at the  same
time lays open the  capsule, proceeds to  break up the crystalline in
its place, by means of a kind of small  polypus forceps, which after-
wards allows of expelling or extracting it without difficulty through the
incision.  The crystalline escapes readily through a puncture in  the
centre, or a semilunar incision at the depending point of the capsule,
as well as  by the numerous incisions vertical and transverse, which
Beer was in the  habit of making upon it, because it lacerates what
makes resistance to it;  but^ the flaps of  the  opening afterwards
approximate, or fall back again into the visual axis, and  may, should
they become opaque, produce a secondary cataract.   On  the con-
trary, by placing the semilunar incision above, as I have recommend-
ed, the tearing  open of the capsule is made from above downwards,
in such  manner that the flap which results  from  it must remain
below the  pupil.   Beer, perceiving that it was sometimes exceed-
ingly difficult to  effect this  destruction of the  capsule conveniently, 
292
NEW ELEMENTS OF OPERATIVE  SURGERY.
decided  upon  removing it  entire,  either  by  means  of a  hook in
cases of silicose  cataracts,  or by a small  forceps, when  it  is an
encysted cataract, or finally, in cases of capsulo-lenticular cataract,
by  means  of his needle-shaped  lancet.  Richter,  maintaining  the
idea,  that, in  depression, the  capsule and crystalline are always
reversed  together,  (Bibl. Chir. du Nord, pp. 269,  271,) asserts
that in  the operation for extraction  also,  it is advisable  and not
difficult to remove them both  at  the same time.  Though  Beer
asserts that he has often followed this  precept  with success, he has
not found, and will not find in the future  but  a very small number
of partisans.   Who, in  fact,  does not see that  the remedy is worse
than the evil; that we should succeed much better by making free
incisions into the capsule than  by detaching it in mass;  that  by
these repeated movements the crystalline will, in most cases, lacerate
it, and leave  it remaining,  so much  the more so  as  the posterior
capsular layer is not susceptible of  being readily  detached from the
vitreous  humor.   It is  not  often, moreover, that  this deep-seated
portion of  the crystalline envelope becomes opaque.  This  is fortu-
nate, for unless it was very limited, the evil probably would be without
a remedy.  Even in such cases I do  not  know  to what extent it
would be allowable to follow the advice of Morenheim  and Beer, by
isolating the opaque point, and attempting its extraction with a hook.
I do not think that  the  laceration of the posterior capsule  in many
directions,  after having  extracted the crystalline, as is recommended
by M. Landrau, (Arch.  Gen. de Med., t. XIV., p. 113,) would be a
prudent course, or present the slightest advantage.
  It has  been suggested when the cataract was  milky to give egress
to the altered liquid, or when it  was  membranous to  destroy the
capsule  only, in  order  to preserve,  according  to M. Jiingken, the
crystalline in its place with its natural transparency; as if in liquid
cataract  the  whole lenticular apparatus was  not  at the same time
diseased; as  if the  crystalline could maintain itself with its  normal
conditions  a moment after the capsule had  been opened !  Diseased
or not, it should be  removed  in every case therefore, should there be
no obstacle to our doing so.   The putrid cataract of Schifferli does
in reality exist; an  instance of  which  I saw at La Charite in 1837.
The lenticular capsule, which was of a greyish  color and very much
distended,  extended beyond  the plane of the  pupil in  front.  The
purulent matter which it contained, emitted  in coming out an infected
odor which surprised all the  assistants.  In  producing a dilatation of
the pupil the preparations of belladonna, which were already in use
in such  cases in the time of Pliny  (Carron du Villards, t. II.) and
Raymar (Causard,  Theses de Paris, &c.,) give  greater facility to
the egress  of the vitreous humor, and may in this  manner become
more or less dangerous.  If they are omitted  the  pupil sometimes
remains so contracted as to interfere with the expulsion of the crys-
talline.   In order to obviate these two  inconveniences, Bischoff and
others have recommended that we should first open the cornea, then
the capsule,  and afterwards turn  the back  of the patient to the
light when we desire to expel the cataract.   By this means  the pu-
pil, which was strongly contracted in the beginning of the operation,
becomes, they say,  dilated of itself, and without  any danger towards 
GLOBE OF  THE EYE.
293
the termination.  If it were necessary, we might also, say these same
practitioners, not  make  use of any medicated' applications until
after the eye had been  opened into; as if the pupil could then  re-
spond to the action of belladonna!
  Finally, before proceeding to any active means, we must cause
the  globe of the eye to be moved upwards, inwards, and outwards,
seeing that such movements frequently favor the egress of the opaque
body.  If from some cause or another the vitreous humor escapes,
we must immediately close the  eyelids and  turn the head of the  pa-
tient towards his back.   This accident, which involves  the complete
loss of the eye when the hyaloid membrane is entirely emptied, is in
the other cases much less dangerous  than has been for a long time
supposed.  It has in fact this thing remarkable about it, that the loss
of a certain quantity of  the vitreous humor seems rather calculated
to augment than to diminish the prospect of a  favorable  result  for
the operation. The loss of a fourth part  or even a half of this liquid
ought not to cause us to despair of success.  There is no evidence that
it is again produced ; but the aqueous humor being more abundantly
secreted, takes its  place,  and the functions of the eye scarcely suffer.
  3. Process of Guerin and Dumont.—With the view of reducing
the operation to  its most  simple condition, Guerin, and almost at  the
same time, Dumont, captain of  the coast  guard in Normandy, each
contrived an instrument, the object of which was, by an ingenious
mechanism  to hold  the  eyelids apart, steady the globe of the eye,
and  complete the incision of  the  cornea by one stroke.  The first
of these instruments, terminated by a sort  of ring bent to a right angle
on its handle, concave behind,  and shaped  to the front of the  eye
to which it was accurately adapted, includes a cutting blade in form
of a fleam, which being put into operation by means of a spring,
immediately  divides the half of the circle of the cornea either from
below upwards or from above downwards.  The ring and the han-
dle of the second are upon the  same line.  Its blade has some anal-
ogy to  the pharyngotome, and is to be applied horizontally, differing
in this  respect from the other,  which falls on the eye in the manner
ofthe cutting edge of a guillotine.  The instrument of Guerin, which
was suggested perhaps by the fleam of Van Wy, has been long since
abandoned in France, and M. Eckhold, after  having modified it, is
the only person to my knowledge who has been desirous of its adop-
tion in  Germany.  Though more convenient and less dangerous, that
of Dumont has not met with a  better reception.
   4. Guerin of Lyons,  (Mai.  des Yeux, p. 380, 1769,) uniting  the
lance of Pamard with the keratotome, was not more fortunate than
his namesake of Bordeaux.
   If the instruments of which  the ancients were so lavish, if every
species of brute  force has been so carefully rejected from practice in
the operations of  modern surgeons, with still greater reason ought
they to be proscribed on the eye, which is an organ of such delicacy
and so easily destroyed.   The stroke which is necessarily given to
them by letting loose a mechanical  spring, the danger of  wounding
what it is important  to avoid, of making  an opening either too great
or too small, and of cutting sometimes too near and sometimes  too
far from the  sclerotica, are the reasons which have especially intimi- 
294          NEW  ELEMENTS OF OPERATIVE SURGERY.

dated practitioners.  It would, however, be unjust to accord no praise
to such inventions, and to qualify them as absurd, as some have done,
without having  it in our power to judge of them with a full  know-
ledge of circumstances.  A number of physicians can attest, like M
Hedelhofer, that Petit of Lyons  frequently and  successfully made
trial of the instrument of Dumont.-  Modified  by the nephew of its
inventor, it has been said to have obtained sixty-two successful results
out of seventy-one  operations, if we can receive literally all that has
been said of it.   What we  may affirm is  this, that notwithstanding
the improvements which have  been made  upon it  by M. Gu6pin,
(Soc  Med. de  Nantes,  1834, 2d  trim., p. 46,)  the  instrument of
Guerin has been completely proscribed from general  practice.
  b.  Superior Keratotomy.—When the  lower  semicircle of the
cornea is opaque or altered in any manner  whatever, its section
is, in the first place, quite difficult  in certain cases.  Afterwards the
wound is found  in unfavorable conditions  for cicatrization.   This
membrane, though sound, may be very small, so  that it  becomes neces-
sary to detach more than half of it  in order to obtain a sufficient open-
ing.   In such cases Wenzel  advises that we should divide the superior
semicircle, and  states that he found it to answer perfectly well in the
case of the Duke of Belford.  Richter is of the same opinion, and B.
Bell has formally advised it, even for ordinary  cases.   According to
him there is less danger ofthe escape ofthe vitreous body, the cicatrix
ofthe cornea is perfected more rapidly and is less perceptible, and less
troublesome to the vision than by the ordinary process.   M. Wagner
states  that M. Alexandre has not  hesitated to put the suggestion of
Wenzel to a trial, and M. Wilmot, as quoted by M. Eccard, asserts
that MM. Lawrence, Green, and  Tyrrel  have frequently employed
it.  Dupuytren, in France, also thought proper to make trial of it;
but nobody, before the time of M. Jaeger, had gathered a sufficient
number of facts upon  living  man to establish  it  into a general
method.   With the upper incision, says M. Jaeger, we have nothing
to apprehend from the friction of the palpebral  border or of the eye-
lashes, the tears run more freely and irritate the wound less, which,
in its turn, does not so often suppurate, while the prolapsus of the iris
must be very rare.  A difficulty which first arrested his attention, was
the tendency of the eye to turn inwards, or to reverse itself under the
upper  lid.  In this  respect  he believes that he has removed every
objection, by contriving a peculiar keratotome formed of two blades,
one of which is a little less than  the other, applied face to face in
such manner as to represent the knife of Beer  or Richter when it is
closed. By pressing upon a lateral button the small blade is made
to glide upon the large one as in opening a knife  with a sheath.
The patient and the assistants are to be arranged as  in the  ordinary
method.   The operator seizes the double keratotome in the manner
of a writing-pen, turns its cutting  edge upwards, and passes through
the anterior chamber parallel to its transverse axis, while conforming
himself in other  respects to the precepts laid down above.  This
being finished he brings back the globe of the eye to its natural posi-
tion, even depresses it a  little if  necessary, and fixes it by means of
the largest blade ofthe knife, while the other blade put into operation
by the thumb of the same hand, effects the division of the cornea in 
GLOBE  OF THE EYE.
295
 Gliding from its point to its base.  M. Alexandre, (Wagner, Bull, de
 ''eruss., t. X., p. 284,) who, after having passed through the cornea,
leaves a bridle of it which he afterwards divides with a small blunt-
pointed knife, appears to have acquired such practice in the use of
this instrument, that he can  operate  alone and without assistants.
Since M. Jaeger, in the space of six months, has forty times extracted
cataract successfully by means of his  double keratotome, it would
be incorrect to say that this instrument was positively objectionable.
A priori, nevertheless, it is  difficult to understand its advantages.
If it be true  that  we may  firmly fix  the  eye with its immovable
blade, while its other blade  is  dividing the  upper segment  of the
cornea,  it must, on the  other hand, pass  through  the tissues  with
greater difficulty.   Upper keratotomy, moreover, may be very well
performed  with  the ordinary knife.  M.  Graefe,  (Arch.  Gen.  de
Med., t. XXI., p. 271,) who  has used this  successfully in seventeen
out of eighteen cases, among others upon the Duke of Cumberland,
believes it preferable to the double  keratotome, and I have employed
no other instrument in the fifteen cases in which I have had recourse
to this kind of keratotomy.   As  to the operation in itself, of all
the advantages that are  ascribed  to it, there are very few that are
substantial.  It perhaps  exposes less to a wound of the  iris, to the
escape of the vitreous body, and to the separation  of the wound
by the border of the eyelids ; but the manipulation in all its stages is
is unquestionably more difficult  and less secure than in lower kera-
totomy.  How  can  we  afterwards proceed to  laying  open  the
capsule, if the eye keeps itself raised up under the vault ofthe orbit?
What means have we of depressing it, if the will of the patient does
not effect it ?   How direct the  pressure, if the crystalline delays in
coming  out ?  And the attending circumstances of cataract, can it be
supposed that it will  be always  in our power to reach them?  It is,
therefore, a method of exception and not of  choice, applicable only to
the cases pointed out by Wenzel, even supposing then that it wrould
not be preferable to recur to the employment of the needle.
   III. Dressing and subsequent treatment.—Dressing  and the subse-
quent treatment  after extraction differ but very little from what has
been recommended after depression, only perhaps that it would not
be altogether useless, before covering his eyes', to exhibit  to  the
patient some  objects that are not shining,  to see if he distinguishes
them.  It is  not in  order to gratify mere  motives of curiosity that
this precaution is recommended, but because we are obliged by such
a  test, when it is not satisfactory, to ascertain again if some opaque
substance which  it is important to extract, does not remain in the
eye.  Repose, avoidance of all movements  of the eye and the upper
portion  of the trunk, now become of more absolute necessity than
ever.  Though the head should be only slightly elevated, I see no
reason,  however,  which  should induce us to place it lower than the
feet, as was done by Forlenze.   The regimen ought to  be more rigid,
and continued for  a longer time,  a longer interval also allowed to
elapse before the first dressing, and the eye not so soon exposed to
the light as after  depression.
   The suppuration of the cornea,  (la fonte de la cornee,) which we
have especially to  dread,  ought to be watched with extreme atten- 
296
NEW ELEMENTS OF  OPERATIVE SURGERY.
tion.  We can prevent or arrest it only by means of very energetic
treatment; bleeding to the amount of from twelve to sixteen ounces
morning and evening, leeches to the temples, purgatives internally,
and cutaneous revulsives, simultaneously employed the first, second
and third day, are not too severe in such cases.  It is important even
that we should not hesitate, but recur to it immediately as  soon as the
linen which  covers the eye becomes soiled, and as it were saturated
with pus, and that the patient complains at the same time of pains in
the orbit, before* the fourth or fifth day after the operation.
  E. Comparative  examination of the  processes. — I. Depression,
which was alone in use up to the middle of the last century, fell into
such discredit, in France at least, after the publication of the labors of
Daviel,  that in spite of the efforts of Pott to cause its revival, it was
scarcely any longer had recourse to by any one at the commencement
of the present century.   The modifications which it has received from
Scarpa  rescued it from this oblivion.  But the question, which ofthe
two methods is  the best? which has so often  been debated,  and
always  remained undecided, is still daily revived.   In admitting that
it is not incapable of solution,  it  must nevertheless be  conceded that
the circumstances  which enter  into its nature  are difficult to be
appreciated.   How can  we  conclude,  for  example, because  one
process  possesses a greater number of distinguished partisans than
another?  because  Scarpa, Hey, Dubois, Dupuytren,  Richerand,
Beclard, Lusardi and Langenbeck, have procured a greater propor-
tion of  cures by depression than by extraction ;  while for Wenzel,
Richter, Beer, Demours,  Boyer, Roux,  Forlenze  and Pamard, the
case  is  precisely the  reverse ?  As  soon as  an operator has made
choice of a method which he is in the habit of employing, his predi-
lection always more or less deceives him, and renders him,  in most
cases, unfit to judge  of other methods. Nor are the results, announced
by different  men equally well instructed, decisive  arguments.   The
successful issues  procured by Dupuytren from depression, in no wise
prove that this  operator would  have been  less fortunate, if in the
beginning he had exerted himself to give popularity to extraction.
In promulgating that by means of extraction Sharp had the same num-
ber of successes as reverses ; that Richter succeeded in  7 times out
of 10, Pelletan and  Dupuytren 20 out of 50, M. J. Cloquet 28 out of
80,  M.  Roux  188 out of 306, and  A.  Pamard  302 out  of 359, we
prove nothing more, either for or against this method,  than do we
demonstrate the  pre-eminence or inferiority of depression, by saying
that in  this manner Beer, Weller and M. Roux  have failed in more
than  half  their cases, while  Dupuytren cites five cures out of six
cases, M. J. Cloquet 97 out of 166,  M. Bowen 154 out of 160, and
M. Lusardi 4168 out of 5034.  M.  Robertson, (Presse  Med.,  t. I.,
p. 430,) having examined 1307 cases of operation by extraction, taken
from twelve different authors, has ascertained that 397 of them were
failures, while out  of 7529 examples of depression, there were but
104 failures.   Out  of 64  patients that he himself operated upon by
extraction, he cured 32 ; 14 obtained some relief from the operation,
while 18 remained uncured.   In 11.5 cases  of depression, on the con-
trary, he  procured 94 cures, with 10 cases of amelioration, against 
GLOBE  OF THE EYE.
297
11 failures.  M. Serre, (Bull, de VAcad., t. I., p. 90,) who  adopts
depression, states that he has succeeded in 62 instances out of 70.
  In the table of Brunner (Anc Journ. de Med., t. 84, p. 80, and es-
pecially p. 86, 1790,) we find 252 extractions, and out of them 149
favorable, 24 mediocre, 61  unfavorable; out of  169 depressions, 134
favorable, 36  unfavorable; out of 100  extractions, 59 favorable, 17
mediocre, and 24 failures; out of 100 depressions, 79 favorable and
21 failures   M. Fabini, (Bull, de Fer., t. XXVII.,  p. 71,) who in 107
patients, operated 100 times by extraction, states that he obtained 71
cures.  In an aggregate of 179 cases of extraction by M. Roux,
(Maunoir,  These citee, p. 78, 79,) there were at one  epoch 97 cures
and 89 failures.  Suppose,  in order to show how deceptive this kind
of proof is, that the,twenty  most skilful surgeons  of Europe have ope-
rated  only  by extraction,  while 20 others taken  at random, have
always had recourse to depression.   Because the practice of the first
shall have furnished a larger proportion of cures than that of the
second, does it necessarily follow and  by that  proof alone, that ex-
traction is preferable  to depression ?
  II. Let us see whether, after having passed in review  the princi-
pal advantages  and  inconveniences of both methods, we  may not
arrive at something more satisfactory.
  Extraction enables us to remove with certainty and without a re-
turn of the disease,  the impediment to  vision.  Besides  being at-
tended with but little pain and rarely followed by an  internal inflam-
mation, it incurs the  risk of wounding  neither the ciliary nerves or
vessels, leaves intact the whole interior of the eye, the retina, choroid,
ciliary circle, &c, but in performing it, we may wound and deform the
pupiL and cause the escape of vitreous  humor;  if the wound which
it  produces does not cicatrize by first intention, it  ulcerates, soon
brings about a prolapsus of the iris, and sometimes an atrophy of the
globe of the eye, or at least a very extensive opacity of the cornea ;
the subsequent symptoms also are tedious ; it rarely happens that the
ophthalmia which accompanies it, terminates before  the fifteenth or
twentieth day ;  finally, it cannot be employed in ail  persons nor at
all  ages.   M. Roux, (Maunoir, These  citee, p.  81,)  who  operated
upon 43 cases in the spring of 1833, had the misfortune to lose three
of them.   In  35 patients operated upon in 1836, by  the same prac-
titioner, (France Med., t. I., p. 50,) the escape ofthe  vitreous humor
took place in five ;  the iris was wounded several  times ; and a violent
inflammation ofthe eye occurred in eleven cases.   Thirteen patients
recovered their vision perfectly.  The result was incomplete in eight
others ; in fourteen cases the operation did not succeed.   One of the
patients operated upon, died of erysipelas.  In 179 patients operated
upon by M. Roux at another epoch, (Maunoir, These citee, p. 79, 80,)
suppuration of the eye took place in 14 cases, opacity of the  cornea
in 28, and a false cataract occurred in 22.  It  would appear, how-
ever, according to M. Maunoir, (These citee, p.  49,)  that at La Cha-
rite, during the  time of M. Roux, membranous  cataract was ascer-
tained to have occurred but in 5 instance  out of the above men-
tioned 179 cases.
  Depression confines  itself to displacing  the opaque  body, and
abandons it in the depth of the organ,  leaves there, consequently,  a 
298           NEW ELEMENTS OF OPERATIVE SURGERY.
 permanent cause of irritation in the eye, incurs the risk of the reas-
 cension of the crystalline, and  is  frequently followed  by secondary
 membranous  cataract, iritis, deep-seated pains and general  nervous
 symptoms.   The  needle penetrates through  delicate tissues, neces-
 sarily wounds the choroid, the retina and the vitreous humor, and
 sometimes also the iris and ciliary body.  But on the other hand, it
 does not give rise to the escape of the vitreous  humor, nor does it
 expose to spots, or ulceration of the transparent  cornea, or prolap-
 sus or excision of the iris, nor to the immediate destruction of the
 eye.   On  the following  day the puncture which it makes is closed,
 and the  conjunctiva, which in a majority of cases is but slightly in-
 flamed, ordinarily resumes its natural  appearance at the  expiration
 of from  eight to twelve days.   Finally, we  may if necessary  apply
 it to all  cases, and repeat it one or several times upon the same or-
 gan, without incurring the risk of any great danger to the patient.
   III. After this enumeration  it would appear at first view, that de-
 pression  ought to have  the  preference  over extraction.   A  rigid
 examination, however, does not permit us to come  to a conclusion so
 clear and positive. It is true that the puncture of the sclerotica, cho-
 roid, retina and  vitreous  body, rarely, produces more pain than the
 section of the cornea, when we proceed in the manner I have pointed
 out.   The wounding of the nerves,  and vessels  of the ciliary  body,
 is easy to be avoided,1 and generally attended with no unpleasant cir-
 cumstances.   When the crystalline capsule is properly lacerated, we
 cannot.see why secondary cataract  should  be more common after
 depression than after extraction.  If the crystalline is securely fixed
 in the vitreous humor, it  is difficult for  it to reascend or for its pre-
 sence to  disturb the retina.  With skill also we may succeed in avoid-
 ing the iris, which  the needle moreover never wounds as seriously as
 the keratotome.   But we  should be wrong in maintaining that this
 method is more simple and more easy  than the other.   It is not so
 easy as some  persons  imagine to pass the instrument between the
 uvea and the cataract; not to get  it entangled between the  crystal-
 line  and  its envelope;  to make the proper  opening into the cap-
 sule ; or  to hinder the  opaque body  from being  reversed, either up-
 wards or downwards, should the concavity  of  the needle press it
 ever so  little  more in one direction than  another, or  be deviated
 from  the direction indicated, or that the lens shall have contracted
 adhesion  with the  surrounding parts ; finally, it is not until after pro-
 longed trials that we are enabled to detach it and fix it at the bottom
 of the eye.  The  greatest degree of address, therefore, is indispen-
 sable to perform depression in such manner that it may have every
 possible  chance of success.  If inexpert surgeons generally prefer
 it, it is less owing to its apparent simplicity, than because it does not
 allow their mistakes to be so clearly noticed as the method by ex-
 traction.   On  the  other  hand, the  irritation which it produces aug-
 ments  the  secretion of the humors, and soon creates in  the  eye a
 feeling of distension wliich does1 not take place in the other method.
 A chronic or acute iritis, and  afterwards a contraction and even a
 complete  obliteration of the pupil, may  frequently be  produced by
it.  The  lesion of the vitreous humor,  without  being immediately
dangerous, may not however be altogether free from inconveniences. 
GLOBE  OF THE  EYE.
299
The crystalline, which  in  fact disappears sometimes by absorption
or dissolution, still more frequently remains with all  its usual form
and size during the space of years, and  even during the whole life,
whatever the moderns may have  said of it to the  contrary, on the
authority of Pott, Scarpa, and Dablin, (Biblioth de Planque, t. III., p.
341, in 4to.)  who, in the year 1722, had ascertained its absorption,"
and concluded that this always took place after depression.  Beer has
seen it reascend at the expiration of 26 years.   Out of twelve pa-
tients  whose eyes I have had it in my power to examine after death
in the  different hospitals,  at  one  year, two  years, two  years  and a
half, and four years after the operation, it had scarcely diminished a
fifth of its size  in the only  subject in whom it was perceptibly al-
tered.  In the  others it had ultimately, by means  of some lamellae
of the  hyaloid  tunic which separated that coat from it, contracted
adhesions with points of the retina and  choroid, which  themselves
exhibited a  sort of knot  or cicatrix of about three lines long.  M.
Campaignac, who has  made special researches upon this point of
practice, also asserts that after depression the crystalline lens is far
from  disappearing as speedily, and especially as constantly as had
been supposed.  This  therefore,  it  must be allowed, is a serious in-
convenience, one which no argument ean-extenuate, and which will
always render the operation for cataract  by depression less complete
than by extraction.
   IV. Keratonyxis,  which  Dr.  Wedemeyer rejects after having
made  trial of it in fifty-three instances, would succeed no better, and
whatever M. Schindler, whp defends it,  may say of it, it would be
an objectionable mode of giving confidence to practitioners by pene-
trating after the manner  of this  author, through the centre of the
cornea, instead of passing through  the depending point ofthe anterior
chamber.  The crystalline, after  it has escaped or  been abandoned
in front of the iris, whether in mass or in fragments,  is far from being
dissolved there as  speedily  as some  authors  assert.  Observations
collected by M. Plichon at the Salpetriere, prove that it then often forms
there  a foreign body, and  that if  we do not hasten  to remove it the
eye is exposed to serious dangers.  Another defect  still  more grave
is the  following: the pupil may remain  movable and perfectly uni-
form,  the  whole  organ have an appearance of the most perfect
integrity, but the vision nevertheless be  totally  destroyed.  I  have
seen four persons at the central bureau,  who were blind  from this
cause, and who had been operated upon at Paris.  A man sixty-two
years of age, whom I had operated upon in 1829, at the hospital of
St. Antoine,  came to consult me in  1831.  At first view one would
say that his  sight was perfectly free.  The pupil is of a  beautiful
black, round, regular, movable, nor abnormally contracted or dilated,
yet nevertheless the blindness is complete.  What has imposed upon
the partisans of depression is this, that the patients  quite frequently
appear to recover  their sight after the expiration of a certain time,
and preserve it, in fact, during the space  of  one  or  two  months, but
afterwards find that it gradually becomes  enfeebled, and that the
vision  is totally destroyed in less than a year.   If the operation, re-
peated seven times in one  case, six times in another, and in a third
as often as thirteen  times on each eye, enabled Hey to  cure his pa- 
 300          NEW ELEMENTS  OF OPERATIVE  SURGERY.

 tients, it is nevertheless true that these repeated attempts prove un-
 successful in a majority of cases.  The truth is, however, that their
 consequences are generally not very serious.   After depression, parti-
 cles more or less opaque almost always remain or are formed in fron*
 of the vitreous body.  Experience  proves that after extraction this
' accident  is infinitely  more rare.   As to this last method it is  evident,
 that the section of the cornea is much more delicate than the  perfora-
 tion of the sclerotica;  that in spite  of every precaution the  vitreous
 body may escape, and the iris be extensively divided  by the knife, or
 separated or torn by  the crystalline; but after all, if  the operation is
 well performed and the patient  in a favorable condition, three acci-
 dents, the escape-of the vitreous  body, the suppuration of the  eye,
 and the consecutive opacity of the cornea, can alone render it dan
 gerous; while all other things being equal, it procures without ques-
 tion a result either immediate or definitive more satisfactory  than the
 method by depression.  It is requisite to state, however, that the
 escape of the crystalline  again exposes to  two other  accidents.
 Though largely dilated by the action of belladonna, the pupil almost
 constantly contracts so much as to oppose a certain degree of resist-
 ance to the opaque body, which  then has a tendency to detach the
 iris from  below, in such manner as to make its escape there if the
 pressure upon the eye has not been made with an extreme degree of
 caution.   This pressure in its turn, if made quickly upon the cornea
 in consequence of some unexpected movement of the patient at the
 moment when the border of the cataract presents itself at the wound,
 may thrust back the lens  above the vitreous body;  in such  manner
 that we may remain in doubt whether it is still in the  eye, or  if it has
 actually escaped, as has happened to me in one instance.
   V. The prolapsus  of the iris, which often occurs after the opera-
 tion, and  more frequently in old men, in consequence  of the cornea in
 them being tardy in  cicatrizing,  is treated by mechanical means or
 belladonna, so long as there is no adhesion; in the  contrary case, by
 nitrate of silver;  and is not more difficult of cure here than under
 any other circumstances.   When our object is to leave no obstruct-
 ing particle in the eye,  there is no objection to throwing up  through
 the wound one or two injections  of  tepid water with a  small Anel's
 syringe.  Perhaps even it  would  be really advantageous  to imitate
 Forlenze  and to adopt this method generally.  Finally, if the  dangers
 of extraction are more serious and more  apparent, those of depres-
 sion are-more numerous and more real.   Operators alike skillful will
 more easily avoid the first than the second, and if the  employment
 of the needle less  frequently fails of procuring some  relief to the pa-
 tient, the method of Daviel  furnishes by compensation  a  greater
 amount of radical cures.  Find a way to avoid the suppuration ofthe
 cornea, and extraction will obtain a large  amount of  cures;  prevent
 iritis after depression, and the patients, though free from suffering or
 danger, will nevertheless run the risk of  obtaining but imperfect re-
 sults from the operation.   Out of 300 operations for  cataract whose
 cases I have minuted, I count 200  cures.  In the  hospitals  where  I
 have adopted sometimes  extraction  above or below, sometimes de-
 pression by different  methods, I am still uncertain  to which method
 I ought to attribute the greatest amount of advantages or  inconveni- 
GLOBE  OF THE EYE.
301
ences.   In private practice, extraction evidently succeeds better.   I
conclude therefore that under circumstances where the two methods
might either of them be indifferently made trial of, extraction is pre-
ferable ; but that in  other cases, it is  sometimes one  and sometimes
the other which should  be adopted.  Depression, for example, ap-
pears to be preferable in children and intractable  subjects; or when
the eyes are small and sunk deep in their sockets, when the cornea has
spots upon it and is small and flattened, when the eyelids or conjunc-
tiva have been for a long time diseased, when we have reason  to
fear an acute inflammation of the connecting tissues of the eye, when
the cataract is perfectly liquid, when the pupil is  contracted  or the
iris adherent to the cornea, and when the eye has great prominence
and is  very irritable.  Extraction,  on  the  contrary, presents more
advantages in old men and even in adults, if the anterior chamber is
large, the crystalline very hard, the cataract membranous  or adhe-
rent, and the  eye perfectly sound,  possessing little  sensibility, and
admitting the keratotome to penetrate through it without difficulty.
   [Ossified Crystalline Lens.—The  crystalline lens  having become
opaque  from a blow in  a man aged 44, (see Mr. France in Guy's
Hospital Reports, Oct., 1845,) was afterwards extracted and found
to consist chiefly of carbonate and phosphate of lime.   T.]

                          [cataract.
   Dr. Dubois,  of Neuchatel,  in Switzerland, (Gaz. Med. de  Paris,
Nov. 8, 1845, t. XIII., p. 72f,) removed in July, 1841, by depression,
a cataract which was  situated in the right eye of a woman aged 49,
accompanied with a slight albugo in the cornea, both of which had
existed for the space of 40 years.   She was induced  to undergo the
operation from  a  cataract having commenced to form  also  on the
left eye, in 1841, which when ripe the succeeding year was also re-
moved.  This left eye being, from its long use, fully developed, could
now see better than  the other, where a contrary state of things ex-
isted, with the  addition of the partial opacity of the cornea, which
still presented some obstruction to vision.  Doctor Tavignot remarks
(lb., loc. cit., p. 720)  that disuse ofthe eye for a long period undoubt-
edly arrests  its development, and that on this account persons  a long
time confined in dark places (as in dungeons) lose the sensibility of
the retina, and thus become liable to amblyopy, or even to  amauro-
sis.  But the condition of the eye, where  a cataract complete has
existed in both organs for a great number of years, is  not precisely,
or at least is only partially analogous to that which takes  place from
the total exclusion of  light from sound eyes.  In  old cataracts, the
retina still retains  its sensibility to a  certain extent, and  receives  a
certain portion of the rays of light  transmitted through the opaque
lens.   Hence the important deduction that such cataracts, however
ancient, as recent facts  have proved, are not beyond the hope of
surgical relief.  Dr. Tanchou  alludes to the  remarkable case  of a
man aged 67, in whom M. Serre, of Montpellier, operated  with en-
tire success in 1844,  for a cataract which had existed in the left eye
for sixty years.   (Gaz.  Med.  de Paris, t, XIII.,  1845, October 25,
No. 43, pp.  677, 678.)  The  occasion  which  led to the operation
was a traumatic cataract, which suddenly formed in the right eye, 
302
NEW ELEMENTS OF OPERATIVE SURGERV.
accompanied with protrusion of the iris through the cornea.  On ex-
amining  the  left  eye, he  found there  a lenticular cataract, with  a
slight albugo in the cornea.   Deeming  this  the most secure, he haz-
arded the operation in this eye, when the sight was restored perfect-
ly.   Dr.  Tavignot furnishes a number of examples ofthe cure of old
cataracts, single or double,  congenital or otherwise, and which had
existed  for various periods from  12  to 20,  26,  30,  and  even 45
years.   Dr. Alexander Watson, of Edinburgh, (Ed. Med. and Surg.
Journ., Jan. 1, 1846, p. 57, &c.,) considers that the process of break-
ing up soft cataracts, in order to promote their solution and absorp-
tion, as now practised and in vogue, is so eminently successful, that
it promises to be substituted altogether for  depression  or  extraction
in this form of the disease.  For hard cataracts, and  where depres-
sion or displacement is  decided upon, he  recommends  a process
somewhat new, and the intention of which is to avoid any injury to
the hyaloid membrane and  iris, and to prevent the reascending of
the lens.   As the important  point is to disengage  the  lens  from its
capsule before depressing it, this is to  be effected by lodging it in a
breach to be first made with the needle in the vitreous  humor, after
which the posterior part  of  the capsule opposite this breach is to be
carefully opened by an incision, and the lens also pushed  through it
into the  humor  by means of the same needle.  Dr. Watson pene-
trates the coats of the eye at a line and a half posterior to the mar-
gin of the  cornea, with  the  small  cataract bistoury.   This brings
him readily upon the part of the vitreous humor designated.  After
making a suitable breach there, the needle  incises  the posterior por-
tion of the capsule transversely from the nasal side outwards. The
point ofthe needle is then applied flatwise on the anterior part ofthe
capsule, between it and the iris, so  as to make pressure  upon the
lens upwards and backwards, in order  that the lower margin of the
lens may pass backwards through  the  opening in the posterior por-
tion of the capsule ; after which, by shifting the point  of the needle
forwards upon the lens, the  latter is pushed backwards and down-
wards into the breach of the vitreous humor, from whence, he says,
it never rises.  If the capsule remains entire, it is an advantage, as the
humors in the different chambers of the eye  are thus prevented from
incorporating, which lessens the risk  of subsequent  inflammation, and
if it should afterwards become opaque, it can  easily be removed by
a subsequent operation.   Address  is required > for  this  operation, as
the capsule is usually transparent.  This process answers also  for
reclination.  If the lens should unexpectedly be found  to be soft, it
can be broken to pieces, and these fragments, or some  of them,
pushed into the breach of the vitreous humor, where they will dis-
solve.  The breaking up  of  an opaque lens, that it may dissolve in
the aqueous humor, and performed in such  manner as not to wound
the hyaloid, is a process well suited  to young subjects, whether the
cataract be spontaneous or from an injury.   For keeping the eyelids
open, Dr. Watson  finds a plain, broad, flat, smooth ivory hook, the
end of which is curved short, so as to be parallel with the shaft, bet-
ter than metallic instruments.   T.]
  F. Artificial Cataracts.—For a long time it has been thought ne-
cessary to produce  cataracts artificially, and  to exercise  ourselves 
GLOBE  OF THE EYE.
303
beforehand upon animals or dead bodies, and to give morever to the
eye all that mobility which renders it so difficult to steady it at the
moment of the operation.  Troja in Italy, and M. Bretonneau in France,
have made trial of some experiments in order to render the crystal-
line opaque, by means of diluted acids.   M. Leroy, (D'Etiolles,) has
supposed that this  could be effected better by means of electric dis-
charges, but nobody before the  time  of M.  Neuner of Darmstadt,
(Maunoir, These citee, p. 43,) had  made this point a subject of par-
ticular attention.   The liquid which he  made use of with most suc-
cess, was a solution of six grains of corrosive sublimate in one  gros
of pure  alcohol.   A small glass  syringe, garnished  with  platina
and terminated by a very fine syphon, and which is traversed by an
extremely sharp probe, in such manner as to be  enabled to  pass
beyond its two extremities, is first filled with this solution.   It  is then
passed through an opening previously made at the outer angle of the
eye, from above downwards, from  without inwards, and from  behind
forwards,  until it  reaches the posterior surface  of the crystalline,
into which the point of the probe,  which serves as a  conductor to
the syphon of the syringe, is  plunged, after having perforated its
capsule.  The small  probe being then no longer necessary, is with-
drawn, and the thumb, resting upon the extremity of the  piston, gently
forces the liquid into the substance of the lenticular body, which soon
changes its color.  The same process is performed, if necessary, on
the inner angle of the eye, when the operation is terminated. Among
the contrivances devised  for representing upon the eyes of the dead
subject, the principal difficulties which are  encountered upon living
man, the opthalmo-phantome of M. Sachs, is certainly the most in-
genious; composed of a socle mask,  and eye-supporter (porte-ceil),
the description of  which I cannot give in this place,  it appears to
me, however, to  be  too  complicated ever to  be received into gene-
ral use.  I have no necessity in saying, that one of the middle re-
fractors of the eye being now removed or displaced, almost every
individual who has been operated upon  for cataract, ought to wear
spectacles with convex glasses, like long-sighted persons.  Upon this
subject, moreover, Maitrejan  had  established upon the dead body,
what  M. Roux and others have since  announced—to wit,  that after
the extraction of the crystalline, the  vitreous body becomes more
convex in front, as if for the purpose of filling  up the void, which
after the operation has been left in the eye,  and to render  spectacles
less necessary.  In children, and in persons  blind from birth, in all
those in fine who for the first time are obliged to subject their sight
to a course of discipline, it is well  to  add to the precautions which
are generally used, a very simple means successfully employed  by
Dupuytren, and which consists in fixing the hands behind the back, in
order that being deprived of the  use of these members, they may be
compelled to make greater efforts with their eyes to direct them upon
external objects.
                    § IV.—Artificial Pupil.

  Two very distinct conditions of things may require the formation
of an  artificial  pupil; the opacity  of the cornea, and  the contrac-
tions or obliteration of the natural pupil.  In the first case, whether 
304
NEW ELEMENTS OF  OPERATIVE SURGERY.
the impediment to vision be the result of a simple ophthalmia, an ul-
cer, or a wound, or any other lesion of the cornea, is a matter of little
importance.  Provided  the interior of the eye is  not  affected, and
that a  transparent point remains  outside, the operation for artificial
pupil  may be  undertaken.  In the  second  case, whether there be
myosis or phtisis, synezizis or atresia; whether the pupil  is completely
closed or merely contracted ; whether the  alteration be congenital
or accidental, the effect of an internal ophthalmia, of an iritis, or of
the operation for  cataract, by depression, or extraction ; whether the
iris preserves its form or not, adheres, or is not adherent to the  cor-
nea or the capsule of the crystalline; or whether there may or may
not be sinechia, whether  anterior  or  posterior,  the  operation  is
equally practicable, (though  it offers  infinitely less chances of suc-
cess,) so long as the retina has not lost the faculty  of perceiving the
rays of light, and that the anterior  chamber retains its transparency.
If this last condition is wanting, it will be  in  vain that we make  a
new pupil, and  that the light  arrives at the bottom  of  the eye.
Acute or  chronic inflammations of the internal tunics, the progress
of which  has not been definitively arrested, also constitute counter-
indications, which, though less  absolute,  are nevertheless  sufficient
with a few exceptions to  restrain  a prudent  surgeon.  Almost all
authors prohibit, moreover, the making of an artificial pupil, so long as
there  is but one eye only diseased, and that the patient sees sufficiently
well to get  along without a guide.   The  operation, in fact, being
sometimes followed by accidents, which may in themselves produce
serious injury to the vision, it would not appear to be prudent to ex-
pose the patient to  lose the  little that remains to  him, when, more-
over, in the attempt to ameliorate his condition, the chances of  suc-
cess are sufficiently precarious.
  A.  Operative methods.—All the processes  recommended for form-
ing a new pupil may be resolved into three methods.  In one, iridi-
otomy  or coretomy, we incise the iris only; in the second, iridectomy
or corectomy, we excise a flap from this membrane; while in the
third,  iridodialysis or coredialysis, we confine ourselves to detaching
its circumference at one of its points.
   1. Coretomy or method by incision.—Before the time  of Cheselden,
no one spoke of iridiotomy ; since  then it has attracted the attention
of Mauchart, Sharp, Sprasgel, Meiners and Rathleaw, who have  pro-
posed it in cases of persistence  of  the pupillary membrane ; and of
Odhelius, Guerin, Janin, Wenzel, and MM. Maunoir,  Adams, &c,
who have subjected it to various modifications.  The patient, opera-
tor, and assistants, are to  be placed in the  same manner as in the
operation for cataract.
  a. Process of Cheselden.—By means of a small  knife of the shape
of a scalpel, with one cutting edge  only, Cheselden penetrated in the
same  manner as is done for depression through the sclerotica as far
the uvea.   Having arrived there, he caused the point of his instru-
ment  to pass into the anterior chamber.   Afterwards directing it
from without  inwards, and from before backwards, according to some,
or on the  contrary, according to others, from the internal to the ex-
ternal angle, and from behind forwards, he made at the centre of the
iris a  transverse incision of from  two to three lines in  length.  A 
GLOBE  OF THE EYE.
305
 puph of an elliptical form, similar to that of certain quadrupeds, was
 the result of this delicate operation, which was attended with entire
 success, and vividly attracted the attention of the learned world.
  6. Process of Sharp.—Sharp in  performing coretomy, professes
 nothing else  than to have  imitated  Cheselden.   A small  scalpel,
 slightly convex on its back, a figure of which he gives, is first directed
 horizontally, its cutting edge turned backwards,  into the posterior
 chamber, between the circle and root of the ciliary processes.   No-
 thing then remains but to incline its point  forward, and to push it a
 little in order  to  penetrate  into the  anterior chamber.  We  have
 now to incise the iris transversely, either upOn a line with or below,
 or what is better, above the  natural pupil.  The opening made by
 this operation, which continued for some time, was not  long in con-
 tracting, and ultimately closed up completely.  Sharp thus appears to
 accord very little confidence to the method of Cheselden.
  c. Mauchart has no  other claim  to  be  mentioned in this place,
 except because he appears  to have been  the  first  to  have ad-
 vanced the idea of perforating through the cornea in order to form
 the pupil.  He  moreover cautions us against giving too  great an ex-
 tent to the artificial opening, and remarks that this kind of pupil is
 not capable either  of spontaneous dilatation or contraction  like the
 natural one.   Henkel  also recommends that we should  go  through
 the anterior chamber.  Heuermann, who is  of  the  same  opinion,
 recommends for the incision  of the iris and cornea, that we should
 use the ordinary lancet in place of the needles, or knife of Cheselden.
  d. Process of Odhelius.—Odhelius, in a patient with an  opaque
 cornea, after having incised the'cornea in the same way  as  for ex-
 traction in cataract, divided  the iris  from its centre to  the  circum-
 ference, on a line with the pupil, which in  other  respects was very
 much contracted.   By this means he obtained  a triangular opening
 continuous in its base With the  remains of the primitive  pupil, and
 which enabled the vision to be completely reestablished.
  e. Process of Janin.—Janin,  having  frequently made trial of the
 method of Cheselden without success, supposed that we would suc-
 ceed better by giving a vertical direction to the wound.   The trans-
 verse incision, he remarks, closes speedily and almost of  necessity,
 because the  radiating fibres of the membrane are separated only;
 while they are  actually divided by means of the perpendicular inci-
 sion, made a  little  within the natural pupil.  It was  an accident
 which led him to make this  modification.  It happened  to him as it
 would to  any person, that he divided  the iris in performing the ope-
 ration for cataract by extraction, and that he thus made, against his
 will, an artificial pupil on the side of the natural one.  Perceiving
 that this opening, which he did not intend to make, did not close up,
 while those which he had effected designedly always became oblite-
 rated, he proposed to take advantage of this, and directed  his atten-
 tion  afterwards to  systematizing the process which chance had
 pointed out to him.  Kortum  proposes that in  place of  the scissors,
 we should incise the iris vertically with the keratotome.  But, not-
 withstanding the experience of Weissemborn, and the observations
of Pellier, which are  calculated to corroborate its  advantages, the
process of Janin was soon abandoned.   It was soon evident that the
                              20 
306
NEW ELEMENTS OF OPERATIVE SURGERY.
pupil  made in  this manner, does  not  endure any longer than, and
closes  and disappears fully as much as it  does by the transverse
method.
  f.  Process of Guerin.—With the view of uniting their advanta-
ges,  Guerin proposed  to  combine the processes of Cheselden and
Janin, and  to employ them  together,  that is to say, to make a cru-
cial incision  in  place of a simple  vertical or transverse slit.  But
while on the  one hand the  operation  is thus rendered  much more
difficult, on the  other, it is not  uncommon to see the four flaps ap-
proximate so much attheif apex as to prevent the light from arriving
at the bottom of the eye; so that this recommendation has been rare-
ly adopted in practice.
  g. When the  vision is impeded by a leucoma, Pellier confines him-
self to enlarging the natural pupil,  in place of making one complete
in itself.   For that, purpose he incises the cornea in the same way
as for extracting the crystalline ; introduces a small canulated sound
into the posterior chamber of the eye ;  uses this as  a guide  to the
point of a small pair of scissors, and first divides the iris outwardly,
then inwardly and upwards, from the pupil to the ciliary ligament.
  h. Process of Maunoir.—The  process by M. Maunoir,  though
the result of  researches made  by  this  author, nevertheless appears
to be only an  improvement of that of  Pellier.  This  surgeon, by
means of a keratotome or lancet, makes an opening of two or three
lines in extent at the outer and  lower part of the cornea ; introdu-
cing through this a small pair of scissors bent at an angle on the
border near their heel, and one of the blades of which terminates in
a button, he opens them in the anterior chamber; then plunges one
branch through the iris into the posterior chamber, in such manner
that the other which bears the button remains behind the cornea; inci-
ses the membrane thus included inwards, then outwards and upwards,
and forms at  its expense a triangular flap whose adherent base faces
the circumference of the eye.   The  needle-shaped scissors, devised
by M.  Montain, with the view of avoiding the previous section of
the cornea, though ingenious, do not  however present  an improve-
ment of sufficient importance ever to obtain the preference claimed
for them by  their inventor.   By  this  double incision the circular
fibres that M. Maunoir supposes to  exist in the iris are divided twice,
while the radiating fibres remain  intact; from whence  it happens
that  these  latter by their contraction  constantly tend  to dilate the
new pupil, in place of favoring its contraction, as in  the method of
Cheselden.
  i.  The ideas  of the surgeon of Geneva, which he  has frequently,
and  again  in 1837 (Bibl.  Universelle de  Geneve, Avril, 1838) prac-
tised upon  with success, have received  the sanction of the  cele-
brated Scarpa,  who,  in order to  sustain them, was  eager  to re-
nounce his own method.   They have also met with  partisans in
Germany.   But in England and France they have not generally
been made trial of.   Moreover, it is  evident that  if we were de-
sirous  of performing  coretomy upon  this principle, of which M.
Carron avows  himself the  champion, it could be advantageously
modified by making use, as I have  often done, of the ordinary kera-
totome, or the movable cutting needle, which I contrived for form- 
GLOBE  OF THE EYE.
307
ing the triangular flap  of the iris, thus doing designedly what we
often do in spite of ourselves  when we  perform the operation for
cataract by extraction;  this is the process which Daviel, Hoin and
Wenzel  appear to have recommended  for adoption, and  which
Odhelius has also sanctioned.
  j. Process of M.  Adams.—M. W. Adams has gone back  to the
process of Cheselden, with this difference, that in place of a straight
knife like that of  Sharp, he employs  a small scalpel convex  upon
its cutting edge, breaks up the crystalline when  he considers it
opaque, and endeavors, what is sufficiently singular, before quitting
the  eye, to entangle some  fragments of  it in the transverse incis-
ion of the  iris to prevent its closing up.  M. Roux frequently made
use  of this  process while I served  him as assistant, and in every
case the new pupil ultimately disappeared.  Nor does it  appear,
moreover, to have received  much respect  in  the country of  its au-
thor, for it is rare that it has been had recourse to there by other
surgeons.  Nor have I myself been more fortunate with it in the two
trials that I have made of it.
  k. Coretomy, still further modified  by  Jurin, MM. Langenbeck,
Weller, Faure, and by Wardrop, who by means of a needle  passed
into the posterior chamber, perforated the iris a first time from be-
hind forwards in  order  to  enter into the  anterior chamber ;  then a
second time from  before backwards, and nearer to the inner angle
of the eye in  order to return into the posterior chamber ; and who
afterwards  united together by means of one of the cutting edges,
rather than by the point of his instrument, the two small wounds, by
detaching  one of the  extremities of the  flaps  which they circum-
scribed, and all this with entire  success,  in a lady 46 years of age,
blind from her birth, has found in these latter years numerous anta-
gonists among the oculists of Germany.
  /. Process of the Author.—I make use of a knife somewhat longer
and of less  breadth than that  of Wenzel,  cutting on its  two edges
to the extent of four lines from its point, and afterwards blunt or
rounded upon the  back as far as the  handle, an instrument in  fact of
which the  serpent-tongued lancet  may  convey  a tolerable  idea.
Held as a writing  pen, it is plunged through the cornea on its  tempo-
ral side, and a little obliquely from before  backwards.  When it has
arrived in the anterior chamber, its point is guided with precaution
into the posterior chamber,  dividing the iris as it proceeds, and then
brought back after making a track of two or three lines, into the  ante-
rior chamber through the same  membrane. In continuing to advance
it forward, up to the point of piercing the cornea a second time, it
becomes easy to divide  the species of bridge  which covers its an-
terior surface, and not to detach completely one of the extremities
of this flap of the iris, until after  having  transformed the other into
a pedicle as  narrow as  may be  desired.   We  thus procure a divi-
sion which amounts to a loss of substance.  The fragment of mem-
brane which  has been cut  out cannot be long in rolling up upon it-
self, and must  ultimately become dissolved  in  the aqueous  humor.
It is even possible in most cases to excise  it entire, when  the mani-
pulation which I have just pointed out has been properly executed.
In fact if the  instrument acts  in  an equal manner on the two ad- 
4
308          NEW ELEMENTS  OF OPERATIVE SURGERY.

herent points of the bandelette to be divided,  up to the moment
when the section of one is completed, all that will  be  required to
detach the other and to transform coretomy into corectomy, will be
to advance the keratotome a  little farther,  and to incline its cutting
edge  correspondingly  towards the cornea.  My keratonyx attains
this object still better.
  II.  Coredialysis  or Method by Decollement.—To Scarpa we are
indebted for having systematized decollement into a method ; many
authors, however, had mentioned it before him.  Sharp for example,
in speaking of coretomy, makes the remark that the iris very fre-
quently detaches itself when pressed  upon  by the  instrument in
place of being divided.   In a  patient operated upon for  cataract
by Wenzel,  the crystalline  escaped in this manner through an ac-
cidental opening.  The natural pupil afterwards almost entirely dis-
appeared, but the patient continued to see by the abnormal opening.
If we may believe Assalini, Buzzi de Milan, who performed coredi-
alysis in 1788, plunged a spear-shaped needle through the posterior
chamber into the body of the iris, at  a  line distant from the oblite-
rated pupil,  and by well directed tractions detached this membrane
from  the  ciliary circle.  A. Schmidt, who on  his part published a
good memoir on this subject in 1803, states that he  had recourse
to this operation in 1802,  and had conceived the first idea  of it
in 1792.
  a. Process of Scarpa.—Scarpa, when his needle has reached into
the interior  of  the eye, as  in  the operation for cataract by depres-
sion, turns  its concavity forwards ; directs it behind the upper and
inner portion of the  uvea; pushes  its point through the iris into the
anterior chamber; and uses it afterwards as a hook in oscillating it
from above  downwards, from behind forwards, and from within out-
wards, in order to detach the great circumference of this membrane
to the extent of three or  four lines, in such manner in fact as to pro-
cure an opening a slight degree  larger than  the natural pupil.
  b. Process of T. Couleon.—Toche-Couleon, one of  the first, Fla-
jani, Himly, Beer especially, and Buchorn, proposed that the needle,
whether straight or curved, should be  directed in some way or an-
other through the cornea, and not through the sclerotica.   Accord-
ing to them, it becomes full as easy in this manner  to place the new
pupil upon the out as upon the inside ;  moreover, we see better what
we are doing, and the puncture of the eye must be less dangerous.
  c. Process of Assalini.—Assalini, after having made  an incision
at the outer  angle of the cornea, introduces into the anterior chamber
a pair of fine curved forceps, soon after opens them, seizes the iris at
a short distance from its ciliary border, and  detaches it as in the pro-
cess of Scarpa.   These forceps are considered  useless  by Bonzel,
who substitutes for them a very small hook, which is conducted in
the same manner.  Dzondi makes use  of a description of forceps, the
inner side of one of whose branches is to be grooved in order to receive
the other when the instrument is closed.   He pretends that with this
forceps we run no risk of lacerating the iris, and that by  it it is more
easy to effect decollement than with any other instrument. The strong-
est and best founded objection  to be made against coredialysis is, that
the detached border  ofthe iris gradually reassumes its natural posi- 
GLOBE  OF THE EYE.
309
tion, and that, at the expiration of a certain time, the  new pupil al-
most always closes.
  d.  Process of M. Langenbeck.—To obviate this inconvenience, M.
Langenbeck, after having seized hold of the iris by means of a small
hook protected in a sheath, draws it forwards and insinuates it into the
wound of the cornea, which should be very small, and then attaches
it there as if for the purpose of producing a myocephalon.   The ad-
hesions which this species of hernia soon contract prevent the pupil
which has been formed from narrowing, and give to the operation all
the certainty desirable.
  e.  Reisenger, who  advances the same  idea, censures the sheath-
hook of Langenbeck, and makes use of a simple eye-forceps, the
point of which is curved like an erigne on one of its sides.  This for-
ceps is introduced flatwise, and shut to the farthest limits of the an-
terior chamber.   Its concavity is  then turned backwards.   It is
opened the space of one or two lines, to be closed again after having
plunged it through the iris, which membrane is thus  found  pinched
or hooked up, and is then detached and drawn to the outside in order
to produce an  artificial prolapsus through the cornea.   The coreon-
cion, so much extolled by M.  Graefe, is used in  the same manner as
the sheath-hook of M. Langenbeck, and differs from it  scarcely ex-
cept in the little keratotome which it has on one of its  extremities.
  /. Process of M. Lusardi.—M. Lusardi  has proposed to reduce
 coredialysis to its greatest degree of simplicity, by devising a hook-
 shaped needle which alone would  answer for the whole operation.
 When closed, this instrument has the  form of  a  Scarpa needle, or
 rather of a .very small serpette.  The two stems which compose it
 are  arranged  in such manner that, by drawing a  little upon the
 shortest or that which corresponds to its convexity,  there immedi-
 ately results from it a notch which transforms it into  an actual for-
 ceps.  In is introduced through the cornea in the  same way as in
 keratonyxis, in order to pass it through the anterior chamber, if that is
 free, or in the opposite  case through the  posterior  chamber,  after
 having cut through the iris up to the ciliary circle.  Having'arrived
 there, the surgeon presses its back against the great border of the
 ocular diaphragm, which he  endeavors to detach by means  of an
 oscillatory movement, then opens his needle, and  afterwards loosens its
 spring, by  which means the membrane  is  thus found embraced.
 Nothing remains but to bring it to the opening of the cornea, with the
 precautions required  for giving to the new pupil the necessary di-
 mensions.
   g. With this instrument, already described in Italy by Donegana and
 Baratta about twenty years  since, M. Lusardi thinks  we run no risk
 of wounding the capsule of the crystalline, which is not demonstrated,
 and that we may be enabled  to establish an artificial pupil upon any
 point whatever of the ciliary circumference, which is more correct;
 but the( ordinary needle presents nearly the same advantages.   I do
 not speak here of the process of Assalini, which, in order to remove
 the  new pupil as far as possible from the crystalline, proposes that in
 coredialysis we should destroy a portion of the ciliary circle and pro-
 cesses, at  the same  time  that we detach the great circle of the iris. 
310           NEW ELEMENTS OF OPERATIVE SURGERY.

This method clashes so much with the object which the practitioner
has in view, that no surgeon has ever yet had recourse to it.
  h. The process  of Donegana is  not obnoxious to the same objec-
tion.  Perceiving that  the pupil, after coredialysis by the method of
Scarpa,  almost  always finished by closing up, this oculist has pro-
posed,  in order to prevent such an inconvenience, that we should
unite the method  by incision to the method by decollement.   He
therefore, after having detached the iris from the sclerotica, divides
it to the extent of one  to two lines,  in a direction parallel to its radi-
ating fibres, and from  its greater to its smaller circumference.  For
that purpose we may penetrate through the posterior or anterior
chamber, and make use of the ordinary needle, Or of an instrument
writh a blade which is  somewhat more slender, almost straight, and
very keen.  Unfortunately it is not so easy  as might be imagined to
incise the  iris  after having  detached it in the interior of the eye.
Unless we  make use of the  keratonyx, it folds itself up under the
knife, and tears or  separates itself from the surrounding parts, much
sooner than  it  is  divided.   Nevertheless it  is  an  improvement
which may have some  advantages,  and  which it would be advisable
to make trial of when we perform coredialysis according to the me-
thod of Scarpa.
  III. Corectomy,  or the method by Excision.—a. Wenzel appears
to be the inventor  of corectomy.  Nevertheless it cannot be denied
that before him it was  put in practice by Guerin, who,  as Sprengel
remarks, sometimes excised the point of the flaps of his crucial inci-
sion.  Sabatier,  who adopts the process of Wenzel, gives the most
satisfactory account of it.  We proceed in the same manner at first
as for the extraction of a cataract.   The keratotome, while passing
through the eye, ought to cut out,  at the  expense of the iris,  a flap
similar to that of the cornea.   A pair of small scissors are then intro-
duced into the anterior chamber,  and serve to excise  this flap near
its base, while the point of it moreover, if necessary, is seized with a
pair of eye forceps.  By this means we obtain an opening with loss
of substance, which cannot be closed up,  and which presents every
possible chance for success.
  b.  Demours,  however, adopted  a mode somewhat  different in a
case of leucomatous cornea.  He made an incision into the anterior
chamber, which comprised  at the same time both the cornea and the
iris ; then with two cuts of the scissors,  he circumscribed and re-
moved a flap of this  membrane of the size of  a sorrel seed.  The
difference between these two modes is in reality very trifling.  The
first has some advantages, in the fact that it enables us to confine our-
selves to coretomy, if we should prefer this after having commenced,
but the second evidently exposes us to less risk of emptying the eye.
It is from  one of these processes,  moreover, that are derived the
principal methods extolled by the oculists of our time.
  c  Process of T. Couleon and of M.  Gibson.—M. Gibson, like
Wenzel,  first opens the cornea to as great  an extent as for extract-
ing a cataract, but without touching the iris.   He then causes this
membrane  to protrude through the wound by means of a slight
pressure  made upon the globe of the eye ; then by means of scissors,
properly  hollowed  and curved on their  flat side, he excises a disc 

                       GLOBE OF THE EYE.                   311

from it of suitable size.  Forlenze has no fear of incising the cornea
to the extent of two-thirds of its circumference, in order to seize the
iris with the forceps or hook, and to remove a flap from it in the
manner of Demours.   In a  thesis  supported in 1803,  M. Mirault
gives the credit of a similar process to Couleon.
  d.  Beer  asserts that all that is  required is to make an opening of
two  lines in the anterior chamber to make the iris protrude of itself
into this small wound, when the part which tends to escape outside
may be immediately excised.  Otherwise he seizes  this membrane
with an erigne, and effects its exsection as in  the preceding cases.
  e.  Process of M.  Walther.—M. Walther, with a view no doubt
of reconciling the principles of Gibson with those of Beer, incises the
cornea to the extent of about three lines, draws the iris to the outside
by means of a hook, and by means of a small pair of scissors excises
a flap from it of the proper dimensions.   By means  of  a wound of
nearly the same dimensions,  M. Lallemand has found that he could
seize the membrane with  a small  pair  of hook forceps, jdraw it to-
wards  him* excise from it a flap of considerable size, and form in this
manner an elliptical pupil dike  that of cats,  vertical in its position,
and two lines in breadth and six in length.  The success in one case,
says the author, was  so complete, that the  patient  was enabled to
follow  the army of Spain in the capacity of a  nurse.
  /.  The needle forceps of Wagner, and of Dzondi; the raphian-
kistron^of Emden; the  iriankisIron of Schlagintweit; the plomise
of Menser, and the process of Himly, do not differ sufficiently from
some of the instruments and processes described above to make it
necessary  for me to detain the reader with an account of them.
  g. I will make the same remark of the method of Autenrieth, which
consists in destroying a portion of the  sclerotica and of the ciliary
circle and processes, and removing a disc, in a word, of the globe of
the1 eye outside the cornea, with the simple precaution  to close up the
opening which has resulted  with a flap  of  the conjunctiva, which
should have previously been separated  from  it.  The best that can
be done in reference to such a suggestion, is to say nothing of it, and
I am  astonished  that Beer,  Himly, Mijller,  Guthrie, Ammon and
Ulman, (Nimmo, Arch.  Gen. de Med., 2d ser., t. III., p. 237,) should
have gone to the trouble of making a trial of it.
  h. Process of Physick.—Physick, after having incised the cornea
and iris, in conformity to the precepts of Wenzel, introduces into the
anterior chamber a forceps terminated by plates, in some respects
.similar to those of our chimney tongs.  The  inner surface of these
plates presents upon its circumference a cutting edge, which  forms a
scissors of peculiar  description, and by means of which  it becomes
easy to seize hold of and remove the flap of the iris which has  pre-
viously been cut out by the keratotome.
  B. Relative  value of  the different Methods.—I.  These numerous
processes show at least the constantly reiterated efforts of practition-
ers, to  improve one  of the  most delicate operations of  ocular surgery.
Unfortunately there are  often to be encountered here obstacles and
difficulties, which the greatest address and most consummate skill are
incapable  of  surmounting.  When  rigidly examined there  can be
no doubt that corectomy  is  preferable to the other two methods. 
312
NEW ELEMENTS OF OPERATIVE SURGERY.
Nevertheless  since, in order to perform  it, it  is necessary that the
instrument should traverse the anterior chamber, it is next to impos-
sible to have recourse to it, when  the  iris adheres  to the cornea, or
when this last membrane  is opaque throughout a great portion of its
extent.   Coretomy presents nearly the same inconveniences without
having the same advantages, since, as  experience has demonstrated,
the opening which it makes rarely endures beyond  a few weeks.  It
is to coredialysis, therefore, that we should then give the preference.
The same would be the case in instances of adherent membranous
cataract, in those of any description of opacity  whatever, situated in
front or behind the iris, and which could not be destroyed, inasmuch
as we are here obliged to bring the pupil to the circumference of the
ocular diaphragm.
  II.  Coretomy  and coredialysis  alone  enable us to operate by
scleroticonyxis.   Nevertheless, as they may also be performed by ke-
ratonyxis, we ought not, as a general rule, to prefer the first, except
in  strongly marked  cases  of anterior synechia, (sinechie,)  inasmuch
as we  almost  unavoidably  wound  the "crystalline.   Should  we be
disposed to restrict  ourselves to coretomy, but not to employ the
process which I have proposed, that  of M. Maunoir, or better still
that of Wenzel, would appear to  me to merit  the  preference.   To
perform corectomy, we may adopt, so to speak, indifferently, the pro-
cess of Demours,  Forlenze, Gibson, Beer, or M. Walther, though the
best of all, in my opinion, would be that of  Physick, such as 1 have
modified it, or the  iridectum of M. Onsenort, if it were  possible to
procure a sufficiently small punch, and one that was  perfectly con-
structed ;  which,  up to the present time, I have not been enabled to
obtain.
  III. When we decide in favor of coredialysis, the simple hook of
Bonzel  is quite as  good  as the more  complicated instruments of
Langenbeck, Beer, Reisinger, &c.; but I  doubt if  it  be as easy as
these authors seem to imagine, to attach in the opening of the cornea,
the portion of the iris which has been brought there with more or
less difficuty.  Should the accident for which we desire to establish
an artificial pupil have taken place as  the consequence of an opera-
tion for cataract, there would be much less inconvenience here than
in the other cases, in directing the instrument through the posterior
chamber.   In such cases, also, the bottom  of  the eye is too much
altered  to  leave room to  hope for much success.  Nor can we per-
ceive that it would be necessary to open into the anterior chamber as
largely as has been recommended by Wenzel, Forlenze, and Gibson.
It would be otherwise should the crystalline or its capsule have pre-
served their natural relations.
  However little  we may suspect opacity in these parts, they should
be extracted or depressed. Perhaps,  also, their extraction or their
displacement should be laid down as a law, whether  opacity has
commenced or not.   We  should  thus avoid the unpleasant conse-
quences  of the occurrence of  a consecutive cataract, destroying
the prospect of success for the first operation, as happened to me
in the case of a man aged  thirty  years.  In this respect, the open-
ing of the cornea cannot be too large,  since we not only establish an
artificial pupil, but perform at the same time an operation for cataract 
GLOBE  OF THE EYE.
313
  IV. When there are spots in front of the eye, and that we cannot
operate by keratonyxis, the case necessarily becomes embarrassing.
If the incision is made on a sound  part of the cornea, the cicatrix
which must result from it, and the inflammation which may super-
vene, very frequently destroy the transparency of  the small portion
which the  primitive disease had respected.  Upon the leucomatous
portion on  the contrary, it is to be apprehended that the wound may
be transformed into an ulcer, and  suppurate and cause the destruc-
tion of the eye.  Nevertheless  many practitioners, MM.  Faure and
Lusardi among others, have  asserted that the section of a cornea
thus  affected, is not as formidable as is  generally thought, and go so
far as to say that it agglutinates more  rapidly than that of a tunic
which is not diseased.  This also  may readily be conceived.   Such
tissues being  less sensitive, less excitable and  more approximate in
their character to vegetative life, must be more moderate in their in-
flammation, than if they were in their normal state.  If then, the
cornea is opaque to a  great extent, we  must cautiously respect the
part  that remains,  and penetrate through its altered portion.  In the
opposite case, wdien its  transparency is not affected but by a  spot
which is accurately circumscribed, and of little extent, it  is prefera-
ble to incise in the natural tissues.
  V. Moreover, in order to be  prepared to meet all the  necessities
and exigencies of the disease, it is well to familiarize ourselves  with
the greater part of the processes which  I have deemed it advisable
to point  out, since  there are cases in which each  of them, may be-
come particularly  applicable^   I  would however  remark, that the
method by excision is in fact the only one which presents real chan-
ces of success.  All the methods by incision, whether simple or com-
plex, are decidedly bad, and ought not any more than decollement to
be adopted, unless as an  exceptionable resource.  I have performed
the operation for artificial pupil according to the precepts of Scarpa,
Wenzel, and M. Maunoir, and I have noticed that the opening in the
iris, after having remained sufficiently large during a certain space
of time, has almost constantly become  ultimately  reduced to a tri-
fling affair.  I performed it in a young girl by  the  process of Odhe-
lius, and although the  slit at first appeared very large, it finally be-
came contracted to a considerable degree.
  VI. These facts, and the wounds of the same membrane, during the
operation for cataract, have moreover satisfied me  that the different
processes suggested by the alleged muscular nature  of the diaphragm
of the eye repose on a false basis.   In  place of retracting  itself to-
wards its root, the flap which  I  made in the iris in  1829, at St. An-
toine, in a man  sixty years  of age, gradually  approximated on the
contrary, by its free border, to the point from which I  had separated it.
The same thing occurred to me in 1831 at La Pitie  ; and I have late-
ly had a similar  instance following the extraction of a cataract.
Here is another example which appears to me entirely conclusive.
A peasant 45 years of age, was operated upon by me at La Pitie, in
the month of  June, 1831.  On one  side the iris slipped  under the
edge of the knife, and I  removed a flap" from it which left a notch, one
line deep and two in breadth, and a little nearer the  ciliary circle than
the pupil upon the border of which it was made.  But in place of be- 
314
NEW ELEMENTS OF OPERATIVE SURGERY.
ing transformed into a large oval opening, and becoming deformed,
the circle of the pupil absolutely lost nothing of its regularity.
  It continued  to dilate and contract as before, to such  degree that
its two extremities appeared to be drawn towards each other, as if
to establish its continuity, rather  than having  a tendency to retract
outwards, or to be withdrawn towards the  great circumference of
the membrane, and to become  confounded with the bottom  of the
notch.  M. Graefe (Arch. Gen. de Med.,  t. XXL, p. 271,) states that
he has five times performed the  operation  for artificial pupil with
success, and M. Eckstrumer (Bull, de Fer., t.VIIL, p.  203) appears to
have been not less fortunate in three of his patients ; I have succeed-
ed with it but twice.  M.  Laugier, (Bull, de Therap., t. VIII., p. 380,)
by introducing a needle through the cornea, has succeeded in de-
stroying  the  adhesions  which kept  the pupil contracted.  I  was
no less fortunate in 1835, in a patient of M. Requin.  This method,
which was so  much extolled at first by  M. Silvy, (Mem. de TAcad,
de Med., t. IV., p.  445,) for cases of obstruction and contraction of
the pupil from the debris of a cataract, would be  better adapted for
the obstructions caused by  inflammations of any kind, as  pointed out
by M. Simeon, (Revue  Med.,  1828, t.  III., p. 126,) and wherever
opaque flaps or adhesions should  mask the pupil, or keep it immov-
able.   I will  add, that in such cases scleroticonyxis, by enabling us
to depress false cataracts with greater facility, would be preferable
to keratonyxis.
   C. Consequences of the operation.—After the operation the patient
is to be submitted  to the same regimen, and treated with the same
precautions as if he had  been operated upon for  cataract.  Never-
theless, the accidents that  follow are rarely as severe.   Should we
confine ourselves  to  keratonyxis, or even  to  scleroticonyxis,  they
are often reduced to inflammatory  symptoms of  the most unimpor-
tant character.  If the eye has not  completely, or for a great length
of time, lost the function of perceiving the light, very frequently the
patient, under  such  circumstances, may dispense with  keeping his
bed, and wear only a black  silk  bandeau during the space of a few
days.  The lady operated  upon by  Wardrop was enabled to re-enter
her carriage  immediately  after,  and without any  inconvenience.
An intractable patient, whom I could not restrict to any systematic
course, got up on the evening of  the same day of the operation, and
on the following day was indisposed to  make  any retrenchment in
his diet or occupations, yet not the slightest inflammation supervened.
Out oT seven other individuals whom I have operated upon, none of
them experienced any inflammatory symptoms.  When,  however,
we perform keratotomy and  largely open  into the  cornea, like
Wenzel,  &c, and when we have deemed it necessary to extract or
displace  the crystalline  or its connections, and when  the  natural
pupil has been completely  closed for a long time, it would  be impru-
dent not to proceed in the same manner precisely as after the opera-
tion for  cataract.  In all  these  cases,  as  that of  M.  Lallemand,
(Arch. Gen. de Med., t. IV., p. 69,) for  example, demonstrates, the
most intense  ophthalmia  may be   readily developed.   Out  of an
aggregate  of  18 operations for artificial pupil, I have obtained only
three successful results, but none  of the patients were attacked with 
GLOBE  OF THE EYE.
315
any severe accidents.   Moreover, we ought not to be apprehensive
of giving too great an extent at first to the opening into the iris, for
besides that the new pupil for a long time retains a great tendency
to contract, we have now the proof that the absence of the iris does
not  abolish vision.  M. Hentzchel  (Lancette, t. V., p.  440,) relates
the  history  of three  sisters, in  whose eyes this  membrane  was
wanting, but who could, nevertheless, see very well.   The same w7as
the  case in  the child  six years of age mentioned by M  Stoeber,
(Journ.  de Vlnstit., 5th year, p. 394,) and  with  the  persons whom I
have elsewhere mentioned,  (Diet,  de  Med., Art. iris, 2e edit.)  I
have already  seen in eight or ten instances, one, or even  three
accidental pupils in the neighborhood of the natural one, without its
being productive of  the  double vision mentioned by  Righellini,
(Portal, Hist, de la Nat., &c, t. V., p. 480.)  If we have to operate
to remedy the  consequences of an internal ophthalmia, we must be
prepared to meet with a sort of true or false cataract behind the iris,
and adopt measures to remedy this difficulty or destroy its effects.

            §  V.—Puncture and Incision of the eye.

  Formerly puncture  of the eye  was made  use  of in onyx,  or
effusion of pus between  the  lamellae of the cornea, in hypopyon or
abscess in the anterior chamber, in empiesis, or  abscess in the pos-
terior chamber, in hydrophthalmia, and buphthalmia, and in all cases,
in fine, where  the eye was  the seat of too great an accumulation,
either of its natural, humors  or of any abnormal fluid whatever.
  A. Onyx.—When the small purulent collections, which are met with
sometimes in the substance  of the cornea,, have obstinately resisted
antiphlogistic, emollient and discutient remedies, &c, nothing appears
more rational than to open  them.   The operation, moreover, is so
simple  that it  is scarcely necessary to describe it.   The  surgeon
depresses the lower  lid; causes the other to  be raised  up by  an
assistant; seizes with  the right  hand for  the left eye,  and with the
left hand for the right eye, a common  lancet,  divides  the layers of
the cornea^ which  separate the onyx from the  exterior, and repeats
this puncture as many times as  there are  distinct abscesses  in  front
of the eye.  A cataract needle would be  full as  good as  a lancet,
and it is readily understood that we might if necessary make use,
with the same advantage,  of any  sharp-edged  pointed instrument
 whatever.   Unless the transparency of the cornea should be irre-
deemably lost, the instrument ought to  be directed as far from the
centre of the organ as the disease will possibly permit.   In the cases
under  consideration,  surgeons of the present  day  do  not  approve
either  of puncture or incision.  It  aggravates, they  say, or repro-
duces the inflammation, leaves among  its  consequences ineffaceable
cicatrices, and may hasten, or even produce the  suppuration of the
eye.  Moreover, the  matter which forms the  onyx,  being almost
always adherent to the lamellas of the cornea, is rarely sufficiently
fluid to enable a simple incision to allow of its  escape.  Finally this
pus, which never constitutes any other than quite thin layers, sponta-
neously disappears as soon as the ophthalmia which produced  it has
subsided or is subdued.  While  adopting  a portion of these reason- 
316           NEW  ELEMENTS OF OPERATIVE  SURGERY.

ings, which  already have been contested by Woolhouse, Mauchart,
&c, I nevertheless  consider the operation useful, when, as an excep-
tion, the  pus constitutes a legitimate abscess.   The facts that science
possesses, and the last memoir of M. Gierl in particular, appear to
me to demonstrate that puncture ofthe eye under such circumstances,
presents  unquestionable advantages, and  that the  moderns  have
exaggerated its dangers.
  B. Ilydrophthalmia.—Hydrophthalmia, whether accompanied or not
by liquefaction ofthe vitreous body, whether there  be or be not blood
or pus effused  into the humors, possesses in puncture of the eye a last
resource, which at the present day, perhaps, has not been had recourse
to sufficiently  often.  It would be doubtless imprudent to commence
the  treatment with this;  but  wtien  the  proper  general  or top-
ical medications have proved unsuccessful, and that the difficulties
which continue are manifestly owing to an unnatural distension of the
globe of the eye, I see nothing more rational than the paracentesis of
this organ.  By putting  a period to the compression ofthe retina, the
iris, and  of  the ciliary circle, processes, vessels* and nerves, it mod-
erates the most violent pains, and appears to me capable  of prevent-
ing the most serious disturbances, and  to constitute a means, if not
curative, at  least  palliative, and one of the  most valuable auxiliary
remedies.
   I. Paracentesis of the eye, which has been practised in Japan and
China  for centuries, and performed by Tuberville and  Woolhouse,
can scarcely be said 4o have been formally proposed for hydrophthal-
mia before the time of Valentini, (Coll. Acad., partie etrahg., t. VII.,
p. 434,) Nuck, (Journ. de Si?nmons, t. I., p. 282,) and Mauchart. In
the beginning  it was performed by a small trochar, which Woolhouse
recommends should be  plunged through the  sclerotica, while  Nuck
directed it upon the centre of the cornea itself.   At present, punc-
ture, properly so called, has been generally abandoned.   Incision in
almost every  case  is  advantageously substituted for it,  except that
some recommend opening  into  the anterior chamber, while others,
as M. Basedou for  example, advise the posterior  chamber.  Bidloo
made use of a bird-beaked lancet, directed upon the  lower part of
the cornea.   Meckren used a large triangular needle expressly made
for this  purpose.   At the  present day we  more  especially employ
the cataract keratotome.   Saint-Yves  made  a transverse incison in
the transparent cornea.  Louis proscribes  too large an  opening,
while Heister recommends that we should incise the sclerotica.  Fi-
nally, there  are those who  recommend a puncture  first, and who af-
terwards enlarge the  small wound by means of scissors or any other
cutting instrument.  But in truth,  we have in reality only to choose
between the process of Bidloo or rather of Galen, and that of Maitrejan
and Heister.  None of the others in fact attain the object better, and
most of them  are infinitely more complicated or much more danger-
ous.  The species of cataract needle devised for this purpose by M.
Adelmann,  who has shown it to me, and  which has a groove upon
one of its sides, would  however possess the advantage of allowing
of the escape of the liquid, while at the same time it  reduces the
operation to a simple puncture.   The incision of the sclerotica, whe-
ther outwardly or below, and parallel to the  fibres  of this tunic, con- 
GLOBE  OF THE EYE.
317
stitutes in reality a puncture of little  importance, and  should have
the preference if the aqueous humor could  always escape through
it.  Unfortunately this is  not  the  case.  To derive  any advantage
from it in simple hydrophthalmia, it would evidently become necessary
to divide  through the sclerotica transversely at less than two lines
from the ciliary circle, and under this point of view the section of the
cornea is  certainly a less serious operation.   It is only then in cases
of liquefaction of the  vitreous body, and which are distinguished
from ordinary hydropsy by the projection which the iris forms in
front,  that the operation  by  the method  of Heister could  possess
some advantage.   Moreover it is of little  importance in such cases,
whether we follow one  process  or  another, inasmuch as the eye is
usually lost beyond redemption.
  II. Operative process.—After having arranged the patient and as-
sistants, in the same manner as for extraction of a cataract;  and af-
ter having properly separated the  eyelids apart, and fixed the eye,
the surgeon makes with the point of a lancet, a bistoury,  Adelmann's
needle, or a keratotome, held like a writing pen, an incision of from
two to three lines in  length, and at the lower or outer part of  the
cornea, as far as possible in fact from the pupil, and in such manner
as not to wound the iris.  It is unnecessary then to make any pres-
sure on the globe of the eye.  The'aqueous humor immediately runs
out; and  an evident relief is  generally the immediate consequence.
So long as any hope remains of preserving the organ intact, it would
be dangerous to do anything to prevent the wound from cicatrizing.
We should dress  in the same  manner as after  the operation for cat-
aract, and should a new accumulation of the  liquid seem  to render it
necessary, repeat this- puncture at the expiration of a certain number
of days, after the  manner of M.  Basedow, who gives  four suc-
cessful examples of it, and as I myself have frequently done. No one
moreover, at the present day,  would recommend that we should imi-
tate Nuck and certain  surgeons of the last  century,  by placing a
piece of sheet lead between  the  eyelids, in order to be  enabled  to
compress  the eye from before backwards, so as to make it gradually re-
enter into the orbit. A practice like this, which moreover  is unworthy
of discussion, could not have been adopted but by those  who have
confounded exophthalmia, buphthalmia, and proptosis, with legitimate
hydrophthalmia.   Should any point on the tunics of the eye be obvi-
ously more altered, prominent or attenuated  than others, there is no
doubt that this point should  be preferred for the paracentesis, and
that we should make it a place of necessity.  When buphthalmia and
the projection of the eye depend  upon  hydropsy or  a dilatation of
the  sclerotica, it  is then  hydrophthalmia also that we have to con-
tend with, and the puncture is indicated, as in the preceding  cases.
On the contrary, it could  have no object, and  must aggravate  the
condition of the patient, when the disease is  owing to the develop-
ment of some tumor, or to the existence of some organic  lesion in the
orbit.
  C. Hypopyon.—Galen appears to have been the first who proposed
paracentesis  for hypopyon. Nevertheless he did not have recourse to
it until after having unsuccessfully made trial of succussion (succus-
sion), so much lauded by Justus, and which  Heister  and Mauchart 
318
NEW ELEMENTS OF OPERATIVE SURGERY.
have since thought not  unworthy of reviving.  According to this
author, we open into the lower part of the cornea, a little in front of
its union with the sclerotica, and the pus soon escapes to the outside.
Aetius recommends that we should perform it with the needle at some
point upon the  membranes which is not inflamed.
  Guy de  Chauliac, Benedetti, Pare, and  Dionis  have adopted the
precepts of Galen with success,  and despite the efforts of Nuck,
Woolhouse and a great number of others,  who like the Arabs re-
commended that we should confine ourselves to one puncture to ena-
ble us to suck out the effused matter, and  who even went so far as to
advise leaving the canula of the  trochar in place,  and  afterwards
making use of  it for throwing injections into the interior of the eye;
modern practitioners also restrict  themselves to a pure  and simple
incision, when they decide upon treating hypopyon by paracentesis.
It would be in fact  the  best process  to  follow under  such  circum-
stances were the slightest operation then necessary, and  if M. Gierl
is to be believed, (Journ. de Simmons, t. I., p. 278;) but the small
quantity of pus which forms the hypopyon  very readily  disappears
of itself when the ophthalmia ceases ; the way to augment its secretion
and produce opacity of the cornea, is to open into the anterior cham-
ber with any instrument whatever.   Chronic  purulent deposits, the
only ones perhaps which paracentesis would not aggravate, are consti-
tuted of a matter too adherent either to the  iris or the cornea, to
enable us to evacuate them by means  of an  incision of a few lines in
extent; we must place our reliance in fact upon general treatment,
resolvent collyria,  and an effort to  put a term to such an affection, so
long as it does  not exceed the limits that belong to  a  true hypopyon,
and so long as we  have  any hope  of  preserving the visual function.
For all these reasons I  am of opinion, with Boyer and Dupuytren,
that puncture of the eye, either with a  trochar or lancet, is but rarely
applicable to  abscesses  in the anterior chamber, unless like  Lehoc
we  should employ  it with the view  of renewing the aqueous humor,
and at  the same time for evacuating the purulent matter.
  D. Empyesis.—In abscess of the posterior chamber, that is to say,
in empyesis or  empyema of the eye,  it would  appear at first view
that all the world would  concur in the necessity of having  recourse
to  paracentesis.   It would   however be an  error to suppose so.
Though many persons have recommended it; and  in fact almost all
the  oculists of the last century frequently made  use of it, it can nev-
ertheless be then but a feeble resource.  By it we  evacuate but in a
very imperfect  manner the morbid collection.   As  it soon shuts up,
the  accidents which belong to it are remedied  but  temporarily.  As
soon as the eye is implicated it  is irrecoverably lost, and there is no
use in incising it any more.   We ought to excise a sufficiently large
portion of it to evacuate it completely and bring  about atrophy.  The
seton employed in China and Japan, and which had already been eulo-
gized by Woolhouse as  a substitute  for puncture, and revived by
Ford,  (Southern Med. and Su?-g.  Journ.,  June, 1838 ;  Gaz. Med.,
1838, p. 617,) is a barbarous remedy, and unworthy of any criticism.
  E. Practice  of  the author.—I  have however  found  that in  all
these cases repeated punctures on some  region  of the sclerotica
which remained intact, by means  of the point of a lancet, possessed 
GLOBE  OF THE EYE.
319
a great deal of efficacy.   So long as the eye is distended and pain-
ful, whether there be hypopyon, empyesis, hydrophthalmia, or ophthal-
mitis, I have found nothing better than this practice.   I  choose the
point of the sclerotica which is most visible and projecting, and plunge
in the lancet there perpendicularly and parallel to the fibres of this coat.
The relief is prompt and  the operation may be repeated the day after.

                  § VI.—Excision of the Eye.

  Staphyloma of the cornea, empyema, hypopyon, and hydrophthal-
mia, are almost the only  diseases which  sometimes require excision
of the  anterior part of the eye, or for which we may properly have
recourse to this operation.  Its object is to evacuate the organ, to
bring  about  its  atrophy, and to transform it  into a simple stump,
which  may be  adapted to the support of an artificial eye.  It is
therefore a dernier resource, which is not  allowable except where
all others have failed, and only in  cases where it  has  satisfactorily
been demonstrated that  the sight cannot be preserved or re-estab-
lished.   In hypopyon, empyesis, and hydrophthalmia, for example, it
is not to be resorted to until after incision or puncture, unless the in-
sufficiency of these last methods should have been  previously ascer-
tained.  M. Dugas, (Ibid.,) in a case of hemophthalmia, did not de-
cide upon it until after having lost every hope of preserving the eye.
The most ancient authors  had already made use of it  in prolapsus
(proeidence)  of the cornea. Galen mentions it  as a common method.
Aetius  recommends that we should associate it with  the ligature ; and
that before removing the  staphyloma, we should  pass two threads
through its base crosswise. The ligature that Paul of Egina and others
proposed to apply either circular, crucial, or transverse, the taxis and
compression  proposed by Manget, and the crucial incision of Wool-
house, are now no longer in use, and all surgeons at the present day
adopt  the advice of Pare or of Louis  when they wish  to obtain a
radical cure of staphyloma of the cornea, that is to say, they perform
pure and simple excision.
  A. Operative process.—Whether it be for one  disease or another,
we must, as soon as we decide upon not  removing  the entire organ,
confine  ourselves to the excision of its apex.   Cancerous affections
alone  would  constitute  an  exception  to this rule,  did  they ever
allow  of a simple excision.   In penetrating beyond the iris, up to
the middle of the posterior chamber, we should incur the risk of see-
ing the muscles  retract  the  rest  of the sclerotica and the  optic
nerve  to the bottom of the orbit, and of having  no stump to the eye
after the cure.   On the other hand, if we should confine ourselves to
a small opening,  the humors contained in the chambers would only
partially flow out, and the wound might cicatrize too soon, and  leave
only in its place a depression which  would be as great a  deformity as
the staphyloma itself.  We should avoid these two extremes by remov-
ing almost the entire cornea and without going any farther.  Then we
are sure that the vitreous humor will finally escape or be dissolved, that a
new accumulation of humor will not take place to such extent as to pro-
duce a painful distension in the posterior chamber, and that after cica-
trization, the muscles will be enabled to impart to the remains of the or- 
320           NEW  ELEMENTS  OF OPERATIVE  SURGERY.

gan the greater part of the movements which it executed in its natu-
ral state, and  transmit them to the artificial eye.   Nothing  is easier
than an operation  of this kind.   The crucial incision with excision
of the four flaps, as Richter recommends, is altogether useless.  The
patient being  properly arranged and secured,  we divide the lower
half of the cornea with Daviel's instrument, the point of a lancet, or
any bistoury or keratotome, in the same way as for extraction ofthe
crystalline.  The flap is  immediately seized with a good pair of for-
ceps, and detached in the remainder of its circumference, by means
of a very sharp pair of scissors or of a bistoury directed from below
upwards.  An erigne plunged into the middle  of the segment to be
removed would render its excision still  more prompt and certain  in
intractable subjects or in those in whom it might be difficult to steady
the eye.   This process, more simple than that of Terras, who passes a
thread through the tumor in order to exsect it more readily afterwards,
would enable  us in  fact to remove as rapidly as possible, and with a
single stroke ofthe instrument, the totality ofthe cornea or staphyloma,
by directing upon its base a good bistoury, which should be made to act
either from above downwards or below upwards.   The guillotine of
Guerin, extolled by Demours, would not be more convenient, and
has no claim to a preference.
  I.  Consequences.—There is generally  developed  after this exci-
sion a sufficiently active  inflammation in  all  the  parts contained in
the orbit, together with fever  and cephalalgia, and sometimes even
symptoms much more serious.   In general, however, at  the end of
from eight to fifteen days, the  swelling which it has occasioned be-
gins to diminish;  the  suppuration, at first  abundant,  soon  dries up,
and towards the end of the month, or a little sooner or a little later,
wre are enabled to adjust the artificial eye.  As it is not an operation
without danger, we ought to make this  known to  those who demand
it for simple  deformities, and ought not to  perform it  under such
circumstances, except at  their  solicitation, as in cases, for  example,
of ancient  staphyloma, unaccompanied with  pain.   When, on the
contrary, the disease which it  is designed  to remedy is dangerous in
in itself, as empyema, hydrophthalmia, &c, we  must not  hesitate.
Before such affections as  these, every apprehension  should  be ban-
ished.  Punctures of the sclerotica,  I should think, would  diminish
the inflammatory reaction and ought to be had  recourse to.

                 § VII.—Extirpation of the eye.

  Though extirpation ofthe eye was not clearly described until near
the close of the sixteenth century, there is however every reason to
believe the ancients had had recourse to  it quite frequently.  There
were two principal classes of conditions in which it was made use of:
1st, for proptosis, or the  fall ofthe eye;  2d, for deep-seated diseases
and degenerations of this organ.
  A. Proptosis—Exorbitism—Fall of the eye.—J. Lange, who wrote
in 1555, boasts of having caused the re-entrance  into the orbit of an
eye which certain surgeons had proposed to extirpate.  Donat, at a
little later period, in 1588, endeavored to demonstrate the inutility  of
this operation, and maintained that  compression, aided by  the judi- 
GLOBE  OF THE EYE.
321
cious employment of internal remedies, always triumphed over those
diseases which seem to require it; which proves  at least that for a
length of time it has been known  to practitioners.   Bartisch, there-
fore, who only published his work in the year 1583, has no claim to
the merit  of the invention, and has only drawn attention to a serious
operation, and one which had already been performed, but the execu-
tion of which  he rendered more easy.
  Some  authors, as Covillard, Lamswerde, and  Spigel, also profess
to have cured without  an operation, patients in  whom the eye vio-
lently protruded  from the orbit and hung upon the cheek.  A. Seig-
neur  stated to Guillemeau, (OSuvres Chir., p. 743, edit. 1612,) that
his surgeon seizing an eye which had fallen to the ground, success-
fully  replaced it  in the orbit.  An eye which had issued from the
orbit  in  consequence of inflammation, was replaced by  Loyseau,
(Obs.  de Med. et de Chir., p. 46 ; Corps de Med.)   The eye of Cap-
tain Naldi, according to Rhodius, (Bonet, t. III., p. 50,) which had
been driven from the orbit by a blow given by a  Turk, miraculously
returned to its place by means of a large cupping glass upon the occi-
put.   In a young infant, the eye which had inflamed and become as
large  as an egg, and escaped from the orbit, returned there by means
of topical applications administered by F. Plater,  (Bonet, t. III., part
2nde, p. 50.)  Verduc (Pathol.  Chir., t. II., p. 44-47, in  12,) does not
admit the fact of Covillard,  but  Lemaire, (Eaux de Plomb., &c,
p. 59,) saw the  same thing  in a hemiplegic at Plombieres.  Sal-
muth, (Cent. 2, hist. 42, c.tat d'Ettmuller,  Prat.  Med., t. II., p. 401.
French trans.) speaks of an epileptic, in whom the eye during a par-
oxysm protruded  to  the size of the fist, and returned after this had
ceased.   Verduc, (Pathol, de Chir., t. II., p. 244, in 12,  1719,) more-
over, admits to have seen a young painter, whose eye descendedvto
the middle of the cheek, and which in less than the space of an
hour, descended  from, and returned to the  orbit more than six times.
In a  patient  of C. White's,  (Cases in Surgery, 1770 ;  Gaz. Salut.
1771, No. 27, p. 3,) the eye, luxated upwards by the contraction of
its levator muscles, was relieved by the taxis : a wound made by a
fragment of pipe-stem which had entered at the bottom of the orbit,
was  the cause of the difficulty.  In a case of protrusion of both eyes,
says  Rossi,  (Elem. de Med. Oper., t. I., p. 203,) which  took place
after  violent  vomitings, I found after the remedies which I had em-
ployed to give greater strength to the muscles of the eye in restrain-
ing the  globes,' that the use of electricity and camphorated vapor
produced a marvellous effect.  M. Champion has known an old lady
who was affected with  strabismus in the left eye, and in whom  this
infirmity succeeded after the reduction of  the eye, which  had been
driven from the orbit out upon the cheek  in consequence of a blow
received upon the temple.  I frequently  meet, says the same prac-
titioner, with a retired officer, who declares that  he had a protrusion
ofthe right eye which it had been proposed at the time to excise^ but
which was perfectly reduced and  is now in possession of all its func-
tions.  The  accident was  said  to have been produced by a  ball
which had traversed the left orbit, and which had come out at  the
inner angle of the right one.  Maitrejan  has long since shown  the
impossibility  of such a result taken literally ; but  Louis has very
                             21 
322
NEW ELEMENTS OF  OPERATIVE SURGERY.
justly  remarked, that in divesting  the  assertions of observers of
every thing hyperbolical that they possess, we find in them the proof
that the optic nerve and the muscles which surround it may undergo
a considerable  degree of elongation without  necessitating the extir-
pation  of the eye.  We have, moreover, numerous examples of this
elongation  effected in a gradual manner, in cases of  exostoses, and
tumors of every description in the orbit, nasal fossas, maxillary sinus,
&c. If the eye  really hung down on  the outside, in consequence
of a traumatic lesion, we  should  then,  instead  of attempting to re-
place or preserve it, complete  its separation and remove it imme-
diately.  In such cases there is no process to be given.  A single cut
of the  scissors or bistoury sometimes suffices,  and the conduct of the
surgeon must necessarily  be regulated according to the accidents
which  exact so severe a  remedy.   When on the contrary  the eye
has only been expelled gradually from the orbit, whether  entirely or
partially, or whether it be or be not in itself disorganized, we should
do wrong to atteptms it extirpation.
  It is not to the eye itself that the resources of surgery  are to
be addressed.   Let the operator destroy, or cause the disappearance
of  the principal  disease if he can, and the  displaced organs will
soon resume  their normal  situation.  St. Yves cured a  severe ex-
ophthalmia, by effecting the resolution of scirrhosities which had been
formed in the bottom of the orbit.  Brossaut, who is  mentioned by
Louis,  has  seen the vision  re-established, and the eye re-enter into
its cavity, when the  exostosis of the ethmoid which had caused its
expulsion had been destroyed ; Guerin of Bordeaux, and Dupuytren,
have brought about the same result by removing the various  tumors
and cysts, of which  the  tissues  which  surround  the eye are very
frequently the seat.   Extirpation of the eye  therefore is not called
for  in buphthalmia nor exophthalmia, whatever  may be their cause,
nor in hydrophthalmia, empyesis, or staphyloma.
  B. Cancers of the Eye and the Orbit.—Cancerous affections only
allow of our undertaking extirpation of an eye which has not been
displaced.  Even when their existence  has been  well established,
the question still remains whether the operation should be  attempted.
Those  who go for the affirmative, with Desault,  &c, argue princi-
pally that cancer of the eye is  much more frequently observed in
children than in adults, and that in the younger period of life its re-
production is much less to be apprehended than after puberty.  Others
appeal to the researches  of M. Wardrop, which show that  the dis-
ease is almost always constituted of fungus hematodes,ji melange of
encephaloid, erectile, colloid or melanotic tissue, or one^f those sub-
stances only.   But since  there is no variety of cancer which repul-
lulates, either in  the  same  place or elsewhere, with more obstinacy
than this, they maintain  that it would be inflicting unnecessary suf-
fering upon the patient, and that we ought to limit ourselves to simple
palliatives.   What analogy and reasoning had foreshown to them, ex-
perience has but too often demonstrated.  Whatever, in fact, some au-
thors may have said on this subject, the labors of the ancients, like those
of the  moderns, sufficiently prove that the ablation of cancer of the
eye is not less liable to a return of the disease than that of any other
part.   I would not, however, therefore conclude  that we ought to 
GLOBE  OF THE EYE.
323
remain inactive.  Far from that, I think we ought to exert ourselves
to operate before the viscera have had time  to become invaded by
the morbific germs, and as soon as the nature  of the disease appears
no longer  doubtful,  and so often as it shall appear to be practicable
to remove it entire.  All this, however, belongs to the general ques-
tion, whether it is advisable or not to operate for cancer.
  1. Operative process.—a. Process of Bartisch.—The extirpation
ofthe  eye, much more frightful than difficult, more formidable by its
consequences than its immediate dangers or the difficulty of its exe-
cution, may be performed  by  quite a number of different  modes.
We find no details on this point  in authors before the time of Bartisch,
who, in order to excise the diseased parts, found no other instrument
necessary than  a species of spoon with cutting edges, like that used
by shoemakers.   Though no person at the present day would ven-
ture to recommend so crude an instrument, it is incorrect to say that
it exposes to the risk of fracturing the bones, and  that it renders the
operation much more difficult than with any other knife.  Its dimen-
sions, it is true, do not allow of our carrying it as far as the extreme
depth  of the orbit, but I do not find that it is often required to go to
this distance.   To be just, therefore,  we should  limit ourselves to
its rejection as  useless, or possessing  but little advantage.   The ex-
cavated  scissors of  Delpech, (Diet,  des Sc Med., t. VII., p. 528,)
and the concave scalpel of Mothe, (Journ.  Gen. de  Med., t XLVIIL,
pp. 121—136,)  are scarcely better.
  b. F. de Hilden, who had occasion  to  extirpate an eye in 1596,
proposed at first to embrace the projecting part by means of a string
purse.  After having censured  the instruments of Bartisch, (Cent. 6,
obs. 1,—Bonet, Corps de Med., p. 389,) he speaks of the simple stran-
gulation extolled by C. H. Chapuis.   Detaching the tumor from the
eyelids by the  cuts  of the  bistoury, he employed for the section of
the muscles and optic nerve a sort of scalpel with two cutting edges,
curved flatwise, and  truncated at its point.   In this  process we
already recognize the principles of a more enlightened surgery, and
the practitioner mentioned by Bartholin (Louis, Diet, de  Chir., t. II.,
p. 124,)  is justly censurable for not having profited by it about  fifty
years  subsequently,  and for not having recoiled at the idea of tear-
ing out  the eye by means  of a  pair of hooks.   The instrument
of Hilden, though more  ingenious, has nevertheless  met with the
same  fate as that of  Bartisch.  If Job-a-Meckren succeeded with the
spoon of the oculist of Dresden,  and Muys  and  Leclerc with the
knife  of Hilden, Lavauguyon  maintained  that a  good lancet fixed
on its  handle would  always suffice, and might be substituted for them.
St. Yves, for every step of the operation, found nothing else required
than, a thread to secure the cancerous mass, and a cutting instrument,
which he does not designate.  Nor do the observations of Bidloo make
any mention of a particular knife, except it be a long  bistoury bent
to an  angle, near its  handle, and which is also praised by V. D. Maas.
  c. It was Heister  who showed, by sufficiently good reasoning, that
an erigne or forceps, and the ordinary bistoury, which Hoin of Dijon
had already found to answer in 1737, are sufficient for this operation.
  d.  Things were in this state  when Louis undertook to systematize
the ideas of surgeons on the extirpation of the eye.   When the tumor 
324           NEW ELEMENTS OF  OPERATIVE SURGERY.

no longer holds on except by the root ofthe recti muscles and ofthe
optic nerve, we must, says this surgeon, make use of a pair of scis-
sors  curved flatwise ;  pass them to the bottom of the orbit, then
divide  the musculo-nervous pedicle, and at the same time act with
them as with a spoon to bring the whole forward.
  e.  Desault,  who, in  the first years of his  practice, had adopted
the process of Louis, ultimately abandoned the scissors as useless,
and  confined  himself to the simple bistoury, which in fact is better
than the curved bistoury of B. Bell.   Sabatier, Boyer, Dupuytren, and
all the operators of the present day, conform themselves to the recom-
mendations of Louis or of Desault almost indifferently.  With the
curved scissors we run no risk of  penetrating into the cranium or
into  the zygomatic fossa.   Their concavity accomodates itself better
to the form ofthe  tumor, whose pedicle also they would seem to em-
brace with more security.  But with a bistoury it is not necessary to
change the instrument, from the commencement to the end.  The
section of the  soft parts is more neat, and all that is required is to
incline it in one direction while the eye is drawn in another, in order
to reach with  facility the root of this last.  We should have to be
very unfortunate or very inexpert to perforate with its point into the
optic foramen  or maxillary and sphenoidal  fissures.  It  is therefore
here also, as we  have  so often already said, an affair of choice or
circumstances, much more than of necessity.
  First stage.—The  patient may, if necessary, be kept  seated upon
a chair, but it is better to  operate upon him  in bed, taking care to
raise up his head considerably.   The surgeon being placed upon the
side  of the affected eye, acts differently according as the  surrounding
parts are or are not  invaded by  the cancer.  In  the first case he
adopts the precept of Guerin, and  makes two semilunar incisions,
which  enable him  to circumscribe the base of the orbit and to detach
the eyelids from it in order to remove them writh the rest of the dis-
ease.  In the second case he is to do all in his power to preserve the
connections of the eye.  If they have contracted adhesions without
having undergone  an actual disorganization, he dissects  each eyelid
on its inner surface and reverses it outwardly.   When the globe of
the eye is found to be free  behind, all that is necessary is to prolong
with one cut of the bistoury the outer palpebral  angle to the extent
of about an inch  towards the temple,  as  Acrel,  and not Desault,
appears to have been  the first to have formally recommended.  In
all cases an assistant secures the head of the patient, and keeps him-
self  prepared to  follow and  to  favor  all the  movements of the
operator.   This last  secures the projecting part  of the  tumor with
his hand  if he  can,  after the manner  of Desault.  Otherwise he
makes use of  a simple  erigne or double  hook, an erigne forceps  like
that  of Museux, or the  string purse of F. de Hilden, or  better still,
as St. Yves recommends, (or a strong simple ligature or ribbon cross-
wise,)  after the manner of Chabrol, (Gaz. Salut., 1782, No. 49. p. 4,)
passed by means of a needle through the degenerated mass.
   Second stage.—The operator takes the bistoury in his right hand,
holds it as a writing pen, and directs its point to the great angle ofthe
eye; plunges it in while grazing the ethmoid bone as far as to the neigh-
borhood of the optic foramen, makes it pass round flatwise the entire 
GLOBE  OF THE EYE.
325
lower semicircumference ofthe orbit;  divides the attachment ofthe
small oblique muscle, the oculo-palpebral groove of the conjunctiva,
and some adipo-cellular filaments; then brings it back into the inner
or nasal  extremity of the wound; directs its cutting edge upwards
and then outwards;  divides the great oblique muscle, and endeavors
to remove at the same time the lachrymal  gland, when, by  passing
around the orbitar vault, he arrives  near the temple and  finds him-
self at the point  of uniting  the  two wounds by their outer ex-
tremity.
  Third stage.—The eye now holds no longer than  by means of a
pedicle formed by the four recti muscles and the optic nerve.  If,
in order to divide this  pedicle, we prefer the scissors, the operator
glides them upon the inner rather  than the outer side,  with their
concavity turned towards  the tumor to  as  great depth as possible,
and with a single cut completes the separation of the cancer.   If any
bridles  still retain it, they  are to be  rapidly  divided in the same
manner,  while with  the other hand  we  make the  proper tractions.
If, in pla:e of the scissors, the surgeon has  recourse to the bistoury,
he directs this  also, by preference, upon  the  inner side.   In this
direction the orbitar wall  being almost straight, it is easy, by inclin-
ing the point of the instrument outward, to cross and divide the mus-
culo-nervous pedicle.  I am ready,  however, to  avow that with the
bistoury, as well as with the scissors, it would not  be attended with
much more difficulty to attain the same object by following the tem-
poral wall of the orbit.  It was, in  fact, here that Desault  usually
entered it by choice, remarking that this route was the shortest and
most convenient.
  An object more worthy of attention, is that we  are more certain
by this mode to avoid falling upon the maxillary and sphenoidal
fissures.   Whether the lachrymal gland be cancerous  or not, we
must when we  have  missed it, seize it immediately after with an
erigne or forceps and  extract it.   The secretion of tears  being no
longer of any use must necessarily be injurious.   It must be by inad-
vertence  that some  have thought  proper  to sustain the contrary
opinion.   This gland when left in the  orbit after the removal of the
eye,  kept  up a copious  discharge  of tears with  accidents, which
obliged M. Nelle (Encyclogr. des Sciences Med., 1838, p. 250) to ex-
tirpate it six months subsequently.   We may moreover, by directing
the forefinger into the orbit, accurately ascertain, the condition of the
parts  that remain ;  and if there  are  any  of them which  are not
sound, we should endeavor to reach them  before we have finished
the operation, and remove or destroy  them, either by means of the
bistoury, the scissors, or even the rasp.
  II. Dressing.—No artery of any size can have been wounded.
All those which are divided come from the ophthalmic ; and their
ligature is unnecessary, even though the blood  should flow in abun-
dance.  Small balls of lint sprinkled  or not with colophane and more
or less pressed  upon, would be  sufficient to arrest it.  In ordinary
cases we fill up  with lint the void which has  been left, but  mode-
rately and as if  for the purpose of supporting the posterior  surface
of the eyelids.   The sponge, which has been proposed by some prac-
titioners in lieu  of this substance, would have  the disadvantage of 
326
NEW ELEMENTS OF  OPERATIVE SURGERY.
irritating the tissues by becommg swollen in the middle of a solid
cavity.   The small bag  filled  with emollient  cataplasms also, as
recommended by M. Travers, and which is placed over all the other
dressing in order to prevent  the slightest degree  of compression,
does not appear to  me to  present any real advantages.  At  the ex-
piration of four or five days the suppuration is established.   The lint
is  removed without any  effort.  Nor is there  any objection if we
wish  to make the removal of the first dressing  still  more simple, in
covering the bottom of the wound with a fine linen  besmeared with
cerate and perforated with holes, and which serves as a sac to the
compresses, and when the eyelids have been removed  may be easily
reversed upon the contour of  the  orbit.  A soft plumasseau, and
which is sufficiently large to support in  front the more deep-seated
portions of  the  dressing, together  with a long compress  placed
obliquely, and the  monocle bandage, complete  the  dressing, which
the least skillful  surgeon moreover  will  know how to modify in a
proper manner, should circumstances make it necessary.  After its
first removal, which is from the third to the sixth day, the dressing
has no longer any thing particular in it.   The wound  being washed
with  tepid water  and gently  wiped out, should be  supplied  each
time with  a  small  quantity of dry  lint.  The eyelids  being gently
raised up and protected by small bandelettes besmeared with cerate,
are finally covered with a  soft plumasseau and a compress; the whole
is supported by the monocle and a few turns of bandage.  The cure
is usually effected between the  third  and tenth week.
  III.  Remarks.—Though  the preservation of the eyelids would
render the  deformity less repulsive, it would nevertheless be  prefer-
able to sacrifice them rather than not to destroy the remotest vesti-
ges of the disease.  The  incision at the external  angle renders the
remainder  of the  ooeration more easy, and does not involve any
particular accident.  One point of suture or a simple adhesive strap
would moreover effect its reunion without any exertion or incon-
venience.   If we  should commence by the  superior incision, the
blood which  oozes  out would necessarily create a slight degree of
embarrassment  for that  below.  The  eyelids  having their fixed
point  upon the inside, we manipulate with  more security from the
nose towards the temple  than  from  the outer to the internal angle.
When the globe ofthe eye alone is affected, as it is attached in front
only by the fold of  the conjunctiva and the oblique muscles, it is not
necesary to  carry  the instrument over  an  inch in  depth.  On the
contrary, when adhesions  are established  between the  soft parts and
the bones, we must go as  deep  as the'bottom of the orbit.  In  such
cases the spoon-knife of Bartisch, the scalpel of  Hilden, and the bis-
toury of Bidloo, would incur the risk of fractures, which it is  always
advisable to  avoid.  It  is under such circumstances  also that any
sharp-pointed instrument  whatever, if  directed without precaution,
might fracture the frontal  bone and  penetrate into the brain, should
we, in order to reach with more certainty the  levator muscle or
lachrymal  gland, elevate its point too much; or it might arrive into
the maxillary sinus  and divide the suborbitar nerve or vessels, if we
should incline it too much in  the opposite direction; or  penetrate
into the nasal fossas inwardly, or into the zygomatic or pterygb-rmx- 
GLOBE  OF THE EYE.
327
illary  fossa posteriorly,  and wound the second branch of the fifth
pair of nerves (nerf trijumeau) or the internal maxillary artery;  or
in fact penetrate into the cranium through  the sphenoidal fissure, and
wound the middle lobe of the cerebrum.   If the bistoury, however.
should not graze the bones, we should incur the risk of not removing
all the cancer, and of being obliged to operate again afterwards. •  The
lachrymal gland in particular being almost entirely concealed behind
the external orbitar process, cannot be extracted with the eye except
with a good deal of difficulty. ,
  The rasp recommended by Bichat, or the chemical caustics, would
be less dangerous  than the actual cautery, at least on the side of the
orbitar vault, should it become  indispensable to go  beyond  the soft
parts.   In fact, the proximity of the  brain would, under such circum-
stances, render the  application  of  the  iron extremely  dangerous.
Should the fungus have  commenced at the exterior of  the eye, there
would be reason to apprehend  that there were branches of it in the
direction of the temple,  sinus maxillary, the  nose, &c.   M. Simonin
(Decade Chir., p.  21, 1838,)  having  extirpated  the eye, was obliged
to resort to tamponing ;  and his patient died.  The  roof of the orbit
was perforated, and  blood was found under  the dura mater.  Being
desirous of arresting the blood  and of destroying some remains of
cerebroid tissue in the temporal fossa and  maxillary sinus, I applied
there  an olive-shaped cautery, avoiding with care  the vault of the
orbit.   The patient died on the  third day,  and we found an extrava-
sation of blood in the corresponding lobe of the brain.  Was it the
operation which was the cause of this  apoplexy,.or was it not only
a mere coincidence ?  Though we may be in the habit of employing
the same hand for the  first and second incision, it nevertheless ap-
pears  to be more convenient for the right eye, for example, to exe-
cute that of below with  the  right hand, and that of above  with the
left one, unless we wish  to make one of them from the temple to the
nose.  We divide the levator muscle, because  otherwise  it wrould
constantly tend to draw the upper eyelid inwards after the cure,
and might in this manner still further increase the deformity.   I have
forgotten to say that  Dupuytren began with the upper incision, and
that he  terminates by detaching the organ  from the  summit to the
base of the orbit.

                   § VIII.—Artificial Eyes.

  Nothing, doubtless, would  be more desirable than to be enabled  to
make  use of an enamel eye, when  the  disease has permitted us  to
preserve the  integrity of its movable  coverings; but we must not
flatter ourselves too  much on this  point.  The orbit, like all  other
natural cavities, when once emptied and void  shrinks  upon itself.  Its
walls  approximate gradually from the bottom to the  exterior.  Its
circumference  diminishes and becomes depressed  in  such  manner
that at the expiration of  a certain time, it is found to be almost com-
pletely effaced by this contraction, and «ilso by the development of a
nbro-cartilaginous substance.  The eyelids being obliged to conform
themselves to  this  retraction, contract  adhesions on their  posterior
surlace, are deformed, and become in most cases incapable of adapt- 
328          NEW ELEMENTS OF  OPERATIVE SURGERY.

ing themselves to the  artificial organ that we wish to  place behind
them.   If the patient,  therefore, is desirous of concealing his mutila-
tion, we must be prepared whether the eyelids have been  destroyed
or not, to  be under the necessity of employing only spectacles that
have been artistically arranged, or  with a colored plate, which is to be
fixed in front of the obliterated cavity.  The ancients,, as it appears,
devoted more attention to these matters than ourselves.  We find that
they had two species  of artificial  eyes, one to be inserted as at the
present day behind the eyelids ; the others, which were still used in
the time of Pare, who is said to have been the first who spoke of them,
and which were a sort of convex plates upon which the anterior part
of the eye and its coverings were  painted  in wax colors, were  to be
kept in place by means of a spring.  Formerly the first were made of
gold or silver: at the  present day the enamel is properly preferred.
In these eyes everything is to be represented, the cornea, the  iris,
pupil, the sclerotica and  its vessels.   To  apply  them, one of them
was held by the extremities of its longest diameter with the forefinger
and the thumb,  in order to pass  its upper border under the frontal
eyelid, while the eyelid was gently raised up with the other hand.
This being done, it enters so to speak of itself, as soon as the other eye-
lid is depressed.  In order to remove it when going to bed at night,
the patient glides under it the head of a pin, and depresses the lower
eyelid  while drawing the lid forward.  Being deposited in a glass of
water during the night, this eye should  be carefully cleansed  every
morning before being replaced.  It is unnecessary to remark that its
dimensions ought to be in relation  with the orbit of different indivkh
uals, and that it is important that another eye should be substituted as
soon as the first  begins to change.   When the enamel eye has  been
properly constructed, and that the  two posterior thirds of the natural
eye remain to form a stump, the resemblance sometimes is so striking
as to produce a complete  illusion.   In the contrary case, as it is not
susceptible of movement, it remains fixed  in the centre of the orbit,
and unfortunately cannot be concealed  in those who are  obliged to
wear it.
  [M.  Morant, of Mettrey (Arch. Gen. de Med., June, 1844, 4e ser.,
t. V.) having found  cashes of epidemic  ophthalmia accompanied in
the beginning with coryza, was thereby induced to try repeated cau-
terizations to the mucous membrane of the nasal fossa, which proved
in many instances an effectual remedy.
  Encysted spheroidal liquid tumors in the anterior chamber of the
eye, with the capsule and  contained liquid more  or less transparent,
and the whole  adherent to the iris, have been noticed in a few in-
stances, (see a case by J. Dalrymple, London Lancet, August, 1844,
and Tywell  on Diseases ofthe Eye—also Archiv. Gen., Paris, Mars,
1845,) and are cured either  by puncture or by dissecting out the cyst.
  Abrasion of the cornea for cure of Opacity.—M.  Malgaigne exhib-
ited to  the Royal  Academy  of Sciences  of Paris, April 28,  1845,
(see Arch.  Gen., June, 1845, p. 236,) a young girl  in whom an opa-
city of the cornea was  completely removed, and transparency re-
stored,  by an abrasion of one half the thickness  of this coat two
years before.  T.] 
LIPS.
329
                        CHAPTER  III.

                   DISEASES OF THE MOUTH.

                       Article I.—Lips.

                         § I.—Harelip.

  The labial fissure known under the name of harelip, is either ac-
quired or congenital.  That which takes place after birth is noticed
almost as frequently upon one lip as upon the other ; the congenital,
on the contrary, up  to the present time has rarely been observed ex-
cept on  the  upper lip.   The  facts cited by Meckel and Nicati, who
profess to have seen it on the lower lip, are truly exceptions.   Since
Louis maintained  that the harelip is not accompanied with any loss
of substance, Blumenbach, Tenon, Beclard,  Meckel, &c, have en-
deavored to  explain its  formation according to certain laws of the
organism, and to show that its  different  modifications  were  the re-
sult of an arrest of  development, (arret de developpement.)  Three
portions, according to some, constitute the upper lip in the beginning,
a median and two lateral.  There are even four, according to others,
who maintain  that  the middle  part  is also divided primitively into
two.  According  to this hypothesis simple harelip is owing to one
of the embryo fissures of the lip having persisted, and the proof of
this, they say, is that it is almost constantly found outside ofthe me-
dian line.  When the two lateral parts  remain isolated from the mid-
dle part the  harelip is necessarily double.  If the authors of some
observations already ancient, and more recently Moscati, wTere not
deceived, and if they have really seen the harelip placed  exactly in
continuation  with the septum  of the nose, it  could be explained by
admitting the non-union of the two halves of the median lobe of the
lip.  Finally, at  the lower lip,  where, as  in  the case of Tronchin,
(Petit, Dissert, sur le bec-de-lievre, p. 5, 1826, Strasbourg,) it induces
marasmus  by the loss of saliva, the congenital harelip must always
occupy the median  line, because in its formation  they say it never
has more  than two portions.    Numerous researches  on  embryos
and the  foetus at every period, induce me  to believe that these ideas
are the result of erroneous observations  or  gratuitous suppositions.
Harelip is not always without loss of substance, and the lips  are no
more formed of two, three, or  four  portions, at  three, four, six, or
eight weeks, than at three or four months.  As soon as we see them
begin to point they appear to be entire, like the buccal aperture that
they accurately encircle.  The  contrary happens  only by accident.
Harelip, like most other monstrosities, has appeared to me to be much
more frequently ascribable to some disease than to  a defect in its na-
tural evolution.  This doctrine, which  I  endeavored to disseminate
since  1825. counts  at the present time powerful advocates.   I see
with pleasure for example, that M. Cruveilhier fully adopts it.    If he
promulgates  it as his own,  it is probably because  he has not taken
notice of what I have said of it  in various places in my publications,
especially in the first  edition of my Tocology, and of this present work. 
330
NEW ELEMENTS OF  OPERATIVE SVRGERY.
   A. Simple Harelip.—1. Analysis of the methods.—Though hare-
lip is one of the  most common deformities of infancy, it has never-
theless attracted but very little attention from the ancients.  Celsus,
who was the first to mention it, speaks of it however quite obscurely.
The Arabs make but slight  allusion to it, and  every thing goes to
show that up to the time of Franco or Pare, its treatment had not
been the object of as much  attention as it merits.   At the present
time, however, this is a point of practice  which seems to leave no-
thing to be desired.   To effect  the  cure three  indications are to be
fulfilled.   Its borders are to  be abraded, its two sides approximated,
and the two lips of the  division maintained  in  perfect contact until
they have become agglutinated.  ^
   a. Abrasion.—It was with the hot iron that Abu'l Kasem, as well
as Ludovic, effected  the abrasion of harelip.   Butter of antimony,
or  some other chemical caustic,  was  preferred by  Thevenin, and
Hunter made use of nitrate of silver.  Chopart,  yielding in this mat-
ter to the advice  of Louis, considered that he would  succeed better
by applying upon the borders of  the fissure which he wished to in-
flame, two strips of blister plaster.  Such means could not have,
and in fact have not produced  any but imperfect results, and have
properly been abandoned.   Excision only, which had already been
in use in the time of Celsus and Rhazes, is allowable at the present
day.  In order to effect it, D. Scacchi and  Dionis made use of the
ordinary scissors, and Henckel of  blunUpointed scissors,  (ciseaux
boutonnes.)
   M. A.  Severin and Acrel, on the contrary, gave an exclusive pre-
ference to the bistoury, which Louis and Percy endeavored to bring
into general  use;  while Ropnhuysen, De  Home, Le Dran, and B.
Bell, had recourse almost indifferently to the one or to the other of
these two instruments.  The partisans of the bistoury maintain that
it produces less pain, gives a  neater wound, and  one that is less dis-
posed to suppurate;  that the  scissors cutting much more by a press-
ing than by a sawing movement, contuse the tissues and make a bev-
elled wound, or one with a double oblique  plane, which is but  little
favorable  to  immediate  Union.  Experience has a thousand times
demonstrated  the slight  foundation there is to these objections,
Bell being desirous  of ascertaining  the fact,  operated  on one side
with the scissors, and on the other with  the bistoury, without ap-
prising any person of it.  The patient, first embarrassed in giving an
answer, ultimately declared that the pain  had been  more acute at
the side  upon  which the  bistoury  had been used.  The  scissors,
adopted in preference by Van Home, (lntrod. Method  de la Chir.,
Severin, Med. Effic, S. 28,) Lombard, (Clin. Chir. relat. aux Plaies,
p.  38, 1802,) &c, have the advantage of requiring no point d'appui,
ancf of instantly dividing every thing that we wish to remove.  De-
sault, who earnestly defended them, recommended that they should
be  very  thick,  and  that  the  blades  should be strongly  sloped.
Those which are preferred at the present day,  and which  bear the
name of those of A. Dubois, are constructed upon this principle. In
order to  increase with  greater  effect the  power which is to move
them, a great relative length  is given to their  handle.   Their blade,
which is short and solid, in this  manner cuts  with all the precision 
LIPS.
331
desirable.   It would  be an error, nevertheless, to conclude that the
bistoury would not answer.  As to the manner of its employment, it
has singularly varied.   Le Dran, imitating Guillemeau, began by
plunging in its  point through  the lip from the mouth towards  the
skin, a little above the summit of the division, and afterwards divided
perpendicularly from  above downwards, or from behind forwards, as
far as to the labial border, doing the same afterwards at the opposite
side.  B. Bell adopted a course directly the converse of this.  Placed
behind the head of his  patient, with the bistoury held  as a writing
pen, he made his incision set out from the free  border of the lip, and
extended it from below upwards and from  before backwards as far
up as above the summit of the abnormal fissure.  Enaux, after having
destroyed the folds and adhesions which unite the alveolar arch to
the lip, glides behind  this last a piece of cork, upon which he recom-
mends that the lower angles of the harelip should be  supported, in
order that the bistoury  may thereby be furnished with a point d'ap-
pui.   In  place of the cork, recommended by  Enaux, we generally
confine ourselves to a piece of,pasteboard, or simple playing-card, or
portion of soft wood.    The forceps, or morailtes^ either of metal, like
those of J.  Fabricius and Lauth, (Erhmann, Dissert, sur le bec-de-
lievre,) or of wood, like  those used by M. A. Severin, which served to
fix the lip while its exsection was being made,  which by the greater
breadth  of their posterior branch, could  replace the piece of paste-
board which the use of the bistoury required, and which also had for
their  object to aid the  approximation of the two abraded  borders,
and  to  prevent  hemorrhage, have  been  long since rejected from
practice.  Heister, Ac'rel, and B. Bell are, I believe, the last authors
who have thought proper, to recommend them.
   b. Reunion.—After the abrasion of its borders, the harelip is founL
reduced to the condition  of a  simple wound, and its immediate re-
union is  to be attempted either by means of suitable bandages or the
suture, or by combining those two modes together.  Franco, who con-
fined himself to plasters fixed upon the cheeks, and small strips crossed
under the nose, in order to make what he called the dry suture, then
by a containing bandage; F. Sylvius, who, according to Muys, suc-
ceeded with the adhesive plaster alone, also supported by a bandage,
and Purmann and G. W. Wedel, who, it is said, were not less fortunate,
found in Pibrac, and especially in Louis, a warm defender.   Accord-
ing to this author, the bloody suture is not only unnecessary, but also
injurious.  Unnecessary,  because the harelip being unaccompanied
with any loss  of substance, it is always practicable to effect its ap-
proximation by means of the uniting bandage for long wounds; in-
jurious, because its presence is a permanent source of irritation, which
cannot.fail to  bring into action  the muscular  retraction.  Following
out this principle, Louis used only a single point of interrupted su-
ture, and to complete  the reunion employed a simple band.   The
ideas  of Pibrac/who desired,  so to speak, to  proscribe the  suture
from surgery, appeared  to find in this operation a judicious application.
Valentin, in order to effect a more perfect coaptation, devised a clasp
or sort of double flat forceps, capable of embracing the two sides of
the wound, and of being approximated at pleasure  by means of a
transverse piece and screw.   Enaux, (Acad, de Dijon, 1783, ti, II., 
332           NEW  ELEMENTS OF OPERATIVE SURGERY.

p 220,) in order to avoid the contusion and unequal compression made
by the instrument of Valentin, proposed a bandage, the model of
wrhich exists  in the museum  of the  faculty of Paris, and which by
being attached by as many circular  arcs at the top of the  nape, at
the vertex, and under the lower jaw. presents two pelotes which are
intended to push the soft tissues forward, when they are applied upon
the cheeks, and which may be reunited in front of the wound by
passing a strip from one to the other.
  Evers rejects all  these modes, and confines himself to two adhe-
sive strips, which he crosses obliquely (en  sautoir) below the nose.
M. Dudan has since invented, with the same object, a new clasp based
upon the principle of that of Valentin.  For another we are indebted
to M. Montain, (Therapeut. Med. Chir., &c, 1836, p. 16,)  who as-
sures us that  he has made use of  it with  advantage both in  children
and  in adults.  Brunazzi (Gaz. Salut.,  1792,  p. 294,  12  July,)  Gi-
raud St.  Rome (Soc Med. de Marseilles,  1811, p. 23, ) and M. Iyluy-
kens (Bull, de la Fac de Med..  1811, p. 184,) have also obtained suc-
cessful results with the contrivances of their invention.  There is no
doubt that in this  manner  we may sometimes cure harelip ;  but it is
incontestable  also, that in the majority of cases the reunion is badly
and  imperfectly made, and that there frequently remains a groove
either in front or beh:nd, and  at the lowermost part a notch almost as
disagreeable as the  first disease, while the bloody suture, if properly
adjusted, protects us from all these  inconveniences.   It is  also  the
one which is exclusively used in  our time, and the bandages, inclu-
ding that of Terras, (Lassus, Med Oper at., t. II., p. 388,) are no lon-
ger recommended except as accessories.
  c. Celsus, who sewed up the harelip, does not give sufficient details
to enable us to understand what kind of  suture was employed in his
time.  It is probable from what Albucasis says of it, that the glover's
suture was the one made use of by the Arabs.  Others, as Heuer-
mann, Ollenroth, and W. Dros, for example have recommended the
interrupted suture, which was also preferred by Lassus, in order not
to be obliged to leave inflexible metallic stems in the wound.  There
is no  kind of suture, even the quilled, which  has not had its partisans,
though the twisted suture is the one  which has been =alrnost always
preferred.  In order to have a kind of twisted suture, M. Van Onse-
nort places  upon each side of the borders of the wound a narrow
ivory plate pierced with three holes  ; having introduced his threads
with an ordinal}' needle, he knots them on the plate on the left side.
M.  Mayor (Gaz. Med., 1838, p. 737,) recommends one or two points
of suture attached to  (entrainant), a  roll  of lint or cotton, and which
are to be fixed upon a similar border.  A. Pare, the first author who
describes it in exact language, made use of the twisted suture by
means of needles  furnished  with eyes, and which he inserted from
one side of the wound to the other,  and  afterwards fixed by means
of turns of thread passed in a figure of 8 round their extremities.
  d. Fabricius ab Aquapendente employed flexible  needles, the ex-
tremities of which,.after having  inserted them, he  bent forwards.
Those of Roonhuysen were angular  or triangular, like those of Part-
He surrounded them with a thread of silk and  cut  off their point
with the cutting pliers.   Dionis recommends that they should be of 
LIPS.
333
steel and curved.  La Charriere, in place of clipping off their points
like Roonhuysen and  Dionis, used only a small compress between
the skin and their  extremities.   In order to introduce them without
difficulty, notwithstanding  their small size, Heister  made use  of a
needle handle, and J. L. Petit, who  made them still  stronger, and
provided each of their two extremities with a head, fabricated them
of silver and  conducted them by means of a sort  of punch.   Le
Dran preferred that they should be of gold, in order that they might
be at the same time very solid, though  sufficiently firm, and  not oxydi-
sable, and that they should have a flattened point and be provided
with a head, to avoid the employment of a needle handle.  If  gold
and silver possess  the advantage of not rusting, they  also have the
inconvenience when  we wish  to make cutting instruments of them,
of not penetrating as easily through the tissues.  In consequence of
this, Sharp proposed to solder upon his silver needles a spear-shaped
steel point.  Wedel asserts that ordinary needles are sufficient, and
that we should  surround them  afterwards with a  hempen thread.
De la Faye maintains that  without having recourse to  so much  pre-
paration, strong long copper pins,  in a word, German pins, are pref-
erable to all others. As their point might wound the patient, Mursinna
recommends to protect it afterwards  by means of a small piece of
quill.  Le Dran had  found it  more convenient to make use, for
this purpose, of a small ball of wax.   Arnemann (Sprengel, t. VII.,
p. 136), had them hollow, the head and point of which might be re-
moved at pleasure.   Those of Desault,  which are  of silver with a
steel point, are made so as to diminish in volume from their cutting
extremity to that which is to  support  the action of the finger, in or-
der that they may be extracted without bringing them back again
through the same track that they have entered, and without passing
their cutting portion  a  second time through the flesh.   These are the
ones which in France at least fiave been  almost universally adopted.
We cannot see indeed that there  is any objection  to them unless  it
be that ordinary pins,  such as are everywhere met with,  may not-
withstanding be wholly substituted for them, if before inserting them
we take the precaution to sharpen their point a little, in order  to
flatten it by rubbing  it against a tile in the apartment, or some stone
vase or any hard stone.
  e. The semilunar incisions, with their concavity forwards, which
Celsus made  on the  inside of the cheeks, and which Guillemeau,
Thevenin, and Manget, made on the outside, and the dissection and
gashes on the  posterior surface of  the lip which Franco, (Traite des
Hernies, &c, p. 460, 1561,)  J. Fabricius and D. Scacchi recom-
mended in order to favor the approximation ofthe borders of harelip
are no longer to be mentioned in simple  cases, except  to  expose
their absurdity and barbarity.  I have mentioned in the chapter on
anaplasty under what circumstances  they may be useful.   But this
does not apply to the suggestion of preparing beforehand  the parts
which are to be approximated.  In place of the pincers of Fabricius,
&c, V. D. Haar, and after  him Arnemann and Knackstedt of Peters-
burg, have recommended a bandage  which, after having been em-
ployed for a week  or two, is capable of approximating towards the
median line the points which it is important for the operator to bring 
334
NEW ELEMENTS OF  OPERATIVE SURGERY.
into contact.   It rarely happens, however, that the moderns consider
themselves obliged to follow out  this indication, inasmuch as they
know that an ordinary uniting bandage would  perfectly attain the
same object.   Unless the separation should  be extreme, the immedi-
ate approximation ofthe sides of the wound is usually attended with
but very little difficulty.
  f.  Surgeons at different epochs, apprehending  that in spite of the
suture the parts  might ultimately retract, have  endeavored to find
some  means  of obviating this inconvenience; from whence is de-
rived that multitude  of  dressings with  which the science is over-
charged, and that combination of the dry suture or bandages with
the bloody suture.  In this respect Dionis is -the one who appeirs to
have  given the example.  He placed  an  agglutinating plaster in
front of his* twisted sutures, and supported the whole by means of a
bandage with four tails.   La Charriere considered that by  means of
a circle of steel, which surrounded the head, and by graduated com-
presses which he placed upon the cheeks, success would be unavoid-
able.   It was for the purpose of replacing his bandage, as modified
since in various ways by Quesnay, Heister, Henkel, Koenig, Stuck-
elberger, Eckhold, &c, that Enaux and Valentin devised those which
bear their name, and that M. Roux (Med. Oper., t. I., p. 451) associa-
ted with the ordinary suture  a square piece of adhesive plaster, pro-
vided with nooses of thread  on each cheek, but which the bandage
of Louis or that of Desault have caused to be  entirely abandoned.
   II.  Operative Process.—As to the rest, the  following is the mode
to be adopted in  the operation: the  different  articles are composed
of an erigne, a claw or dissecting  forceps, a pair of harelip scissors,
three, four or six prepared needles,  a  simple  waxed thread  two to
three  feet long, a  second thread  composed  of two to three strands
and twice as  long  as the  first, small rolls  of adhesive plaster or linen
to place under the extremities of the needles, a thin  plumasseau of
lint besmeared with cerate, two compresses somewhat longer than
broad, and folded six or eight double, to  be applied  upon the cheeks,
a band an inch wide and rolled into  two heads and  sufficiently long
to make four  or five turns round the head, the sling bandage, strips
of adhesive plaster in  case we do not wish  to employ a bandage, a
playing card, and a straight bistoury when we do not wish to operate
with the scissors.
  a.  First stage.—The patient being placed  upon a chair in a well
lighted  apartment, is  to  have his head steadily supported by an
assistant, who is to prepare himself in such manner as to be enabled
to compress at the same  time the external maxillary arteries  below
and in front of the masseter,  to push forward the cheeks towards the
median line, and to hold  the lip if  it  is necessary, while the operator
excises it.  A second assistant is charged with handing all the differ-
ent articles according as they are required..  The surgeon being
seated or standing up in front of the patient, passes a thread through
the lower left angle of the division, as Koenig recommended, should
he not prefer to introduce there a pin or hook it up with an erigne,
as M. Roux does,  or more simply  make  use of the tooth forceps as 1
do, or of the  forefinger and  thumb, in order to secure it with the left
hand.  The  scissors being  held in  the other hand, are immediately 
LIPS.
335
carried- to two or three lines higher than the upper angle of the
fissure, and separate the whole rounded portion with a singe cut, if
possible, encroaching even  a little upon the sound tissues  in  such
manner  as to  make  a fresh, straight, regular, and neatly incised
wound.   On the other side he stretches the lip itself  by embracing
or drawing upon it with the thumb and forefinger  placed a little out-
side of the border which is to be exsected.  The scissors, which are
to be directed.as before, are to be raised at their point as high as the
upper extremity of the first wound, and even a little higher, in order
that the two strips which have been isolated, and which, by their re-
union, represent  a V reversed,  may  be found at the moment  free
from every adhesion, even at their nasal angle.  Nevertheless,  if at
this point a pedicle should remain, it should be divided by a third cut
of the scissors, and as high up as possible.  Otherwise this  part  of
the wound, being too much rounded, would not  allow of an exact
coaptation without difficulty.
  b.  Second stage.—In order to insert the suture, the operator again
seizes the right side of the solution of continuity with the forefinger
and thumb of the  left hand.  With  the right hand he  directs the
point of a first needle upon the skin, at half a line  above the vermil-
ion  border of the  lip, and  at three  lines external [to the wound];
plunges it in somewhat obliquely from below  upwards, from before
backwards, and from  the  skin towards the mouth, in order that in
traversing the tissues it may come out at the  union of the two ante-
rior  thirds with the  posterior third  of the bleeding surface ;  then
changes its direction ; pushes it  through the other lip, from behind
forwards, from above downwards, and from within outwards, in  such
a manner that  its place of entrance and exit may be as accurately
upon the same line as possible, and that in its whole  track  it  shall
have made a slight curve whose  convexity is directed  slightly back-
wards and upwards.   Its two extremities are immediately encircled
by the simple noose of thread, prepared for this purpose, and which
enables the assistant, who is charged  with this, to stretch in a proper
manner the whole extent of the lip, while the surgeon inserts the se-
cond needle.  The latter needle,  if we want but two of them, should
be inserted at an equal distance from  the first  and the upper angle
of the harelip.  There is no necessity, as with the other needle, of
making it describe a curve  or traverse separately through the  two
halves of the division.  It is therefore pushed in transversely  with
the right hand, while the fingers  of the left hand hold  the two  bor-
ders of the wound in coaptation, taking care nevertheless to make it
enter and come out upon, the skin at about three lines from  the  solu-
tion  of continuity.  In making  use  of fine  pins,  of insect  pins for
example, I have often employed as many as five with advantage.  The
middle part of the double thread  seizes the last  immediately after.
Conducted by the two hands the two  halves of this thread envelope
it afterwards with cross  turns in figure  of 8, are  then brought for-
ward by forming  an  X  under the adjoining  needle, which is sur-
rounded in the same manner, and thus in succession from one to the
other, until the thread is exhausted or the whole wound is concealed
by the figures of 8 and X which it has furnished.   To terminate this 
336           NEW  ELEMENTS  OF OPERATIVE  SURGERY.

operation its two ends  are rolled up, in order to be fastened under
the head or point of the upper needle.
  c  Third stage.—The first thread having become useless is divided
by the surgeon, who then places small protecting rouleaux between the
integuments and the pins, together with the plumasseau of lint, and the
adhesive plaster or bandage, if he  has concluded  to make use of
them.   In this case he applies the middle ofthe bandage on the mid-
dle of the forehead ; carries the two heads under the occiput, crosses
them and changes hands, brings them back below the ears, and upon
the square compresses  which the assistant maintains in  front of  the
masseter muscles ; arrives on the sides of the nose; makes  a slit in
one of the heads of this bandage, opposite to the wound, in  order to
insert the other there, and to cross them with greater facility ; car-
ries them back above the nape in order to cross them a second time,
and to terminate by circular turns around the cranium.  The sling
bandage, which  is to fasten the whole, is  first  applied to the  chin by
its middle portion.  The two lowrer heads are  then raised up in front
of the ears, over the cheek  compresses, and  as high as the vertex,
where they are attached.  The two anterior heads which remain  are
to be carried backwards in order to  cross at the occiput, and to be
brought forward upon the  forehead.  At present,  however, I dis-
pense" with  every kind of bandage  and find I can get along very
well.
  III. Subsequent treatment.—This being done, the patient  is to be
replaced in his bed, where he is to remain at  rest without speaking
or attempting the slightest movement of the jaws, during the space
of three or four-  days.  Broths and very light  soups, weak wine and
water, or any ptisan whatever, constitute his whole diet.  At the  ex-
piration of three days, if everything goes  on well, the upper needle
may  be removed ;  and on  the fourth day that also below.  The
mass of nooses of thread, glued to the skin, and left in place for one
or two  days  longer, enable the cicatrix  to   gradually consolidate.
When the front  part ofthe lip is entirely freed of them, we may sub-
stitute adhesive  plaster, if any apprehension exists that the reunion is
not yet sufficiently firm. About the ninth or tenth day the cure is usu-
ally complete.   There will  be  no impropriety in  beginning on  the
fourth to allow  of soups somewhat more substantial, and to perm:t
the patient to get up and walk.  When the needles  are fine and in
greater number, they may be withdrawn much sooner, beginning on
the day after the operation.  They have not,  to the same extent as
the others, the inconvenience of ulcerating and of mortifying the tis-
sues which surround them.
  IV. Remarks.—Before  commencing the  operation  it is almost
always  necessary to divide the frenum  of  the upper  lip.   It  can
scarcely be dispensed with when we make use of me scissors, except
in cases in which the fissure has but little depth and is  situated out-
side  of the median line.  The  bistoury  forms no exception to  this
remark unless we dispense with giving  it a support.  When using
this latter instrument we place, after the frenum has been divided,  a
card  as high up  as  possible  between the maxillary bone and the  lip.
After having fixed,  by embracing it  at its  lower angle, the  left bor-
der of  the harelip  upon this card, we direct  the point of the instru- 
LIPS.
337
ment, held as a writing pen, to the spot where the incision is to begin,
in order to plunge it in perpendicularly, then gradually to depress its
handle and to cut  with a single stroke the whole extent of the fleshy
border included between the cutting edge of this instrument and the
card which hinders  it from penetrating into the mouth.  In order to
excise the other border the surgeon seizes hold of the lip outside of
the  division, unless he should  be sufficiently practised to do with the
left  hand what he  has donq on the opposite side with the right hand;
carries in every case the point of  the bistoury to the upper angle of
the  first wound, and terminates the incision moreover on this side in
the  same manner as  in the other.   The compress which Lavauguyon
placed between the lip and the gum, in order to prevent the adhesions
of this last, already rejected by Le Dran as useless if not dangerous,
and again proposed  by Heuermann, is no  longer employed  at the
present day by any  person, any more than is the piece of sheet lead
advised for the same purpose by Eckholdt.  Cases where the lip has
been separated  to a great extent  from the maxillary bone are the
only ones wrhich would allow of its being thought of.   De la Faye
and Mursinna, who  recommend that we should commence with  the
highest needle, doubtless forgot that in that event the two labial ex-
tremities of the division incur the risk of not continuing upon  the
same line.   De la Faye himself was obliged afterwards to exsect the
deformed tubercle, which was the result of it in one of his patients.
Without conforming entirely to the precept of Le  Dran, or plunging
the  lower needle into the vermilion border of the lip, we ought how-
ever to recollect that at the distance of more than a line above it
the  reunion  might not be complete and might leave a small notch
below.   If it did not penetrate nearly as far as to the buccal surface
of the organ, the  agglutination would be  effected  only in front.  A
groove or gutter of greater Or less depth would continue behind, and
render the success of the  operation imperfect.  The bleeding  sur-
faces not being  in accurate contact, nor pressed together in a uni-
form manner throughout their whole thickness, would  favor hemor-
rhage.  It is readily perceived, On the other hand, that there would be
a disadvantage in traversing  the two halves of the lip through and
through.  In making the needle describe an arc the object is to depress
the  tissues a little  more upon the median line than  upon the sides, in
order thereby to reproduce as much as possible the tubercle or  small
projection which should naturally exist there.  The  curved or flexi-
ble needles would  be incapable of fulfilling this indication, which has
been particularly  recommended   by A. Dubois (Heurtault, These,
I'aris, 1811.)  Although, as a general rule, we should  excise rather
a little more than less and prolong the wound, as B. Bell has pointed
out, as high up nearly as the nose even when the notch has but little
depth, it will be found sufficient however, by removing the whole red
portion  or cicatrized border, to transform the harelip into a  fresh
wound with loss of substance, of an exact triangular shape, and  the
edges of which present in every part the same degree of thickness.
it would however, perhaps,  be  well to make each border of the
division  concave,  as recommended by M. Husson, the son, (These,
  am    ifans' 1836') should  il appear that the reproduction of the
middle tubercle of the lip would without this expedient  be attended
                              22 
338
NEW ELEMENTS OF OPERATIVE SURGERY.
 with  too  much difficulty.  If the effusion of blood, which at first
 comes out with considerable force from  the coronary artery, should
 not yield to pressure made on the facial artery on the border of the
 jaw, the assistant in order to arrest it would only have to pinch the
 corresponding  half of the lip.  Neither the ligature nor caustic  are
 ever indispensable in these cases.  As soon as the two bleeding bor-
 ders are brought together the hemorrhage ceases ; their want of con-
 tact in one point or another, or some unforeseen accident, could alone
 enable it to continue.   The surgeon moreover would be censurable
 not to pay attention to this subject during the  first hours, especially
 in children.   The  blood, in fact, in place of being expelled outside,
 is swallowed by them in proportion as it oozes into  the mouth, and
 as  Platner says, the hemorrhage in this manner may go on to some
 degree unperceived, or  may even,  as in the examples given by J.
 L.  Petit and  Bichat, proceed to such  extent as to cause death.  Be-
 fore applying the  bandage  it is well to cover the head with a cotton
 cap, drawn down so as to prevent its  being disturbed without some
 difficulty;  also  to  comb out the hair well and to besmear it with
 mercurial  or veratrum  (cevadille)  ointment, in order to prevent the
 necessity of scratching, which young patients could not resist should
 vermin make their  appearance on the  cranium.
  The two compresses, which are placed  in front ofthe ears, possess
 the triple advantage of crowding the  tissues forward, rendering the
 bandage more supportable to the other parts of the face, and prevent-
 ing the movement of the cheeks.  Instead of making a slit in one of the
 heads ofthe bandage, to pass one within the other at the point ofthe
 wound, we may, if necessary, limit ourselves to crossing them care-
 fully below the nose.  The important point is, that they should not
 make any folds,  and that the pressure  which they exert should be as
 uniform as it is gentle.   Louis cut the free extremity of his bandage
 into three  strips of from  fifteen to eighteen inches  long, and also
 made in them three button-holes at nearly two feet beyond, with the
 view of effecting a more uniform and firm crossing opposite to the solu-
 tion of continuity.   Desault, on the contrary, rolled up his only in a
 single head, fixed it by a circular turn round the cranium, and when
 he had brought  it as far as to the labial angle on one side, before
 carrying it back to  the occiput, he strongly drew towards him all the
 soft  parts  of the opposite  side, by means  of the cheek compress,
 which without  that precaution would have incurred the risk of
 being  pushed backwards, contrary to the  intention of the opera-
 tor.   But  the ordinary bandage,  whatever Bichat  may say of
 it, has fewer inconveniences, while  at  the same  time it retains the
 same simplicity  as  that  of Desault.  The sling  bandage generally
 used is a very useful auxiliary in certain cases.  By resisting the
 separation of the jaws, it favors the action of the  suture.   When we
 recollect that in a patient of Garengeot, a burst of laughter was
sufficient to disunite the wound ; and that a young boy operated upon
by De la Faye experienced the same accident in consequence of his
sneezing, from a person  taking a pinch of snuff near him, we may
well be permitted to do all in our power to prevent the  slightest
movement  of the mouth.   In withdrawing  the ordinary needles not
 jntil the expiration of five or six days,  as is recommended by Garen- 
LIPS.
339
 geot, after having removed the threads, we have reason to apprehend
 that we may transform the track  of the wound  into a suppurating
 ulcer, and retard the ultimate cure.  If they are taken away on the
 day after, or  the day after that, as Le Dran assures us he has done
 without any inconvenience, it is almost certain that in the majority
 of cases  the reunion will not  be maintained.   Moreover, not having
 yet had time to excite suppuration  around  them, their extraction then
 would not always  be unattended with difficulty.  In  every  case,
 when we are  about to withdraw them, it is  advisable to grease with
 butter, oil, or cerate,  the  extremity which is to pass  through the
 tissues in coming out, that is to  say, the  point for the needles which
 have  heads, and the blunt extremity for the others.  They must  be
 drawn out gently, and  without shaking, turning them upon their axis
 as soon as any resistance is made, and constantly furnishing to the
 corresponding side  of the lip, while we are removing them, a point
 d'appui with the forefinger of one hand.  A small quantity of lint
 spread with cerate and some lotions of vegeto-mineral water are all
 that is required for the subsequent cure of their punctures.
   B.  Complicated Harelip.—I.  In the double harelip two different
 conditions may be encountered  if the vault of the palate  does not
 participate in  the deformity.  Sometimes the two fissures  are  only-
 separated by  a narrow and slightly projecting tubercle, which must
 oe removed by comprising it  in  the angle of reunion of the two
 excisions, which have been made in order  to raw  the ordinary hare-
 lip.  Sometimes, on the contrary, this tubercle is  too  large to  be
 destroyed without inconvenience-  In such cases, whether it descend
 or not down to a level with the border of the lips, it is better to ex-
 cise its two sides.   We then pass through  it all the needles in the
 first case, and the highest, or two highest only in the second, in order
 to attach it to the middle of the suture.   This method, which is the
 most ancient of all, is at the same time the most simple, prompt and
 certain.  If, however, the middle flap is very wide at its base, we
 may,  after having  embraced  it at its summit with a first needle,
 traverse it with one or two others on each  side, as M. Gensoul does,
 and as I  have done in one instance.  After the cure the cicatrix re-
 sembles a capital Y, and represents also the track of the naso-labial
 columna.   It  is scarcely perceptible to the patient that  he has been
 made to undergo two operations in place of one.   He soon recovers,
 and the consecutive inflammation is neither more nor less active than
 that which follows  simple harelip.   The idea,  therefore,  advanced
 by Louis  or by Heister, of operating on one  side only at first, and
 waiting for its complete cicatrization before proceeding to the other,
 though imitated since by some practitioners, has not been and ought
 not to be adopted.
  H.  The deformity, however, is sometimes much more complicated.
 It  was so extensive in a worker in gold wire, mentioned by Covil-
 lard, (Obs. Iatro-Ckirurg., p. 86, obs. 29, 1639,)  that there  was a
 separation of two  fingers' breadth on each side.   The portion of
 maxillary bone which supports  the  middle flap,  makes, in certain
 cases, a considerable  projection  forward-  Like  Dupuytren, (Gaz.
 Med. de  Paris, 1833, p. 6,) I have in such cases  seen the raised up
lobule continuous with  the end of the nose, and projecting directly 
340
NEW ELEMENTS OF  OPERATIVE SURGERY.
 forward.  Whether  it coexists or  not with a double division of the
 palatine vault, we must attend to  the complication before proceeding
 to  the  rest of the  operation.   Franco (Traite des Hemics, &c,
 chap.  120, 121, p.  460  et  suiv.) at first,  then D. Ludovic, and
 afterwards Chopart and many of the moderns, have proposed to re-
 move it either with the small saw or cutting  pliers, or gouge and
 mallet, after  having isolated the  soft parts from it.  Desault having
 remarked  that this  excision leaves  a void behind the lip, which then
 no longer finds in  this direction a convenient support;  that there
 may, moreover, result from it so considerable a contraction  of the
 superior dental arcade, that it ultimately becomes incased in the infe-
 rior dental arcade during mastication, an example of which he cites;
 proposed  to  preserve  the osseous  projection,  and to limit himself
 to pushing it backwards by applying upon the anterior surface of the
 tubercle which it sustains a moderate degree of pressure during the
 space of two or three weeks. ' This method with him succeeded per-
 fectly in many instances.   Verdier and other  surgeons have since
 obtained the  same advantageous results from it.   We should there-
 fore adopt it in cases of simple deviations of the teeth the most approx-
 imated to the median line.   To extract the projecting teeth after the
 manner of Gerard, and as most modern operators recommend, is an
 extreme remedy, which must not be decided  upon until  after having
 fruitlessly endeavored to restore them to their place, either by com-
 pression or by drawing them back towards the mouth by means of
 metallic wires fixed  to the lateral teeth.  Finally, it rarely happens
 that by means of precautions judiciously applied, and a little patience,
 that we do not succeed, in young subjects  in causing these osseous
 projections to  disappear without destroying anything.   If the teeth,
 or the bone which encloses them,  do not present in front either irre-
 gularities or angles too acute, the operation, nevertheless, may ulti-
 mately succeed. The reunion having been once  effected, the pres-
 sure of the lip upon these parts suffices to give  to them again, at the
 expiration  of a greater or less period of time, their proper direction
 and position.   In certain cases there would be an  advantage also in
 proceeding after the manner of  M. Gensoul,  in a female in whom
 the intermaxillary projection, containing incisor  teeth, had acquired a
 position almost horizontal, and after  the manner of M. Champion
 (communicated by the author) in another case.  M. Gensoul, after
 having  dissected and reversed towards the nose the flap of soft parts,
 and removed  the four incisors, seized the  projecting portion of the
 bone with  a strong pair of forceps, as if for the purpose of breaking
 it off, and succeeded in this manner in giving it a perpendicular direc-
 tion ; then depressed, in the same manner,  the right canine tooth;
 afterwards  excised  the four borders of the double harelip,  inserted
 the  twisted suture into it, and maintained the whole by means of a
 bandage.  This young patient, who was thirteen years of age, was per-
 fectly cured.   The bone thus consolidated, as well as the canine tooth,
'in the new position which had been given to it, and its border, which
 reached to the line  of the molar teeth, became sufficiently firm to
 serve as a point d'appui to the inferior incisors during  mastication.
 M. Champion, who dispensed with extracting the teeth,  nevertheless
 succeeded perfectly well.   In a newly born infant which I operated 
LIPS.
341
upon with M. Rivaille, in 1837, I found that the median point, which
sometimes makes an appendage to the lobule of the nose, had to be
elevated posteriorly, in order to reproduce the nasal subseptum, and
not depressed into the fissure of the lip.
  III. The simple fissure, or  that in the form of a capital Y, in the
maxillary vault, to remedy which  the ancients  supposed nothing
could be done, and which moreover prevented them from attempting
to treat the harelip with which it is so often complicated, presents no
obstacle whatever to the success of the operation, and requires in this
respect, unless there  should be too great a  separation, no special
modification  in the process.
  After the suture, the  borders gradually approximate, and it some-
times, of itself, ultimately disappears completely, as is proved by ex-
amples which are already found in Roonhuysen, Sharp, De la Faye,
Levret, (Art. des Accouch., 3d edit., p, 252,) Quesnay, Richter, B. Bell,
and Lapeyronie.  In the instance noted by Gerard, this fissure, which
was not less  than a finger's breadth in width, closed up at the expira-
tion of two years.  Some few weeks were  sufficient to  effect this in
a patient of Desault, and M. Roux mentions a child  three years of
age  in whom scarcely  any traces of a similar  separation -were ob-
servable at the expiration ofthe fifth month.  The moderate but reg-
ular and constant pressure which the lip, whose continuity has just
been re-established, exercises  upon the whole external surface of the
bones, is the cause of this truly remarkable phenomenon.   Neverthe-
less, if it should be too tardy in being accomplished, either in conse-
quence of the long standing of the disease or because of the very con-
siderable chasm which the two maxillary bones leave between them, I
do not see why we might not endeavor to favor it by means of Com-
pressing bandages either below the cheek-bone and on the skin, after
the recommendation of  Jourdain, (Mai. de la Bouche, t. II., p. 449,)
and of Levret, {Anc. Journ. de  Med.,  t. LXXXIX., p. 543, 40, 772,)
though censured by Richter, but justified by Leblanc, (Precis d'Op-
erat., t. I., p. 25,) or directly upon the  alveolo-dental  arcades them-
selves, as was done by me  in 1825, or by  embracing almost the
entire head with Dent's  bandage, or the ribbon dressing of Terras.
There would be moreover a great number of modes of effecting this;
and the object being once clearly ascertained, each surgeon would be
enabled to devise the most suitable course to effect it.   As in these dif-
ferent cases  the lip has posteriorly but  a very unequal point  d'appui,
and that any extraneous plate kept behind its posterior surface would
have the serious inconvenience of irritating the parts, the bandage
should be arranged in such manner that it would not exercise  any
great degree of pressure in front.  It  is unnecessary to add  that the
needles cannot be withdrawn  with any degree of safety until the
fourth or fifth day.
  IV.  The most proper age for the operation.—Another point still
remains to be examined.  Is it  prudent to operate for harelip in the
first months  of infancy,  or is it better to wait until the age of reason?.
This last opinion, advocated by Dionis and most of the  surgeons of
the 18th century, is almost exclusively adopted at the  present  day
among  us.  The reason given for it is, that the young infant, incapa-
ble of assisting in the precautions that such an operation requires, cries 
342
NEW ELEMENTS OF  OPERATIVE SURGERY.
 and becomes agitated and abandons himself to the most violent move-
 ments as soon as he is attacked.  The mere sight of the surgeon or
 those who have approached him during the cheiloraphy, are sufficient
 to excite his terror and to throw him into a state of emotion.  The
 slight degree of consistence and the little resistance of  the tissues to
 the knife, (secabilite,) occasion the points of sutures to be  torn out upon
 the slightest degree of traction.   The tongue, hab tuated to the efforts
 of suction, constantly presents  itself between the  lips,  and more or
 less interferes with the reunion.   The  rigid diet which  is necessary
 for several days sometimes produces,  says Lassus, an emaciation so
 rapid that, at the expiration of 24 or 48 hours, the cheeks of the infant
 become flabby and all the  portions of the suture greatly relaxed.
 Finally, it is a matter of very little consequence to the patient whether
 he is cured a little sooner or a little later, so long as he  has not yet
 arrived at  the period of talking.  After the third or fourth year, how-
 ever, the difficulty  which he experiences in giving  utterence  to his
 thoughts, the railleries of his little comrades, and the consciousness of
 his own infirmity, naturally create in his mind a desire to be relieved
 of it.   Then too, reasoning  or entreaty or menace, have  already
 begun to have a certain influence over him.  He may then support
 the diet, and the density of the tissues is much greater.
  To these arguments Busch, of Strasbourg, who with Roonhuysen,
 Sharp,  Le  Dran  and Heister, had adopted the opposite opinion, re-
 plies, that we may prevent the cries and movements of the child by
 interrupting his  sleep for several days beforehand,  and  by adminis-
 tering to him preparations of opium a short  time  before operating
 upon him,  in order that he may become calm, and  may sleep imme-
 diately  after ; that a child of three, six  and even ten years of  age, is
 often more difficult  to restrain than if he was still at the breast; that
 the latter, entirely unconscious of fear,  is affected only by real pain or
 wants,  whereas  the  other recoils  even at the suggestion  of the
 slightest degree of suffering, and in reality attaches but  very little
 importance to the results of the operation which is  about to be per-
 formed  upon him ; that if in the first case the tissues are more easily
 divided and lacerated, this is compensated by their being better dis-
 posed to favor the completion of the agglutination with  promptitude
 and certainty.  I will add that when the suture is adjusted, the move-
ments required for the introduction of a  small quantity of milk or broth
 present but a very  slight  obstacle to the cure;  while  up to that pe-
riod  the harelip has scarcely permitted the little patient to become
accustomed to sucking.  The prolonged duration of the disease in-
volves many more  inconveniences than would seem to be imagined.
 It interferes with the development of the intellectual faculties  by the
impediment which it occasions to the pronunciation, and therefore to
 the employment of the ordinary means for education.   When the
separation  of the vault  of  the palate is  complicated  with  it, the
longer  we wait, the  more  the bones become  separated apart, in
 consequence of the want of resistance from without.   In this last
 case, sucking and even deglutition itself may be rendered extremely
difficult, and death  by inanition become  unavoidable;  examples of
which exist.   Moreover, in  opposition to the arguments of Lassus,
 Sabatier, M. Roux, &c, we may oppose the daily practice of the Eng- 
LIPSv
343
lish surgeons, the successful result obtained by Muys, Roonhuysen,
Le  Dran, Bell, Busch and  Bonfils, (Ephem. Med. de  Montpelier,  t.
VI.—Gaz. Med. de Paris, 1832,) on infants only some days or a few
weeks or months old, and the three instances which have  been pub-
lished by M. Delmas, (Ibid.)  It is moreover during the first months,
and as near as possible to the period of the birth of the infant, that I
would operate, unless I should think proper to wait till the termination
of its first year of its infancy.  As soon as the second year arrives, the
patient having become more intractable, does not therefore possess
more reason, and the inconveniences of his position, which are no
longer of a nature to jeopardize his life, allow us to  temporize for three
or four years longer;  thus I would choose the six first months of in-
fancy, or from ten to fifteen years, as the proper time of operating for
harelip; that is to say, I would rather recommend to those who have
not been operated on in the first period, that they should wait for the
second. If, however, the borders of the division were separated so
wide apartas to render it almost impossible to bring them into contact,
it would be useless to attempt the suture.  I have seen it under such
circumstances attempted  without  success in 1822, at the hospital of
St. Louis on an infant about a month  old ;. but it is doubtful if  it
would have succeeded better at a  later period.   Why not commence
in serious  cases by diminishing the intermaxillary fissure by means
of a good compressor, similar to the spring that M.  Pointe, of  Lyon,
(Journ. Univ. des  Scienc. Med., Juillet, 1825,)  in 1825,.  and M.
Maunoir, of Geneva, (Clin, des Hdpit., t. III., p. 48—Gaz. Med., 1.1.,
p. 229,) a little later found to answer so satisfactorily ?  Why not
separate the posterior surface of the two halves of lip from the bones
as far as to the  neighborhood of the cheek, in order afterwards to
bring theni  together  with greater  facility, in the manner as had
already been recommended by Franco, J. Fabricius, Horn,  Nuck,
Roonhysen, &c. ?  In whatever manner the surgeon moreover pro-
ceeds, he should before  taking the instrument  in hand duly reflect,
that notwithstanding all  its simplicity, the operation  for harelip re-
quires skill and dexterity ; that if he does not properly appreciate all
the different stages of the  operation, he will necessarily perform  it
badly, and  to the same  extent that it will confer honor  upon him
when he performs it in the most skilful manner, to the same degree
will it be discreditable to him when he only succeeds imperfectly.

                   § II.—Cancer of the Lips.
  All kinds of cancerous tumors  and degenerescences are neither
more nor less capable of being cured in  the  lips  than elsewhere.
The ablation, when it is  practicable, is almost  the only remedy.  It
is doubtful, except in  a few slight cases, if caustics, which  are still
employed successfully it is said by MM. Fleury, Patrix,  (Emploie
de la Pate  Arsenicale, 1816, in 8vo,) Hellmond, (Bull, de Feruss.,
t. VI.,  No.  74 ; t.  IX., No. 244,) Haime, (Precis Med.  d'Indre et
Loire,  3e trimestre, 1817.) Chelius, (Bull, de Fer., t.  XIV., p. 79,)
Magliari, {Ibid.,  t. XIX., p. 284,) Heyfelder, (Ibid., t. XII., p. 63,)
&c, can be substituted for it, even though we should make use of the
zinc paste eulogized by M. Conquoin, (Bull, de Therapeut., t. VII., p.
243, 375,) or  the Eau Regale or chloruret of gold made trial of by 
 3 ±4           NEW ELEMENTS OF  OPERATIVE SURGERY.

 M. Recamier, (Ibid., t.  VIII., p.  300.)   1  have shown in another
 article what course is to be adopted when the maxillary bone itself
 is affected;  I do not therefore  intend, on the present occasion, to
 treat,.of any other matter than what concerns the soft parts.  When
 the disease occupies only a small extent of the labial border, or that
 it extends more in a vertical than a transverse direction, the opera-
 tion, which is as simple as it is easy, may be  performed in two ways.
   A.  Excision in V.—The first consists in  circumscribing the can-
 cer  by two  oblique incisions in a  triangular flap or sort of V,  the
 base of which should correspond to the free  border of the lip.  The
 patient and  the  assistant are' arranged in the  same manner as  tor
 harelip.   The surgeon embraces the morbid  tubercle with the thumb
 and forefinger of one  hand; while with  a good  pair of scissors or
 straight  bistoury in the other, he forms his  flap, taking care  to cut
 into the sound parts and from the buccal opening to the point of the
 V. which he proposes to excise.  The excision being now completed,
 nothing remains  but to approximate the  borders of the wound pro-
 duced, by it, to maintain it  united  by  means ofthe suture, and  to
 treat it in the manner of harelip.   This method, the only one which
 has been for a long time  followed, is applicable  to the upper as well
 as to the  lower lip, to its middle portion as  well  as to the angles  of
 the mouth, and ought  to  be preferred so long as it does not become
 necessary that there should be any  considerable loss of substance, or
 that we should destroy more than half, for  example, of one of the
 lips. "
  B. Semilunar excision.—The other mode is  still more simple in
 appearance.   It resolves itself into a simple semilunar incision, which
 includes  in its concavity all the diseased tissues, is made with the
 bistoury, or the scissors curved flatwise, and  leaves as its result only
 a notch of greater or less depth.   It is adapted only to the lower lip
 and when the disease extends less in  a vertical  than  a transverse
 direction.   Some modern surgeons have erroneously  claimed the
 first suggestion of this process.  It was in use  at the time of Le Dran,
 and Louis mentions a patient who  had been operated upon by this
 mode,  and in whom it was  said the lip had  grown out again, (etait
 repoussee.)  Camper (Prix de I'Acad. de Chir.,i.lY.,o. 585,1819,)
 also  gave it  out as his  invention.  We  find it  even  in Fabricius
 ab Aquapendente, who remarks very justly that we may in this man-
 ner remove a large portion of the lip, and that the deformity which
 results from it is infinitely less than one would be induced to suppose.
 However this may  be,  it was almost entirely  forgotten until M.
 Richerand, A. Dubois,  and Dupuytren revived it  into credit among
 us.   Two circumstances  combine, after excision  performed in this
 manner,  to favor the  elevation of  the wound  towards  the dental
 arcade.  These are  the pressure outwards  upon the sound tissues
 produced  by the development of cancer, and secondly the gradual
 tractions which, at a subsequent period, the  cicatrix exercises upon
the integuments of the chin or even upon  the upper part of the neck.
It has  been seen, in fact, that the  surrounding  soft parts, in per-
sons who  had  in this manner lost  the lip from one  commissure to the
other, and in  the whole extent of its breadth, became elevated and
sufficiently convergent towards  the mouth to reach as  far as to the 
LIPS.
345
root of the teeth and even still higher.   In the most fortunate cases
the mucous membrane of the arch of the gums becomes united to
the corresponding portion of the wound, and yielding to the cuta-
neous tissue which tends to draw it outwardly is reversed forwards,
as if in order to furnish to the border of the new lip the vermilion
pellicle which naturally belongs to it.
  C.  Hem.—This, process however is not as good as the first; when
using this the cure is always less  prompt  and the deformity always
more perceptible.  Consequently  it should be reserved_  for excep-
tional cases.  An improvement which  might be  made  in  it,  and
which M. Serre has already employed in practice, would consist in
immediately uniting the mucous border with the cutaneous border of
the wound, or as I have successfully done, bring it down  in form of
a hem by means  of the simple or whip  suture.   We should in this
manner procure in three  days, a cicatrix more pliant and neat than
that which we could get from the ancient mode in a month.
  D. Under the most  unfortunate circumstances, a greater or less
extent of the jaw remains exposed after  a removal of  cancer of the
lip.   Speech  then becomes imperfect,  and the  patient  constantly
losing his saliva, is placed under  the necessity of wearing a metal-
lic apparatus to the chin furnished  with a sponge.   Fortunately how-
ever at  the  present day, we are  in  possession  of other  modes of
avoiding this inconvenience. (See Cheiloplasty.)  It is important how-
ever, to remove in good season and freely, cancerous tumors of the
lips; otherwise  they repullulate in the neighborhood and below the
jaw  with  frightful rapidity.  A  peasant of a robust appearance, in
whom I removed one which  did not exceed in size a small nut, died
at the expiration of eight days with hundreds of cerebriform granules
in the liver!

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

  The lumps, and especially the species of red-colored' ridge which
many persons have on the internal surface of the free  border of the
lips, is a deformity which  has been hitherto paid very little attention
to in surgery.  They  are sometimes seen in the upper  lip, which
is most predisposed, to them, sometimes upon  the lower lip, and oc-
casionally  in  both lips at once.   In  certain cases, under the form
of one or many tubercles that are scarcely perceptible, at other times
under the  aspect of a transverse, projection, which strongly pushes
the lip towards the skin as soon as the patient attempts to laugh or
speak.  Though it is usually a congenital defect, if sometimes occurs
accidentally, especially in persons who play the horn or are obliged
to cry with great force.   Their presence has nothing dangerous  and
involves no other inconvenience than that of rendering the counte-
nance somewhat less  agreeable.   Also, most of those who are af-
fected with them, have them all their lives without ever thinking of
getting rid of them.   Nevertheless in certain classes of persons they
become embarrassing,  as in hunters, musicians  and orators for exam-
ple.  Instances of this kind are seen in the two patients  who were
operated on in 1829, by M. Roux  and Boyer.  They are, however,
cured with great facility.   They are  to  be excised either with the 
346          NEW  ELEMENTS OF OPERATIVE SURGERY.

scissors curved on the flat side or with the ordinary bistoury.  While
an assistant stretches the lip at its two angles, and exposes its inner
surface to view, the surgeon seizes hold of as much ofthe vegetation
as possible by means of a good  pair of forceps placed transversely,
raises  it up a little, and afterwards proceeds as in the excision of the
bourrelet of the conjunctiva in ectropion.   Numerous cases from diffe-
rent authors, or those mentioned in the lessons of Dupuytren, show that
at the end of a week or two the cure is complete, and that the deform-
ity which has been thus treated, has entirely disappeared.  Neverthe-
less, as there are in this part under the elongated tissues numerous hy-
pertrophied mucous glands, which glands and follicles it is necessary
to remove, and as I have seen the wound in certain persons take on a
bad aspect, and require nearly three weeks or a month to cicatrize, I
have adopted another method.  Having seized the mucous fold with
a pair  of forceps, I pass through its  root or base near the muscular
tissue,  three or four threads which I leave there.  I then immediately
excise  the  bourrelet near these threads, after which I have nothing
more to do than to knot the  points of the suture, which may be re-
moved on the second or third day.   The same operation would be
equally applicable without doubt, to the eversion of the lips produced
from any other  cause,  as for  example,  by bridles  or  ancient cica-
trices,  so true it is that this  condition of the mouth has the greatest
degree of  analogy to  ectropion  or eversion of the eyelids, and that
it is susceptible of  the same surgical remedies.

                §  IV.—Hypertrophy of the Lips.

   The thickening of the upper lip, which may be considered almost a
natural result in scrofulous  subjects, may exist  to  such  extent as
to constitute a serious disease if not a disagreeable deformity.   In
certain cases the  totality of the lip  acquires so  great a degree of
development that its  posterior surface ultimately becomes reversed
downwards and its free border directly forwards.   So long as there
is a morbid action going on and that the  hypertrophy is not posi-
tively established and not reduced to  the condition of a simple defect
of conformation, we should  confine  ourselves to internal or external
treatment and to the proper general or topical remedies.  But when
all the resources indicated  by a sound  therapeutic have been em-
ployed in vain, and that the affection has  become purely local, there
is no other than the cutting  instrument which can destroy it, Unless
we should  be disposed to  make trial of compression and caustics.
The operation which is proposed for the relief of the patient was sug-
gested, in 1826, by M. Paillard,  (Journ. de Progres, t. III., p. 213,)
who performed it in  three  instances with  entire success, and who
gives three other examples of a fortunate issue obtained in the same
manner, by  MM. Marjolin and Belmas.  It consists in un-doubling the
lip and  reducing it to its normal dimensions by excising a layer
from its tissue of greater or less degree of thickness.  The assistant
charged with supporting and holding the head of the  patient back
against his  chest, is  also made to stretch the part and cause it to pro-
ject outwards by seizing it at the left commissure with the forefinger
and thumb of the corresponding hand.  The operator placed in fron 
LIPS.
347
and a little to the right seizes hold of the other commissure, then
with a bistoury in his right hand makes, from one labial angle to the
other, and perpendicularly on the border of the diseased lip itself, an
incision which is slightly somewhat more approximated to the mucous
membrane at its extremities  than at its middle; in this manner cir-
cumscribes every thing which  it is  his intention to  remove;  imme-
diately embraces this flap with the forceps and dissects it  rapidly
with the same bistoury from the free to the adherent  border, and
from the left to the right extremity of  the part, down to a level with
the sound tissues; endeavors to give it all the breadth and thickness
required, while taking care to approximate it gradually to the mucous
coat before terminating the  excision near the  alveolo-labial groove
with the last cut of the bistoury or a good  pair of scissors.  The
wound which results from it sometimes bleeds copiously, though  in
general  it yields with facility.   No kind  of dressing is necessary,
inasmuch as the traumatic surface, from being continually lubricated
by the saliva, becomes rapidly cleansed.  In cicatrizing it reacts upon
the integuments, gradually brings them forward, or even tends to
incline them downwards, and in cases of complete  cure, the lip not
only returns to its natural thickness, but also to its normal direction.

                    §  V.— Various  Tumors.

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

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

  Boyer, who says that he never saw an instance of imperforation of
the mouth, was doubtless unaware of  the fact, that Haller had men-
tioned several instances in  the human species and in animals ; that
Monro had noticed this imperforation in young pigs, and that Verdier
(Abrege dAnat., t. II., p. 124,) states he had seen an instance in a dog.
This last author also relates, on the authority of Gregoire, an instance
of a newly born infant who  had neither mouth nor nostrils, though it
was  born alive.   Schenckius,  (Planque, Bibl. de Med., t.  I., p. 305,
in 12, art. Accouch.,) had already mentioned  that he had met with 
348          NEW ELEMENTS  OF OPERATIVE SURGERY.
 infants in whom he was  obliged to lay open the  mouth, and Des-
 genettes (Gaz. Salut., 1792, p. 95,)  states that he had seen a seven
 months' foetus in which  the mouth was imperforate.  It  is shewn,
 therefore, by these facts, that imperforation of the mouth may be
 congenital.  Other observations prove  that it may also take place
 after birth. G. Horstius (Turner, Mai. de la Peau., 1.1., p. 120.) relates
 that  in a miller, the lips,  after having been excoriated, became glued
 together.  A small hole which  had  previously allowed of the intro-
 duction of aliment into the mouth,  by means of a  funnel, itself ulti-
 mately closed up, so that the poor patient starved to death.  Though
 the entire obliteration of the mouth may be infrequent, it  is not so
 with simple contraction, or coarctation of the lips.   This contraction,
 which, like imperforation, may be either acquired or congenital, may
 result, moreover, from  various  descriptions  of diseases.  A newly
 born infant mentioned by Demarque, (Op. cit., pp. 449, 450,) had the
 opening of the mouth so  small that it was scarcely  possible to intro-
 duce a pea  into it.   Another  individual mentioned by the same
 practitioner,  had the mouth contracted to the extent of a finger's
 breadth on  each side, in consequence  of small pox.   Demarque
 (Traite des Bandages, p.  447,) mentions also a woman and child  in
 whom the opening of the mouth was in this manner almost entirely
 closed,  in consequence  of burns.  When the imperforation is com-
 plete, as in the patient of Buchner, (Planque, Bibl. de Med., t. XVI.,
 p. 166,) or in that of Percy, (Memoir-e sur les Ciseaux, §  5, p. 70.)
 we  must  in the  first  place  incise  in the direction of the natural
 opening, and upon the part of the cicatrix which appears to be the
 thinnest.   As soon as  the  bistoury has  passed into the mouth, it is
 well to  replace it by the scissors, one of  the blades of which is to be
 inserted through  the  small opening which has just  been made.
 Percy succeeded in this manner in the young Count  D'Ambly.  The
 operation was also followed with entire success in the child mentioned
 by Buchner.   In those cases, on the contrary, where an aperture still
 remains, the  operation  is  manifestly more easy, since it is always
 then practicable to  follow with the eye as far as into the mouth, the
 instruments that we  make use of.   I will not  recur again to the
 methods which present the best chances of success in such cases, and
 which I have described in  the  chapter  on anaplasty.  I will refer
 only in  proof of the'difficulty of curing coarctation,  or imperforation
 of the lips by simple incisions, to the  history of the miller of Horstius.
 The lips of this patient, in fact, after having  been  separated by the
instrument, obstinately reunited a first, second, and even a third time.
We  also  find in a case  of M. Bondi,  (Bull, de  Fer., t. II., p. 6!),)
that the incision made in  order to  destroy a coarctation of the lips,
did not  prevent the infirmity from being re-established to so great a
degree  in  fact, that -the opening of the  mouth was reduced to the
diameter of a pin's head, and that death succeeded at the termination
of a few days, during a paroxysm of asthma. . It is, however, to be
remarked, that in the  patients mentioned by Demarque, this opera-
tion appears,  to have fully succeeded, and to  have  been unattended
even with any difficulty.  (See Cheiloplasty.) 
LIPS.
349
          § VII.—Too Large an Opening of the Mouth.
  In the Germanic Ephemerides, (Bull, de Feruss., t. II., p. 69,) we
find the history of a child in whom the mouth extended as far [nearly]
as the ears.  Having operated  upon one side, an interval of some
weeks was left before doing  the same for the other, in consequence
of the first operation having  produced an alarming hemorrhage.   I
do not know to what  extent  it is  possible for the  mouth to reach
up  to the ears.   I have, however, myself  seen  an old man  in
whom the mouth had been enlarged as far as the anterior border of
the masseter  muscles.   This man had entered the hospital  of La
Charite for a double cancer, which obliged me to remove almost the
entire length of the free  border and the whole of the commissures of
the lips as far as to the cheek-bone.  The union of the parts had been
effected by means of numerous points of twisted  suture.  But  in
consequence of an  erysipelas, accompanied  with intense delirium,
which supervened on the third day, the patient, in separating his jaws
with  force, speedily destroyed  and tore  out the suture, together
with the first agglutinations, which had already begun to take place.
As the general  affection  continued nearly fifteen days,  the lips of
each wound cicatrized separately.   In consequence of which there
resulted a hideous deformity, which prevented the unfortunate old
man from  entirely closing his  mouth, or from being enabled to retain
his saliva effectually, or from performing mastication in. a proper
manner.   It might have been practicable or even easy, by abrading
the borders  of these enormous prolongations  of the mouth, to unite
them  by suture, and  in  this manner destroy the deformity; but the
patient, satisfied with the cure  of his cancer, and  weary of his
sojourn in the hospital,  was  desirous  of returning home, and  posi-
tively refused every proposition  for  another  operation.  As  to the
remark, that the mouth is either  too large  or  too small when there
are no traces  of cicatrix or degenerescence upon'the free border of
the lips, this can scarcely be  conceived to  be  possible, inasmuch as
the natural dimensions of this  opening have not and cannot have any
thing  absolute about them; unless we  should admit with G. D. Tho-
losin,  (Gaz. Salut., 1766,) "that  the mouth (in every person) should
be limited to the exact length of the first bone of the thumb."  Opera-
tions,  therefore, cannot be required  except for  extraordinary cases of
narrowness or enlargement, which  are produced by certain diseases.

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

  Temporo-maxillary arthropathy,  like all those diseases which may
be developed around or  in the neighborhood of the condyles of the
jaw, are capable of producing there an induration or stiffness to so
great  an  extent, that the separation of the dental  arcades will be
thereby more or less impeded. Certain chronic inflammations of the
windpipe, internal phlegmasias at the bottom of the mouth, those espe-
cially which take place in the neighborhood ofthe last molar tooth, may
also sometimes give rise to the same infirmity.   The patient in such
cases cannot open his mouth.   Various methods of cure are then re-
sorted to. 
350
NEW ELEMENTS OF OPERATIVE  SURGERY.
   A. M. Ghidella, and  some  other  practitioners,  who  assert that
 they have succeeded by making numerous  incisions  upon all  the
 indurated  ligamentous or  cellular plates, could only  have encoun-
 tered those anchyloses,  which  are  produced  by retraction of the
 fibrous tissues.   In  my  own opinion, it would not be prudent to
 recur  to  this process,  unless  the  fibro-muscular bridles  should
 be distinctly perceptible through the integuments.  Tenon, (Mem.
 sur VAnat. et la Chir., t. II., p. 261—262.)  who  saw a case of
 this kind, resulting from a deep-seated  disease of the jaw, and af-
 terwards another, which admitted only of-a separation of some lines
 in extent, had recourse to the employment of wedges of cork.  The
 defect of conformation was congenital; after having divided one of
 the labial commissures, it was found that a cicatrix  formed and  re-
 duced the opening of the jaws to two lines.  Tenon insinuated be-
 tween the teeth  two wedges of cork, the thickness or number of
 which were gradually increased, until the mouth could be opened to
 the extent of nine lines in place of two.
   B. Dilating wedge.—This idea, of placing a wedge between the
 dental arcades, has been improved upon by M. Toirac, (Mem. sur la
 derniere Dent Molaire, p. 13,1828,) who has obtained really successful
 results from it in  different patients whom I have seen, and  who had
 been, during many months, unable to  separate their teeth beyond a
 few lines.  The remedy moreover is simple and of easy application.
 We begin by a thin and  very elongated  wedge, which is  to be  in-
 serted between the two dental arcades, nearly as far as to the coronoid
 process ; the size of this wedge is  to be daily increased,  until the
 movements of the mouth have regained their  extent and liberty.  It
 is obvious, however, that the presence of a cork or wooden wedge
 between the dental arcades can  scarcely present any hope of suc-
 cess except in cases of immobility unaccompanied  with unnatural
 adhesions of the gums with the inner surface of the cheeks or with
 actual anchylosis  of the articulation.
   C. The wedge and incisions.—M. Mott having met with many ob-
 stinate and complicated cases, has devised an  instrument, which acts
 at once in the manner of a  wedge, lever,  and  saw.   This instrument
 which might, if necessary, be made to divide the coronoid process or
 the root of the neck of the  condyle of the jaw, possesses the power,
 as a wedge and  a lever, of gradually widening, and  with a great
 degree  of force, the two maxillary bones.   The surgeon  whom I
 have just cited, and  who performed  this operation successfully on
 seven different patients out of the eight that  came  under  his treat-
 ment, was  obliged in some cases to divide  the commissure of the
 lips largely in the manner of Tenon, and to leave each  border of the
 wound to cicatrize separately, not reuniting them until after having
 completely re-established the movement of the jaws.  This is  an
 operation, however, which, notwithstanding what has been said of it
 on the authority of M. Mighels (Gaz. Med., 1834, No. 26,) and of  M.
 Mott, (Journ. de Progres, t. XIII., p.  925,) and what the author has
recently written to me concerning it, is  still  too imperfectly under-
stood among us to enable me to  affix to it  its just value.  [See chapter
on this subject by V. Mott, infra.  T.] 
CHEEKS.
351
            § IX.— Unnatural adhesion of the Cheeks.

   It frequently happens in consequence of mercurial, carbunculous,
 or other inflammations, and as the result of any other kind of ulcer
 which may occur in the mouth, that the inner surface of the cheeks
 becomes agglutinated to the outer surface of the jaws or gums.  From
 whence happens  a deformity analagous to that I have just described,
 that is to say, an  impediment  to the separation of the jaws and the
 movements of the mouth.   These  adhesions  sometimes make such
 effectual resistance to the movement of the jaw, that it is impossible
 for patients to open their mouth. Numerous examples of this are re-
 lated in scientific works, and I have myself met with some of them.
 In appearance nothing is so easy as to remedy this disease; in re-
 ality nothing, however, is more difficult.
   A. Decollement.—The first idea which suggests itself is to  attack
 and  destroy, either with  the scissors  or bistoury,  the  bridles  and
 cellular attachments  which  constitute  the  abnormal  adhesion,  and
 without interfering with the continuity of the tissue  proper of the
 cheek.   But in reflecting on this point we soon perceive that  this
 dissection, which  as an operative process presents no difficulty, and
 in fact momentarily destroys the deformity, can only effect a radical
 cure in exceptional cases.  What prevents  the  outer  side of the
 gums and inner surface of the  cheeks from agglutinating together in
 the natural state, is the existence  of the mucous membrane which
 lines both of them.  Now this  mucous  membrane, which has  disap-
 peared in the cases of adhesion, cannot  be reproduced by the dissec-
 tion which I have just mentioned.   It must result, therefore, that the
 incisions which have been made will, in  cicatrizing, reproduce the de-
 formity. In even admitting that the entire traumatic surface may have
 cicatrized upon the cheek, independently of the gums, it could only do
 so at least by the  production of an inodular  callous  and inextensible
 tissue, which in itself would be calculated  to interfere  excessively
 with the separation of  the jaws.   This difficulty is  met with  in all
 the other modes of operation which have been proposed as a remedy
 for the  closure of the jaws.  It is important  therefore that we should
 not deceive ourselves on  the subject of the apparent simplicity of
 this  deformity, any more  than we  should upon the efficacy of the
 means which we  may have it in our power to  oppose to it.
  B. However this may be, there are  many processes to  be  made
 trial of in  such  cases.   The: most simple  is that  which I have
 attributed to M.  Toirac in the preceding paragraph, and which con-
 sists  in forcibly separating the jaws by means of wedges successively
 augmented  in  size, and introduced to  a great depth into  the most
 remote part of the dental arcades.   This means, when there is no
 rigidity in  the  tissues or when the adhesions are recent and of but
 little extent, will  suffice if continued for the space of fifteen days or
 a month, giving a respite of some hours to the patient from time to
 time, and resumed afterwards from week to  week.
  C. The process of M. Mott,  that is to say, the introduction of  a
wedge performing the office of a saw and lever, in such manner as
to allow of  the division of  the bone  if necessary, would become
requisite should the jaw be anchylosed  or surrounded with inodular 
352          NEW ELEMENTS OF OPERATIVE SURGERY.

tissue endowed with a great degree of resistance.  The instrument
of the surgeon of  New York would also have its advantages as an
auxiliary means, when it becomes indispensable to destroy the inter-
nal adhesions ofthe cheek or lip, with  the cutting instrument.  This
last method comprises three principal processes.
   D.  Simple dissection of the adhesions.—The most rational method
apparently, would consist in destroying  by means of a straight or
blunt-pointed bistoury, glided upon the finger or a canulated sound,
or  even without  a director, from  above downwards between the
cheek  and lower jaw, and then from  below upwards between the
cheek  and upper  jaw, all the abnormal adhesions to a sufficient
extent,  and in such manner as not to arrest the knife until after
having reached as far as the pliant and  perfectly sound tissues of this
region.   In this manner the  operation  is easy and prompt, and the
immediate result of it as satisfactory as possible.  The patient is to
be  seated upon a chair.  The operator, separating one  of the com-
missures with the forefinger and thumb of one hand or a good forceps,
directs his bistoury with the other  between the two dental arcades
as far as to the neighborhood of the coronoid process.  Turning then
the edge of his instrument towards  the outer surface of the teeth, he
divides with free strokes and in a direction parallel to the plane of
each jaw, all the bridles and unnatural  tissues which attach them to
the cheek.   Should the teeth be so approximated as to prevent the
instrument from gliding between them,  he should make use of a
canulated sound in order to conduct  it outside  of  and along the
alveolo-zygomatic  (alveolo-jugale) groove.  It would even, if neces-
sary, be practicable to plunge it into the tissues from before back-
wards, if there should be no groove to  admit of a free passage to
the director.   Having reached this point we have now to  struggle
against the tendency of the wound  to reagglutinate.   To attain the
object in these cases we have need of two kinds of resources; in the
first place we must procure, by means of  wedges or levers, a suf-
ficient  separation of the jaws, and it  is for this  purpose  that the
wedges and levers of MM. Toirac and Mott are indicated.  If in
fact we did not commence by giving a great degree  of freedom to
the movements of the  lower jaw, new adhesions and an almost insur-
mountable contraction of the tissues wTould not fail  to take place.
On the other hand, we cannot prevent the  inner side  of cheek, now
transformed into a traumatic surface, from becoming reunited to the
outer side of the gums, except by keeping some foreign body between
them.  Tenon, in  the  three cases which  I have quoted from him,
and which relate rather to the adhesions under consideration than to
a false anchylosis, appears to have succeeded by means  of pieces of
cork fastened by the aid of catgut against the outer side of the teeth.
It is to be confessed, however, that we rarely succeed in  this manner.
  A young girl aged  sixteen years, who, in  consequence of a car-
bunculous (charbonneuse) affection of the mouth, had had from her
birth a complete adhesion of the cheek and the right half of the lips
to the dental arcades, and who was  admitted into the Hospital of La
Charite in the month of January, 1836, had already undergone two
operations of this kind without any benefit.   I in my turn destroyed
all the abnormal adhesions, and I succeeded in procuring a separa- 
CHEEKS.                         353
tion of fifteen lines between the jaws in the  space of a week.   A
piece of sheet  lead, protected by cork, and  kept permanently be-
tween the teeth and the cheek, appeared to me calculated  to pre-
vent any new  adhesion.  After the  cure, however, there resulted
only a slight amelioration, and a separation of only from three to four
lines.  It is necessary however to add, that the young girl evinced
an extremely intractable disposition, and  that in consequence of a
confluent small-pox, with which she was attacked at the expiration
of a month, I was compelled to remove every  portion of the dressing
or foreign bodies from the interior pf the mouth before the perfect
cicatrization  of the wounds.   A young  man who had similar adhe-
sions, which M. Serre had previously destroyed by a crucial incision
in the cheek, and which I treated in the  same manner in 1837, was
not less unfortunate.  After  having carefully dissected and  isolated
the inner surface of the cheek throughout its whole extent, and after
having sufficiently widened the jaws by means of levers and wedges,
I inserted in  his mouth a broad piece  of  sheet lead, upon which I in-
tended that the wounds  should cicatrize uniformly in every part  of
them.  Every thing at first went on as well  as I could wish, and at
the expiration  of five weeks, I considered my patient  cured.  The
dispensing however with the use of the plate of lead during the space
of two days, caused the separation of the jaws to be diminished one
half, and nothing afterwards could prevent the inodular tissue from
reproducing  the deformity to as great a degree nearly as before.
  E. Like M.  Mott, I also was desirous in one case to  ascertain if I
could succeed  better by laying open the whole cheek from the  com-
missure as far  as to the masseter  muscle, and afterwards  dissecting
  ich of the  borders of the  incision,  and  leaving them to cicatrize
  parately in such manner as to reunite them at a later period, as we
do in harelip.  The cheek being thus separated, no  longer interferes
with the movements of the  jaw, which can afterwards be  relaxed
and widened by the proper mechanical means.  Having once ob-
tained all that we desire in this respect, we reunite the borders of the
artificial division.  As the  internal surface of each of the flaps has
had time to cicatrize, we need have no farther apprehension that it
will reagglutinate  to  the  outer side of the  gums.   This method,
which had failed in  one of the patients of Tenon, and which suc-
ceeded no better with me, nevertheless procured some successful re-
sults writh M.  Mott.   It would therefore  be  a process to be  made
trial of as well' as that of simple decoUements, which, united with
cauterizations  by nitrate of silver, obtained a remarkable cure in the
hands of M. Gensoul,  (Journ. des Hop.  de Lyon, t. I., p. 494.)  I be-
lieve moreover, that by means of determination on the part of the sur-
geon, and docility on the part of the patient, we could very frequent-
ly obtain cures by both these processes;  but I repeat that success
here is infinitely less difficult to be accomplished than would at first
view be imagined.  We should be wrong moreover not to anticipate
a swelling and sufficiently marked inflammation of the cheek and a
large portion of the  face, when,  after such separations, we decide
upon placing any foreign body between the cheek and the teeth with
the view of preventing all reagglutination.  Perhaps it would  be
better, should there be any  inodular productions implicating the skin,
                                 23 
354
NEW ELEMENTS OF  OPERATIVE SURGERY.
to remove them, and immediately repair the loss of substance by means
of genoplasty, in taking a large flap in the neighborhood, as was done
successfully by M. Mott.   (American  Journal of Medical Sciences,
Nov. 1831.)
                Article V.—Salivary Fistulas.

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

               §  I.—Fistulas of the Parotid Gland.

  A. Cauterization, either with a hot  iron or by means of chemical
substances,  as employed by Galen, on a patient in whom the fistula,
the result of a critical  inflammation of the parotid glands (suite de
parotides  critiques), was  situated under the  ear; and as employed
by Pare, the two Fabricii, Heuermann,  Boyer, Langenbeck and a
multitude of others, succeeds very well for fistulas  of the  parotid
itself, that is  to  say,  those  which derive  their  origin  from some
branches and  not from  the principal trunk of the excretory ducts of
the  saliva.   Galen  had recourse to  catheretic plasters (emplatres
catheretiques), Pare to  aqua fortis, Diemerbroeck and Jourdain to the
actual cautery, M. Higginbottom (Bull, de Fer., t. XXVI., p. 95), to
sulphuric  acid, and  Boyer to nitrate of  silver.  The lapis infernalis
deserves the preference, because it produces a drier eschar and one
which is more adherent than any other.  Nevertheless if the ulcera-
tion  should  be narrow and very deep,  a cautery of the red oxide of
lead might be  substituted for the nitrate of silver, as was practised by
me with success, in November, 1831, at La Pitie, in a man who had a
parotid fistula produced by the opening of an abscess behind the bor-
der ofthe jaw.
  B. Blisters. Styptics and astringents, which were equally eulogized
by  some  practitioners, Becket  among others, being less efficacious
than caustics, have been long since abandoned.   I have cured t o
patients, who  had been affected several months with parotid fistulas,
by means of repeated temporary blisterings upon  the diseased parts.
  C. Compression,  made trial of successfully by  Beaupre, Le Dran
and Ruffin, who invented a machine for this purpose, advocated also
by Imbert, Jourdain  and Richter, almost always answers the purpose
when the patient can support it, and when the state of the parts per-
mit  its employment.  For that purpose we apply lint or graduated
compresses upon the  fistulous  orifice, after which, by means of a
fronde or chevestre bandage, or  by means of turns of the ordinary
bandage  properly arranged, we  produce  pressure  on this point in
such manner  as to keep the walls of the diseased  duct in contact.
   D. Irritating  injections,  as  proposed by Louis,  have for their
object to inflame the fistulous passage and to bring about its agglu-
tination.  They may be made  with sweetened barley-water, decoc-
tion of French roses in red wine, alcohol itself or any other exciting
liquid, according as  the tissues, whose adhesive inflammation we wish
to  produce, are  more or less  irritable.  It  is a remedy however
which comes  only in the third class, because it exposes to more acci- 
SALIVARY  FISTULAS.
355
dents and is  not always successful, but one which, in some cases of
obstinate fistula, is not to be despised.
  E. If none of all  these succeed, we may make  trial of excision,
comprising the  ulcer in an elliptical wound, and afterwards reuniting
by means of  adhesive plasters or the twisted suture.  If the disease
still resist, we have no other recourse than extirpation of the gland ;
but this remedy, ascribed to Pouteau,  by M. Hedelhofer, has  never,
I believe, been carried jnto execution.  It would be, in fact, a case in
which the remedy is worse than the disease ;  so much the more so as
these fistulas  sometimes finally disappear spontaneously, examples of
which are given by Nuck, Ferrand, A. Dubois and M. Richerand.

               § II.—Fistulas  of Stenon's Duct.

  These different  modes of treatment, though  less efficacious when
applied to fistulas of Stenon's duct, have nevertheless, in some cases,
effected unquestionable cures.
  A. Cauterization, for example, alone or associated with compres-
sion, obtained for  Louis an unexpected cure, in a  patient in whom
the fistula had  existed for the space of nineteen years, and who had
already been.operated on several times without any benefit.  Mun-
nicks, (Praxeos Chirurg., lib. II.,) Lentilius,  Lange, (Bibl.  Chir. du
Nord, p.  135,)  and Mosque. (Ancien Journ. de Med., t. LXXL,  p.
506,) have or had also succeeded in the  same way.  Ferrand, Ne-
del, Mursinna, Imbert, Jourdain and M. Langenbeck have been no less
fortunate.  But M. Gendron (Annates de Cercle Med. de Paris,  t. I.,
pp. 55, 92) has since maintained  that in all the cases of this descrip-
tion the fistulas were in the gland and  not in  the salivary duct.
  B. Compression without caustic and as an exclusive remedy, has
also appeared to  have been efficacious.  Maisonneuve, who was the
first to recommend it in such cases, established  it between the fistula
and the gland, with the rational  object of closing up the passage to
the saliva and enabling the wound to cicatrize.  His patient, who had
received a sabre cut upon the cheek, was radically cured at the ex-
piration of 20 days.   Louis, and with him most of the moderns, have
considered that by acting in this way, we almost necessarily produce
inflammation of the parotid, and that consequently this process cannot
but be dangerous.  Desault hoped to dissipate all these apprehensions
by directing the compression upon the gland itself, which he proposed
to atrophize.  Whether the atrophy had really taken place as Desault
asserts, (Gavard, Splanchnol., p.  208,)  or that the parotid continued
to perform its  functions afterwards, as Boyer seems to think,  cer-
tain it is that the fistula speedily cicatrized and that the patient suf-
fered no return of it.  However this may be,  there is in the treat-
ment of these authors, two distinctions which it is important not to
confound; that of Maisonneuve,  who proposes  only to interrupt the
course of the  saliva temporarily, and that of Desault, (Vedrine, Journ.
de Desault, t. IV., p. 294,) who  prefers  to dry it up at its source.,
Without agreeing with Heuermann, that the parotid, under such cir-
cumstances, will always suppurate and ulcerate, and pass  into the
state of scirrhus or cancer, I can nevertheless not admit the innocu-
ousness of a remedy like this, which should in  my opinion be reserved 
356
NEW ELEMENTS OF  OPERATIVE SURGERY.
 for  patients who have a dread  of every other kind of operation,
 or have not been cured by them.   Trecourt (Mem. de Chir., p. 75,
 1769,) had recourse to it by applying it upon the ulcer-like Courtavoz
 because the seton was not admissible.
   C. Ligature upon the duct.—Zang, who shares in part the opinion
 of Maisonneuve and Desault, resorts  to  the process of Viborg,  to
 atrophize the parotid.  In place of compression, which is always un-
 certain, this surgeon, inasmuch as the object is to prevent the  saliva
 from passing, proposes to apply a ligature on the duct  of Stenon
 outside of the fistula.   Quite a number of experiments upon animals
 towards the close of the last century, demonstrated to him that this
 ligature is unattended with danger.   In order to apply it, it would be
 necessary to make a vertical incision upon the anterior border of the
 masseter, immediately below the zygomatic arch.  The canal  being
 once laid bare, is to be isolated from the other tissues, especially from
 the branch of the facial nerve which accompanies it on its upper side.
 Nothing afterwards is easier than to surround it with a ligature, and
 obliterate it.  There is no doubt in principle that if the sacrifice of the
 functions ofthe parotid gland has been  decided  upon,  the advice of
 Viborg should be followed to the exclusion of  that of Desault and
 Flajani, if it could be proved that the saliva would allow the ligature
 to effectually obliterate the duct in this manner; but compression,
 presenting moreover the advantage of requiring no incision, will not-
 withstanding  be  adopted in preference, by timid and pusillanimous
 patients: whence it follows that these two methods might each be-
 come susceptible in practice of particular application.
   D. The twisted suture, as in  harelip, when the anterior portion of
 the canal  remains  unaffected, answers, according to Flajani, Percy
 and  Zang, in many  persons, and in most cases renders any other
 means unnecessary should it be  applied in  good season.  M. D. Las-
 serve (Cas. de Chir., p. 27, Perigueux, 1830)  having wounded the
 canal of Stenon  while  extirpating  an osteo-fibrous  tumor of the
 cheek, made at the bottom of the wound  an opening of two  lines
 which penetrated into the mouth, and the lips of which he successfully
 united by suture.  M. PI.  Portal (Clin. Chir.)  having extirpated a
 salivary tumor, was no less successful  in  another case.  The same
 occurred to M. Begin, (Pathol.  Chir., t. I., p. 209, 2d  edit.)
   E.  Seton through the natural  duct.—Morand first, and Louis after-
 wards, are the two authors to whom we are indebted for the idea of
 dilating Stenon's duct for the cure  of its fistulas.  The surgeon being
 placed in front ofthe patient, seizes  the labial angle by means ofthe
 thumb introduced into the mouth, and the two first fingers of the left
hand applied upon the cheek if the fistula  is on the right side, and
with the two fingers of the right hand, if it is  situated on the  left;
 stretahes*it and reverses to the outside ; introduces with the other hand
the head of a fine probe, furnished with a thread, into  the natural
orifice of the parotid duct; withdraws it through the  wound, where
he leaves the little seton whose two extremities he unites by a knot, and
 by which he is enabled on the day after to  draw into the mouth from
the exterior to the interior a small cord of silk ; and each day renews
this meche by withdrawing it through the wound and by adding to it
each time one strand more.  Should  it be attended with too much 
SALIVARY  FISTULAS.
357
difficulty to  penetrate through  the  mouth, Louis proposes  that we
should immediately introduce the probe through the  wound.   It must
be almost a matter of indifference, in fact, whether  we enter by one
mode or through the other.
  In  this last case,  however,  the  thumb should be substituted in
place of the fingers, in order to  straighten  the canal  and to incline its
orifice forwards when the probe is about coming out; not because it
makes an angle while it traverses the buccinator muscle, as is gene-
rally  thought with Louis, but because it falls  at an acute angle on
the mucous  membrane, which shuts  it up in great  part and appears
to throw its aperture backwards to the extent of a line.  As soon as
the saliva passes freely into  the  mouth, and the ulcer has become
contracted up to the periphery of the  meche,  the seton is to be re-
moved, or what is preferable it  is to be divided upon a line  with the
integuments, in order to draw it  towards us by its  buccal extremity
to the distance of about a line, and not to take it away entirely until
after  having completely closed the fistula by means  of repeated cau-
terizations and drying applications.
   F.  Seton  through a new duct.—If it were always easy to find the
anterior end of the divided canal; if it were not  that  this canal in
most cases  has been for a long time obliterated when  the physician
is called for; if, in fine, its preservation was a matter  of much  im-
portance, the process of Louis  accurately imitated from the method
of Mejean  in the  treatment  of fistula lachrymalis,  would  certainly
have obtained unanimous concurrence ; but this is not the case,  and
the following is the method which almost all operators at the present
day have recourse to.
   I.  Deroy, who, according to Saviard,  appears to have invented
this method, pierced  the cheek  through and through with a hot iron,
thus obtained a loss of substance and cured his patient.   Cheselden a
short time after gave the same advice.
   II.  Duphenix adopted  a mode somewhat different.   He made use
of a long and narrow bistoury; plunged it in from above downwards
and from before backwards ; made it turn several times upon its axis
in order to round off the opening which  he  had just  made; intro-
duced in its place a canula shaped like the point of a pen which was
designed to conduct the saliva into the mouth,  and the outer extrem-
ity of which, concealed in the  cheek, was made to  correspond with
the parotid  opening of the fistula.   The  borders  of the  ulcer were
then excised, and in  order to shut it up Duphenix  immediately  had
recourse to the twisted suture.  The canula left to itself came away
on the sixteenth day, and the cure was thus accomplished.
  III. According to  Monro  the cautery of Deroy and the bistoury
of Duphenix are advantageously replaced by a shoemaker's  awl.
By means of this instrument, which the celebrated surgeon of Edin-
burgh appeared to have a great regard for, he traversed the cheek in
the natural direction of the canal and contented himself, for a seton, with
a thread passed  into the wound.  When  its track was thereby ren-
dered callous he removed this thread, ascertained that the saliva ran
into the mouth, and then paid attention to the small external ulcer.
  IV. Platner, who  was a warm advocate of this mode of operating,
recommends that  the patient should be  made to  use a gargle of 
358
NEW ELEMENTS OF  OPERATIVE SURGERY.
brandy, in  order to accelerate the induration of the internal orifice
of the new duct, and  that we should at the same time compress the
wound on the exterior or touch it with the nitrate of silver.
  V.  J. L. Petit, after having traversed the parts, recommends that
we should  enlarge the buccal opening of the perforation by daily
introducing into it a small  piece  of sponge  until  the fistula is
closed up.
  VI. Tessart as soon as he had passed a simple thread through the
cheek perceived that  the saliva flowed  into the mouth.  The use of
a few strips of adhesive plaster proved sufficient to  close up the ulcer
promptly.
  VII. Flajani recommends that we should pass a double silk thread
through the fistula by means of a needle, and  that in other respects
we should proceed after the manner of Monro.
  VIII. Desault, in a patient who could not support compression,
made use of a  hydrocele  trochar  to  pass  the  thread through  the
cheek, fastened a meche to the internal extremity of this thread, and
drew it from the mouth to the bottom of the fistula, in such manner,
however, as not  to interfere with the cicatrization.   Withdrawn and
replaced each day of a little larger size, the meche was abandoned
some few days before the thread which supported it, and when  the
wound had become almost entirely  closed.
  IX. Bilguer like Desault had recourse to the trochar; but in place
of the seton he left a leaden canula permanently in the inner half of
the wound, which he closed up outside.
  X.  Richter placed  in the mouth a piece of cork in order to sup-
port and receive the  point of the  trochar;  made  use of a seton of
thread,  the  size of which was gradually increased ; withdrew it
when the new canal  was  sufficiently solid; afterwards cauterized
the exterior wound or scarified it, and then reunited  its borders.  In
the most obstinate cases he introduced through the mouth into  the
artificial duct, and  left there  permanently, a  gold  or silver  canula
provided with a head, in order to prevent its falling out.
  XI. M. Atti more  recently, in 1824, intending  to improve upon
the process called  Beclard's, has on the other hand, rather modified
that of Desault.   By  means of the canula of a small  trochar, he is
enabled to conduct through  the cheek a tent of lead, pierced on its
sides with several holes, supported externally by a thread which keeps
it in the wound,  and divided to the  extent of about a line at its inter-
nal extremity into three branches, which being bent  in the  mouth,
hinder it from being drawn upon -by the thread.   When the fistula
is sufficiently  reduced, M.  Atti touches it with the  lapis infernalis,
after having removed the thread, or even endeavors to close it up
entirely.  The leaden tent abandoned  in the cheek leaves behind it,
in escaping into  the mouth, at the expiration of a certain time, a new
canal, which perfectly replaces the old one.  The  successful re-
suits which the author brings  to the support of his  method confirm
in fact its value, and his process is without contradiction one of the
most  certain that can be imagined.
   XII.—Jt is . for  example  assuredly preferable to  that of M. Ch.
Bell, who like Flajani passes a needle through the cheek in order to
introduce a thread and afterwards  a seton into the fistula ; and who, 
SALIVARY  FISTULAS.
359
when the internal opening of the wound has become callous, fastens
a hair  or very fine  thread to the external  extremity of the first
thread, and  afterwards proceeds  in the  manner of  Desault and
Bilguer.
  G. Internal tent.—Since the last thirty years, surgeons with the
hope of rendering the operation more prompt, and of being  enabled
to unite the wound by first intention, have turned their attention into
another direction.
  I. M. Langenbeck, rejecting every kind  of  foreign body, has pro-
posed  to  dissect and to isolate the  posterior  extremity of Stenon's
duct, then to make  at the bottom of the  fistula an opening, which
would allow of  its being conducted into the mouth, and in order to
fix it in its new relations  to unite immediately the  borders of the
wound.  But I am not aware that this professor has up to the present
time had  any imitators, nor should he have any in future.
  II. M.  Latta says that  the best mode  of curing salivary fistulas,
consists in passing a  catgut through the cheek, after which we should
endeavor  to  introduce its external  extremity in  the  parotid duct,
leaving the other in the mouth, and closing up the wound accurately,
either by the suture or adhesive plasters ; as if it were a thing that was
always possible to find the orifice of Stenon's  duct at the  bottom of
an ulcer !  Zang, however, eulogizes this mode of operating, when the
fistula is very large, and the anterior portion ofthe canal shut up. Only
he recommends that  we should make use of the canula of the trochar
for the purpose  of conducting the catgut,  that this latter  should  be
shaped into  a point at the extremity, which  is  to penetrate in the
direction  of  the parotid, and in order that the saliva may run  along
its sides, that it  should be made so as not  to fill  up exactly the arti-
ficial canal.
  III.  In reducing the practice of Latta and  Zang to its. true value
it is immediately perceived  that it  differs from that of Desault or
Ch. Bell,  or that of Vedrine, (Journ. de Desault, t. IV., p. 294,) which
latter traversed the bottom of the wound with a carlet needle, (aiguille
en carlet,) only in the fact that they dispensed with  retaining their
tent outside by the aid of  a foreign body; which enabled them to
close up  the  fistula immediately, and to do this, whether  they suc-
ceeded or not in placing one end of the catgut in the natural duct of
the gland.  It is, however, possible that we may cure by this mode,
as by  most of the  processes which  have  been pointed  out  above ;
but it  has the disadvantage of not holding the seton sufficiently secure
in the thickness of the cheek, and of enabling it to escape too soon.
  IV.  The same objection may also be made to Percy, who on his
part states that  he had often succeeded by making use of a leaden
sound, instead of the catgut which the Germans employ.   Without
claiming  any pretension to it, M.  de Guise, (Bull,  de la  Fac de
Med., 7 annee, p. 40—44,) proceeded in the following  manner in a
young patient in whom the fistula, which had already existed a long
time, had  resisted a greatest variety of means resorted to.   A hydrocele
trochar inserted through the wound from without inwards, and from
before backwards, enabled him to introduce into  the mouth a leaden
wire through the canula of this instrument.  By means of a second
puncture  in  the direction of the natural  canal, that is to say, from 
360
NEW ELEMENTS OF OPERATIVE SURGERY.
behind forwards and always from without inwards, he was  also en-
abled to b -ing the other extremity of the metallic wire into  the buc-
cal cavity, reverse its two  portions upon the inner surface of the
cheek, and  then  unite the exterior wound by means of the twisted
suture.   At the expiration of a few days the agglutination appeared
complete.   The leaden noose, whose convexity corresponded to the
fistula, and which included in its concavity the internal tissues of the
cheek, was  cautiously withdrawn, and from  that time the cure was
no longer doubtful.
   V. Three observations  related under the name of Beclard, prove
that this surgeon frequently imitated M. de Guise with success.  In
place of leaving  the two extremities of the leaden wire free in the
mouth, he united  them and  twisted them upon themselves, with the
view of gradually cutting through the  intervening tissues, as in fis-
tula in ano.   Moreover, in order to make the second puncture, he
introduced the trochar through the mouth, in order that the  beak of
the canula might not prevent its being withdrawn through the same
track after having adjusted the other extremity  of the tent; which
is not practicable  when  it  is passed from the exterior to the interior,
as it is the first time.
   VI. M. Grosserio, finding that it was not as easy to pass the tro-
char through the mouth as it was through the wound, and desirous of
remedying the inconvenience pointed out by Beclard, has recom-
mended a trochar provided with a canula which  is wholly devoid of
any shoulder.   By means  of this modification we withdraw it with
full as much facility through the  mouth in the second stage of the
operation as through the wound in the first stage.
   VII. Finally, M. Mirault, who has since recommended the same
course, considers that a meche of thread would be preferable to a
leaden wire, and that by means  of a  knot-tightener, made like that
of Desault, we  would more speedily accomplish  our object than by
simple torsion.
   VIII.  M. Roux, (Journ.  Heb., t. II., p. 178,) governed by the same
idea as  M.  Mirault, made use of a silk seton with entire success.
Finally, M.  Vernhes, (Revue  Med., 1830, t. IV.,) has been  no  less
successful with a gold wire, placed  from above downwards,  not
transversely, as recommended  by M. de Guise,  and which  he  em-
ployed like  Beclard  to  cut  through the intervening tissue by twist-
ing it gradually upon itself.
   IX. Perhaps  also we might confine ourselves to perforating in  any
manner  whatever  the  parotid duct posteriorly at a short distance
from  the fistulous orifice, and to establishing on the track which the
saliva takes  an internal fistula  in order  to be enabled to*close  that
which is outside.  But this process which I proposed  in 1823, has
not yet  been put to  the test, and  the facts of Trecourt, (Mem. de
Chir., p. 71,) or of Charve, (Lombard, Opusc de  Chir., p. 24,) which
have reference  to  it, are  not very conclusive.  Like that of M. de
Guise and all its modifications, moreover, it would be applicable only
in cases where the wound of the duct has not approximated too near
to the masseter muscle.  Also, in order to determine the relative va-
lue of so many different  methods, it  would be necessary to exhibit
all the modifications  which  salivary fistulas  may present.  In  this 
                             RANULA.                         361

point of view there are none of them which may not have their ad-
vantages.
  H. Appreciation.—Nevertheless, the portion of quill of Ravaton,
(Chir. dArmee, p. 571,)  the  seton, after the manner of Desault, or
Ch. Bell, the leaden tent of M. Atti, or that of Percy, Latta, or Zang,
are, all things being considered, the best, and ought to be preferred.
To proceed  in the manner of M. de Guise or Beclard, in  adopting
the modification proposed by M. Grosserio, it would be requisite that
the fistula should  be sufficiently remote from the masseter muscle.
Under such  circumstances  this method is the most certain, and un-
questionably the best of all.

                  §  III.—Sub-maxillary Gland.

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

             Article VI.—Ranula,  (Grenouillette.)

  Ranula is a disease of little importance, and one which,  as Boyer
says, is not dangerous.  If has, however, been seen on more than one
occasion to compromise the life of the patient, and in all cases it is suf-
ficiently annoying  to induce us to devise some mode of relief.  F. de
Hilden speaks of one which filled the entire mouth; and Marchettis
of another which was so large  as to  compress the carotid arteries
and the trachea.   Alix states that he operated upon one in a child,
which was upon the point of  producing suffocation, and Taillardant
mentions  another  which  was of so large  a size that  it prevented
the patient  from eating.  A.  Burns speaks  of an adult man whom
he saw in the practice of  Cline, and whose respiration was so much
interfered with by the  presence of a ranula that he swooned away
after having been  attacked with violent convulsions.  A  man who
came,  in  1837, to the public consultation at the hospital of La Cha-
rite, had a ranula  which,  occupying the totality of the left parotid 
362
NEW ELEMENTS OF OPERATIVE SURGERY.
and supra-hyoid regions, must have contained near a pound of fluid.
I have seen two other cases in which the mouth was as it were filled
up by them.   Though the ancients were but imperfectly acquainted
with the nature of this disease; though some make of it with Cel-
sus an encysted tumor, and that  others with Aetius ascribed it to
a  varicose  dilatation of the  sublingual veins, or with  Abu'l  Ka-
sem  to cancer,  or with  Paracelsus  considered it to be an apostema
ofthe vessels  of the tongue, or with Aranzi an  ordinary abscess;
they nevertheless attempted its cure by almost all the different means
employed  since  the  time that  Louis endeavored to prove  that it
is nothing  else  but a tumor produced by an accumulation of saliva,
either in  the maxillary gland itself,  transformed into a cyst, or in its
excretory duct, which has been enormously dilated.  MM.  P. Du-
bois and Stoltz (Gaz. Med., 1833, Novembre ; Journ. des Conn. Med.
Chir., t. I., p. 182,) have each given an  example to prove that ranula
is sometimes congenital,  and that it may occupy the sublingual gland.
In place of pure and  limpid or inspissated  saliva, mucus or purulent
matter, or  a viscous substance of more or less consistency, the dis-
eased pouch is sometimes filled with gravel, sand, or even legitimate
calculi.   In a case related by Tulpius it was composed of a concre-
tion  so hard,  that it became necessary to use the actual cautery in
order to  destroy it.   Schultz, E. Koenig and V. Rieddlin, mention
facts ofthe same kind, which have also  been met with by J. L. Petit,
Freeman.  Sabatier,  Taillardaut, Loder and Boyer.   M.  Walther
(Revue Med.,  1826, t. II., p. 142,) asserts that he has, in two instan-
ces,  found calculi in Wharton's duct.  An analogous fact  has been
since published by M. Baker, (New Amer. Archiv., &c, p. 249, July,
1835.)  The diagnosis was clear in all these cases.   An incision of
sufficient extent upon the tumor  allowed  of the  extraction of the
foreign bodies, and  the  cure was  speedily accomplished.   Ranula,
(grenouillette,) properly  so called, requires  other precautions.  Ex-
perience has shown  that, whether,  after the example of La Faye,
(Journ. de Connais. Med. Chir., t. I., p. 182,) we admit two species
of it, one for the sublingual gland,  and the  other for Wharton's duct,
or whether on this point we concur with  the general doctrine,  the
evacuation of the liquid will not be found a sufficient preventive of
a second obstruction.  For  the treatment  of this disease, incision,
caustics, tents,  dilatation,  excision, extirpation, permanent canulas,
the seton, &c, have each in turn had their partisans.

                               §  I.

   Incision, which first presents itself, immediately empties the tumor
 and appears to cure the disease.   The organism,  moreover, must
 have first  suggested this  idea, inasmuch  as ranula very frequently
 bursts of  itself.  Hippocrates had already recommended it,  and
 effected  it by means of a lancet.   Celsus and Aetius speak of it, but
 do not appear  to have any great confidence  in it, any more than
 Rhazes,  who had his fea-s on this subject, from the vessels which
 the  bistoury may at  the same time wound.-  Abu'l Kasem, though
 somewhat bolder, did  not venture to have recourse to it except tor
 sublingual tumors that were of a whitish color and fluctuating, seeing 
RANULA.
363
that by cutting into the otners we incurred the risk of making them
pass into a cancerous condition ;  that is to say, that Abu'l Kasem had
been led, without knowing it, to distinguish the legitimate grenouil-
lette from the tumors with  which it was  in his time confounded.
Paracelsus, in place  of plunging the instrument into the cyst itself,
confined himself to opening  the vessels which go  to it,  and can
scarcely  therefore be considered  among the number of partisans
for the incision of ranula.   When a fluctuation  is perceived in  it,
Aranzi, who does not distinguish it from abscesses, recommends that
it should be opened with the phlebotome, and P.  Forrest says that it
does not return if,  after having  incised it, the surgeon takes  care to
make pressure upon it, and to expel  all its  contents.   According to
Bartholin, Six waited until the inflammation in the tumor had  ceased,
when he pierced it  through and through,  in order to evacuate the
contained matter.  Jourdain, notwithstanding the arguments of  V.
D. Wiell, and the experience of every day, still maintained, about
the middle  of the  last century, that a free incision by  means of the
lancet very frequently effected a cure of the grenouillette, and that
we may confine ourselves to this remedy. There are, in fact, patients
who have been  in this manner permanently cured of their disease;
but all the world, at  the present day, agree that this remedy is only
palliative, and that in general the salivary cyst  is not long in again
becoming filled up.

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

   Paracelsus, in order to retain for the operation a part of its  ancient
simplicity, to prevent the wound from closing up too rapidly, and to
effect in fact a cure which incision alone was  far from always obtain-
ing, maintained in the wound detergent substances ;  Purmann intro-
duced styptics into it and was successfully  imitated  by V. D. Wiell;
Camper touched it with the  lapis infernalis, and Acre!  left init a roll
of lint saturated with the spirit of salt; while Callisen recommends that
we should place in it lint only or cauterize  its bottom with a  mineral
acid;  which causes,  he says, the cyst to become detached and ena-
bles us to remove it.   A surgeon of Saltzbourg, quoted by Sprengel,
found it more convenient to inject  into it camphorated spirits or
essence of turpentine and cured his  patient.  It was the same with
a patient mentioned by M. Haime, of Tours, (Precis  Med.  d'Indre
et Loire, 1821, 2nd trim.,) and whom this physician cured by means
of  injections, thereby inducing the adhesion of the walls of the cyst.
Leclerc  had not been less fortunate with  the nitrate  acid  of mer-
cury, and the case of Sabatier  proves that  a tent of lint renewed
or  cleaned each day, suffices after the incision of the ranula to ren-
der the wound fistulous and to effect a radical cure.  Nevertheless,
as it not unfrequently happens that the disease resists all this combi-
nation of remedies, it has  been proposed to destroy  a portion of  the
sac of which it  is constituted.   I am in truth surprised  that no one
up to the present  time has  applied to salivary tumors  the puncture
and irritating  injections used in hydrocele.  Everything, for exam-
ple, induces us  to believe  that iodine injections would prove  suc-
cessful. 
364
NEW ELEMENTS OF  OPERATIVE SURGERY.
                      §  III.—Cauterization.

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

  Tulpius, J. L.  Petit,  Desault  and Richter, desirous of systematiz-
ing the process of La Cerlata, who hooked up  the ranula with an
erigne  and excised it  with a razor, or that of F. ab Aquapendente,
who seized it with the  forceps and divided it with the scissors or ap-
plied the ligature to it, have endeavored to  prove that by removing
a flap of sufficiently large size  from the cyst,  the tumor is scarcely
ever reproduced.    The fact is, that in his practice at the Hotel Dieu,
Desault almost always succeeded  by this method, one which M.
Coley  (The Lancet, 1828, vol.  II., p. 495),  states  that he had had
every reason to be satisfied with, and which Boyer, who never prac-
tised otherwise, had the highest opinion of.   It is the method adopted
by M.  Graefe, (Revue  Medical., 1830, p. 143.) who in this manner
removes half of the cyst.   It is moreover performed in various ways.
The most simple and  surest mode is the following:  the jaws of the
patient being separated  as much as possible, the surgeon  provided
with a  straight bistoury commences by making a semilunar incision
with its convexity outwards, upon almost the entire surface of the
tumor facing the gums ; he then seizes with a good  pair of dissecting
forceps the  flap  thus  cut, and  detaches it by means of the scissors
while giving it an  elliptical form.   In  general  no vessel of any im-
portance is wounded.   It is rare that there are more than a few drops
of blood  or that the patient  experiences any pain.  Dressings are
useless, and the  wound which  diminishes  from day to day without
however entirely closing, prevents any return of the disease, at  least
in most cases. 
RANULA.
365
                       § V.—Dilatation.

  Though the disease in general is owing to the course of the saliva
being interrupted, and though Louis, (Mem. de IAcad, de Chir., X. IX.)
imitated by Leclerc, may have succeeded in clearing out the orifices
of Wharton's ducts, which seemed like two aphthas on the sides of the
frenum, and that-he has been enabled to dilate them by placing a sound
in them, and that the patients thus treated have recovered; it must
nevertheless be conceded with Richter, that dilatation  in such cases
would be a most uncertain resource, one that was exceedingly diffi-
cult, and often even wholly impracticable.   Excision after the man-
ner of Boyer has undoubtedly immense advantages over it, without
exposing to the same manipulations and difficulties.

                   § VI.—Permanent  Canula.

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

the other hand, was rarely attended with failure in the hands of
Boyer.
                         § VII.—Seton.

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

                     §  VIII.—Extirpation.

  Loder  and  Sabatier  have  seen  the disease resist these  different
modes of treatment, and many authors had already  contended that
the surest mode is to extirpate the grenouillette  or to  destroy it
entire by means of caustics.  Celsus,  in a rather obscure passage in
his works, would lead us to believe that he himself was  acquainted
with this extreme  remedy.  Treating of sublingual tumors, he re-
commends when they do not yield to puncture, that we should incise
the skin  that covers them, in order to extract them, taking  care not
to wound  the  vessels, while  an  assistant  separates the  lips of the
wound.  Mercurialis, the first author who distinctly recommended
it, raises  up the tumor with an erigne, cuts it at its base in the mouth,
and  says if  we do not destroy the whole cyst, the disease is sure to
return.   Diemerbroeck commenced by making a crucial incision into
it, and then extirpated the whole of it.   Alix, without going  as far
as this, incised  it largely, but lengthwise, and  then removed as much
of the cyst  as he could  by means  of  the scissors.   Marchettis, who
in a very severe  case had introduced a  meche as far as into the
mouth, by penetrating through the supra-hyoid  region, was, never-
theless, obliged to extirpate as much  of the  tumor as he could, and
to destroy the  rest with a  hot  iron.   It appears, nevertheless, that
complete extirpation was  but rarely performed by these different 
TUMORS OF THE  MOUTH.
367
practitioners.   It scarcely ever becomes indispensable unless the evil
should threaten to take on a serious degenerescence, or to be trans-
formed into a solid tumor.   Otherwise,  all  that is actually necessary
is, to excise the portion which projects into the mouth;  so much the
more so, because by then touching the  bottom of the wound some-
what actively with the nitrate of silver, its exfoliation is readily ac-
complished.  An enormous  cyst occupied  the  entire supra-hyoid
region;  M. Malcolmson  (Gaz.  Med.,  1838,  p.  743,)  excised an
ellipse from it, and the gland was seen at the bottom ; he then excised
this, and extirpated  it  nearly  entire, when  the patient recovered;
but I am not satisfied that the lymphatic ganglions may not have
here constituted the great  bulk of the disease removed.

            Article VII.—Tumors of the Mouth.

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

the method of this  surgeon ought to be  adopted, unless we should
prefer to confine ourselves merely to the process of Beclard for sal-
ivary fistulas, or to  the treatment of grenouillette.

                  Article VIII.—The Tongue.

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

  The species of fibro-mucous fold which  attaches the free portion
of the tongue to the posterior  surface of the  chin, and  which is
called frenum when its  dimensions  are properly proportioned, takes
the name of Filet, when it is too long from before backwards, or too
short from above downwards.  It then becomes impossible for the
infant to suck.  The point of the tongue being then arrested against
the lower wall of the mouth, renders  it impossible  to  draw it out-
wardly, in order to  seize the nipple.  This is an  arrangement, there-
fore, which might be attended with serious consequences, if we did
not immediately attend to its removal.  Only  that  we should be
careful not to suppose that the infant is tongue-tied as soon as it  does
not suck, or  is a long while in beginning to talk.  Such accidents,
which a thousand different causes may occasion, do not depend upon
the frenum of the tongue, unless it be  found that when the finger is
passed into the mouth, it is impossible  to be seized hold of by it, or
that  its point cannot reach as far as on the lips,  in which cases  only
we should undertake the section  of the filet.
  A.  There is nothing to show, unless  it be a remark in Cicero, that
this small operation had been described  before the time of Celsus,
who,  in order to perform  it, recommends  that we should raise  the
tongue with the forceps, and  already at that  period advises that we
should be careful not to  divide its vessels.   Paul of Egina and Abu'l
Kasem employed a  hook in place of the forceps.  Avicenna, in order
to be more  certain to  avoid any  hemorrhage, passed a ligature
through the base of the frenum, and in this  manner dispensed with
the cutting instrument.  De la Cerlata, who  censures midwives for
tearing out the filet or  dividing  it with their nail, destroyed it by
means of a particular instrument, and raised  up the  tongue with his
two fingers.
  The sharp-pointed scissors of Friederich are justly condemned by
Fabricius ab Aquapendente, who severely  censures  the pernicious
practice  of midwives, already pointed out  by  De  la  Cerlata, and
moreover remarks  that this operation is rarely  required,  F. de
Hilden  is of the same opinion, and performed the operation with a
cleft instrument, which served at the  same time as a scissors and as
a fourchette to raise up  the tongue.   The instrument of M. Montain
(Mem. de Therap.,  1836, p. 34,)  is nothing more than  an  improve-
ment  of that of F.  de Hilden.  The blunt fourchette  and  the large
scissors devised by  Scultetus and Solingen are useless.  The idea of
cutting  the  filet with a bistoury heated  to a  white heat, as was
practised by Lanfranc, would at the present day be considered ab-
surd.   The  spring  instrument of J.  L. Petit, and which was  eulo-
gized by Platner, appeared to be attended with  too much inconveni-
ence in the opinion of Le Dran, who maintains that the blunt-pointed 
THE TONGUE.
369
scissors will always answer, and that  it is unnecessary to go to the
extent of Dionis, by lacerating the wound with the finger, in order
to enlarge it after the incision is made.  The cleft spatula of Richter
and Callisen, and the curved and blunt-pointed scissors invented by G.
Schmitt, are  not  in use with  us at the present day, though in fact
they might be made to effect the object intended  by their authors.
M. Colombat, who is always  ingenious in constructing new instru-
ments, has proposed one, which appears to me altogether useless, as
does  also the excision which  he recommends to be substituted in
place of the simple incision.
  B.  Operative Process.—We adopt the method of Le Dran,  that is
to say, the infant being seated and  its head held back by its nurse,
or some other person who  will not be disturbed by its cries, the sur-
geon raises up its tongue by  means of one or  two of the fingers of
his left hand, while with the other hand holding a blunt-pointed scis-
sors, he  rapidly divides the frenum.  But, inasmuch as the size of the
fingers may frequently embarrass the remainder ofthe operation, we
have generally made  use, since the time of J. L. Petit, of a canulated
sound, the cleft  plate  of  which  being  substituted  in  their  place,
protects at the same time  the vessels.  When the filet is properly
secured  in the bifurcation of this plate, the operator slightly raises up
its handle towards the forehead of the child, in  order to push the
tongue backwards and upwards.  Then introducing the scissors un-
derneath, he  divides  with a  single cut the small membrane thus
stretched, taking care to direct the point of the instrument slightly
downwards,  in order to be sure  that he  runs no  risk of wounding
the ranine arteries.   The wound requires no precaution, and it is ex-
tremely rare that  the little patient suffers any pain from it beyond a
few hours.   The movements of the organ prevent its reagglutination,
and 1 am not aware that there  is any necessity in this  matter to touch
it  with  nitrate of silver,  as  is recommended  by M.  Hervez de
Chegoin.
  C. Accidents.—Tetanus, which was produced  by the section of
the filet, in the child mentioned by J. Fabricius, and which operation
had been performed by a  charlatan, has never been  observed since.
According to some authors, two serious  accidents, hemorrhage and
reversion of the  tongue into the  pharynx, may however be caused
by this  operation.   The first  happened to Roonhuysen, who could
not arrest the blood until  he had applied vitriol to the bottom of the
wound   Maurain incurred still greater dangers, and was obliged to
come to the actual  cautery.   J.  L. Petit  mentions two cases  in
which the operation having been badly performed, the patients would
have evidently succumbed if he had not immediately afforded them
relief.  A circumstance which in these cases aggravates the danger is
this,  that the blood in place of being spit out, is swallowed in propor-
tion as it flows, and that if we are not vigilant the child  may  die be-
fore  we have suspected the cause.
  I.  If  we employ *the sound, and  take the precaution to incise
nearer the inferior wall of the mouth than to the tongue, it is next to
impossible that such a hemorrhage can take place.   If it should hap-
pen,  however, it  may be stopped by directing upon the point which
bleeds the head of a  probe heated to a white heat.   J.  L. Petit suc-
                               24 
 370          NEW ELEMENTS  OF OPERATIVE  SURGERY.

 ceeded by means of a wooden fork an inch long protected by linen,
 and having its point d'appui against the inner side of the maxillary
 symphisis  on the  one part, on the other  embracing the top of the
 wound, while a small band passed transversely in the  mouth, then
 brought out and crossed under  the jaw,  and raised up above the
 ears to  be fastened  to  the child's cap, hindered the tongue from
 moving.  Two  stems united in  any manner whatever at their mid-
 dle portion so as to form a forceps, by means of which the bleeding
 part should be seized, and which should be  made to act by pushing
 a wedge between the two halves of its other extremity, would  bring
 about the same object, and in fact  attain it with still more certainty.
 The natural softness of the tissues, and the retraction of the arteries,
 would in general render the ligature  recommended by  Courtois
 wholly inapplicable.
  II.  As to the reversion of the  tongue, the  moderns  have  with dif-
 ficulty admitted  its possibility.  J. L.  Petit, who has seen three ex-
 amples of it, explains it  in  saying that  the  frenum having been di-
 vided the  tongue  becomes free, is raised up and directed towards
 the windpipe with so much the more facility, because the infant,  who,
 up  to that time  had  not been able to seize hold of the nipple,  now
sucks upon it with a  degree of voracity.  In one  case, this prac-
titioner had three times to draw back the tongue out of the pharynx,
but the fourth time the  patient  died  notwithstanding.  J.  L.  Petit
has seen the reversion in question during life, and has demonstrated
its  existence after  death.   It  is therefore an unquestionable  fact.
Nor can I see why it  should be so  difficult to comprehend, nor why
we should call in doubt what travellers have said of those Eastern
or African people, who, in order to escape severe punishments, killed
themselves by swallowing their tongue.  Any person may ascertain
upon himself, that  the tongue can  be  reversed to the upper part, of
the pharynx, and that there would be no  very great difficulty in  clos-
ing with it the posterior opening of the nasal fossas.  A similar fact to
those of Petit, has moreover been related since by M. Cross, (Presse
Med., X. I., p. 388.)   We avoid  this  reversion by not dividing the
filet too deeply.   In  order to remedy it  we must  bring back the
tongue by means of the finger into its natural position, make the in-
 fant constantly suck so long as there is danger, and when it  does not
suck, keep its mouth carefully shut.

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

  Adhesions of the tongue have at every epoch attracted the atten-
 tion of surgeons.  Whether they be congenital  or acquired, the re-
 sult of simple inflammation or the product of more  deep-seated le-
 sions, ancient or recent,  the cutting instrument  is nevertheless the
 only resource for their relief.   Aetius  says that the abnormal mem-
 brane, or cicatrix, is to be seized with  a hook, and to be then divided
 with the necessary  precautions.   J. Hellwig, having  been  consulted
 by  an individual who could not articulate  sounds, destroyed by dis-
 section the adhesions  of his tongue, and thus restored his speech. At
 the present day, we proceed in the same way.  Only it is important
 that we  should  not allow ourselves  to  be imposed upon by an ar- 
THE  TONGUE.
371
rangement that is sometimes met with in new-born infants.   In such
cases their tongue is  merely glued (collee) either against the vault
of the palate, as Louis has seen it, or to the lower wall of the mouth,
which has caused more than one  old  grandmother to  suppose that
the child had no tongue.  The finger,  the handle of a scalpel, or the
spatula, will be found sufficient to  destroy this simple agglutination,
which in fact is nothing more perhaps than the beginning of a true
anchyloglossis.   The method to be adopted would be still the same in
an adult, if we should  be called before the adhesions, which have
been the result of a diffused inflammation, have acquired a certain
degree of solidity.
  A. If there  should be only a few bridles of  slight extent upon the
sides of the frenum, we should divide them with the scissors, like the
filet, and with the same precautions.   We should divide in the same
manner those  which are not unfrequently found to have been formed
between the cheeks and borders  of the tongue, in  consequence  of
mercurial gastritis and other phlegmasias  of the mouth, examples of
which have been communicated  to the  Academy by  MM. Duval,
Cullerier, and Bernard.  Should  they have  a  certain  degree  of
breadth, they  should  be excised in place  of  simply dividing them
After having detached them from the buccal wall by one  cut  of the
scissors, we should  seize them near the tongue, in order to remove
them by a second cut with the same instrument.   We  may also re-
move them by embracing them successively at their middle portion
with the forceps, while we-detach their borders with the  scissors 01
bistoury.
  B. When on the contrary these adhesions are close, or cellular,
as it is termed, the dissection must be  conducted with more particu-
larity and caution.   The surgeon being  placed behind, and  to  the
right of the patient, whose head is held back upon a pillow, the arm
of the nurse,  or against the chest of an assistant, endeavors to sepa-
rate by means of the  left  forefinger, a  spatula, or a  portion of a
sound, or any other suitable  instrument, the free portion  of the tongue
from the point in the mouth which keeps it  immovable.  Dividing
gradually with a straight bistoury held flatwise, all the  lamellae or
unnatural attachments which  he  intends to destroy, and not forget-
ting, at the inferior region especially, slightly  to incline  the edge of
his  instrument towards the wall of the mouth, or to remove it as far
as the state of the parts will permit  from the body of  the tongue
itself, in order to  avoid the vessels with greater certainty, he sponges
up the blood in proportion as it runs out and stops from time to time,
in order to afford the patient time to  breathe and to have his mouth
cleansed out.   He then cauterizes with a  hot iron if any hemorrhage
exist, or in other  cases  prescribes some styptic or astringent lotions,
and finishes by pressing his  finger upon all the points of  the wound
in order to assure  himself that there no longer exists any improper
adhesion.   Emollient gargles, extended   and frequent movements
of the tongue, and the precaution of frequently gliding the finger
between the divided  surfaces in order to  prevent their reunion,  are
all  that  remains  to be done until the cure  is completed, which is
usually  accomplished from the fifth to the thirtieth day, but which
requires all these attentions in order to be  effected with certainty. 
372
NEW ELEMENTS OF OPERATIVE  SURGERY.
           § III.—Tumors and Ablation of the Tongue.

  A.  Gangrene, induration, fungous  and schirrous tumors, cancer-
ous ulcers and true cancers, are  the  principal diseases which may
require amputation of the tongue either  entire or in part.  It is  an
operation which has been only lately introduced  into practice.   De-
terred by the idea that the tongue is the  exclusive  organ of speech,
although J. Lange asserts that he had already often removed it in con-
sequence of gangrene, this operation was thought of only with dread,
when Louis demonstrated that many individuals, though deprived of
a large portion  of this  organ, nevertheless  continued  to have their
speech and to distinguish the taste of  different substances.   The la-
borer mentioned by Roland de Saumur, and who had lost his tongue
down to the root in consequence of gangrene, could speak, spit, swal-
low without difficulty, and taste different substances.
  The young  girl noticed at Lisbon,  by De Jussieu; the Margaret
Cutting mentioned in the Philosophical Transactions ; the Marie Gu-
lard referred to  by Bonami and Louis; the girl, A.  M. Federlin,
whose history is published by Auran;  the young man whose tongue
was torn out by the corsairs because  he  would not be made a Mus-
sulman, and whom Zulpius states he  saw, and another person who
had his tongue cut out by robbers, and whom Zacchias mentions to
have seen, were cases of this description.  It is also known that in
Germany, Italy,  Spain, &c,  it  has a long time been the  practice to
punish malefactors by cutting out their tongue but most of whom,
notwithstanding, have retained the faculty of speech.  All the world
in fact are familiar with the two cases  so quaintly described by A.
Pare :  1st, of a mower, who  after having been mute for the space of
three years  in consequence  of having lost  a portion of his  tongue.
being  ridiculed  by one of his comrades while  he was holding a
wooden vessel between his  teeth, made  an effort and uttered, to his
great astonishment, a few words,  and  who,  taking advantage of this
circumstance, finally learned to speak distinctly by means of a saucer
or small  cup; 2d, of a young boy  whose tongue had  been cut  off.
and  who  recovered  his speech  by making use  of the  instrument
invented  by the preceding person.   Though it  be  satisfactorily
proved that the loss of the tongue does not always involve complete
loss of speech, it is nevertheless  true that  its  amputation has been
more than once performed without  any very evident necessity.  We
should dispense with it for example at the present day, and would
not imitate Pimpernelle, (Bonet, Corps de Med., X. IV.,  p. 305,) even
though the organ had become so much  swollen as to  protrude out-
side, unless  it  was accompanied  at the  same time with an actual
schirrous or cancerous degenerescence.   Serous cysts, abscesses and
collections of blood might be laid  open or excised without the neces-
sity of extirpating the tongue.   In a case cited by Thymceus, (Ibid.,
t. III., p. 201,) and in another for which we are indebted to Bona-
vert, (Trans. Philos. Abreg., X. IV.,  p. 340,) a tumor upon the tongue
contained a stone of the size of an almond.  A patient of Sedehus
(Bonet, Corps de Med., t. IV., p.  62) presented the same phenome-
non.   Dumonceau (Mem. de TAcad,  de  Berlin, t. VII., Append., p-
130) mentions that a retention of urine was not removed until after 
THE  TONGUE.
373
the extraction of a stone which was found under the tongue, and we
see also in a case of Leautaud  (Ibid.) that  a similar calculus had
produced fever with an abundant salivation.   In all  cases of this
kind we should never think of amputation of the tongue.  It is an
Operation therefore which in the mam must be reserved  for cancerous
tumors, and other degenerescences of bad character.
  B. Operative Process.—The operation, moreover, is performed in
quite a variety of modes, and should be  modified in fact according
as the disease presents itself on this or that part of the organ.
  I. Process of Faure.—The erigne forceps or scissors curved flat-
wise, will answer for the excision of pediculated tumors of greater
or less size, and which rarely appear upon the tongue  except on its
dorsal surface.   The ligature would not  have the same advantage,
and however little of the disease we may apprehend to have left
behind, it is important, in addition, to cauterize the bottom of the
wound with a hot iron.
  II. If the alteration should  be confined to the tegumentary layer,
it would be necessary, as Walee,  after  the  manner  of Bartholin,
appears  to have done long since, to remove  only the degenerated
lamellas  and to preserve the muscular tissue.
  III. Should the chancrous ulcer be deeper and situated upon the
borders of the tongue, we should then, in order to destroy it, no longer
make use of the curved  bistoury,  as was done by a surgeon made
mention of by Ruysch.  The point of the  tongue being wrapped in a
dry piece of linen, is drawn to the  outside by  the  hand of an
assistant, who inclines it  towards the  side opposite  to that of the
disease.   The  operator, provided  with  a  straight bistoury, com-
mences by,making an incision of several lines in extent  on the lower
surface  and  throughout  the  whole  length  of the organ; makes
another  on its  dorsal surface; thus  encircles  the cancer, including
with it a certain extent also of the sound parts ; then secures it with
the forceps or erigne, and promptly  completes its excision.  The
actual cautery, without being really necessary, becomes a matter of
importance at the termination of  the operation, as in  the preceding
case.  If, out of the  three persons operated upon in this manner by
M.  Heyfelder, (Journ. des Conn. Med.,  X.  II., p. 347,) a cure was
effected  only in one,  it was certainly not the cautery which, did it.
  IV. Ligature.—When  the  disorganization  is still  deeper, when
especially it has extended very far backwards,  and that it, neverthe-
less, appears to be practicable to preserve one of the  halves of the
tongue, we may have recourse to the ligature.   It would protect us
with more  certainty against hemorrhage than the  bistoury,  and
nothing prevents us, if we apply it  in a particular way, to go back
with it nearly as far as the larynx.  A tumor of a doubtful character,
which was situated upon  the side of the tongue and which was tied
at the supra-hyoid region, and also at the mouth, was in this manner
ultimately detached,  resulting in the recovery of the patient, (Arnolt,
Gaz. Med., 1839, p.  106.)
  a. Process of M.  Mayor.—The organ  is first  transfixed  through
the  mouth, and at its  most remote  part,  from below upwards  and
horn before backwards, by a strong bistoury, which being  brought
forward  divides its whole length into two equal parts without touch- 
374
NEW ELEMENTS OF OPERATIVE SURGERY.
ing the neighboring  arteries.  The operator then adjusts, at a point
beyond the disease  and upon the affected portion, the noose  of a
strong ligature of thread, the two ends of which he passes separately
through  a  metallic tube, of a square shape and  pierced with two
openings slightly convergent, then through the other pieces of the
chaplet knot-tightener which I have spoken of in the chapter on  liga-
ture en masse; thus embracing the base of the flap which is to be
destroyed,  he  turns  the small winch, and when  the  constriction is
carried as far  as is desired  he attaches the free portion of this appa-
ratus to  the labial  commissure, either by means of a thread  or a
small band.   The pressure is increased in the same manner daily,
and even several times during the day.   The  tissues soon mortify,
and either separate or may be excised without danger on the third
or fourth day.  The knot-tightener  of M. Mayor, which has been
employed in five instances with  success by its inventor, and which
is a real  improvement upon the instrument devised by MM.  Bouchet
and Braun, has the advantage  in consequence of its flexibility of
adapting itself without difficulty to the inequalities of the tongue, of
occasioning but very little inconvenience in the interior of the mouth,
and of allowing of a constriction which is at the same  time moderate,
energetic, and permanent.   Should  it not be at hand, however, the
knot-tightener of Desault or that of Levret might, in these cases, be
employed here with full as much advantage as  for the ligature of
polypi in general.
  b. If the whole breadth ofthe tongue is diseased, either at its point
only or as  far down  nearly as its base, the  ligature would still be
applicable.  The proof of this is  demonstrated in the observations of
La Motte  and Godard, each in a different  case.  Ev. Home and
Mirault (Soc de  Mid.de Montpellier, X. IV., p. 517,) passed a double
ligature through the centre of the tongue and brought its two halves
out, to be knotted upon the sides of the organ, which they succeeded
in this manner in dividing and separating by suppuration.  M. Galen-
zowski (Journ. de Progres, 2e serie. 1.1., p. 256,)  in order to destroy
a fungus  hematodes which occupied one of the sides of the tongue
employed a triple ligature and succeeded.  In place of previously
slitting through the tongue from before backwards, as is recom-
mended  by M. Mayor, M. Maingault (Journ. de Prog., X. XIV., p.
511, Ire serie,) proposes that we should  apply the ligature by the
mouth and pass it through each  half of the tongue on its side, by
means of the  curved needle of Deschamps, which certainly would
be  preferable if it were possible  to go far enough back.
   c. By the supra-hyoid region.—I have elsewhere described, (Arch.
Gen. de Med., 2e ser., t. V., p. 638,) after having  seen the operation
made trial of by M. J. Cloquet,  another process,  since improved by
M. Mirault, the son,  (Mem. de  VAcad. Roy. de  Med., Paris, 1835,
t. IV., p. 35.)   An  incision between the  os hyoides and  the  chin
enables us  to  introduce in this  manner, from below upwards  and
from before backwards, through the base  of  the tongue, a double
ligature which is to be turned one on either side, upon  each half of
the organ, in  order to bring them  out  through  the same opening
below, and  to fix them with a knot-tightener under the jaw.
   V. So long as the tumor does not  extend too far  backwards, and 
THE  TONGUE.
375
that it retains a small  portion of sound tissues upon its borders, ex-
cision with the cutting instrument is preferable.   Louis recom-
mended, after the manner of the ancients, that  after having hooked
the tongue by means of an erigne forceps, or the forceps of  Museux
for example, we should amputate it by merely cutting through  it
simply and transversely with the bistoury.
  VI. At the present time we adopt a much more rational  process.
The surgeon having seized the morbid mass with a strong erigne or
hook forceps, draws  it out of the mouth with one  hand,  circum-
scribes and removes it with the other  by means of two cuts of the
scissors, making a V incision through the sound parts, and the point
of which faces backwards and is to fall upon the median line.  Im-
mediately approximating the two sides of the wound, they are to be
united by three points of suture, one on the dorsal  surface, a second
at its point, and the third on its lower surface.  The agglutination
is often completed by the second day.   The threads  may be with-
drawn on  the third or fourth  day, and  the  cure  is generally com-
pleted from the eighth to the tenth.  This is what has been seen to
take  place by Boyer and M. Langenbeck, and what I  myself have
witnessed.  In this manner the deformity is  reduced to as slight a
degree as possible, and the  accurate coaptation of the bleeding sur-
faces so frequently of itself  arrests, the hemorrhage that it becomes
unnecessary to recur to any other hemostatic means.
  VII. Process ofthe Author.—-Whatever process may be preferred,
a noose  of thread passed through the point of the organ always sim-
plifies the operation.  By means of this noose the surgeon does with
the tongue what he  pleases ; he draws it out,  relaxes it, depresses
or elevates it, and directs it to the right or to the left, without in any
way interfering  wTith the movement of the instruments.  M. Diffen-
bach, (Gaz. Med., 1838, p.  808,) who employs two  nooses of this
description, passes them behind the tumor and not  near the point  of
the organ.  Since the year 1831 I have employed them in ten cases,
and I cannot too highly recommend them to the use of practitioners.
M. Graefe (Bull, de Fer., X.  XX., p. 211,) and M. Delhaye (Journ.
Univers. Hebdom., X. IX., p. 20,1832), have been equally well satis-
fied with them.  If the tumor does not occupy the end ofthe tongue,
and  should it be  found nearer the  middle  than the  border of the
tongue, after making use of this precaution, I hook the degenerate por-
tion with an erigne in order to stretch it and encircle it in an ellipse
by two semilunar  incisions.   Should it become necessary to remove
one half of the organ, I first detach its lower  surface transversely by
a cut of the bistoury.  The instrument then  being immediately car-
ried behind and beyond the limits of the disease, enables me to divide
the tissues from above downwards  with a second cut, which termi-
nates the operation.   It would be difficult to find a more simple mode
cr one that is more generally applicable.
  C Appreciation.—Transverse amputation ofthe tongue therefore
should be  reserved for those  cases in which there is no opportu-
nity for  the formation of lateral flaps.   The  dividing  the tumor  by
a crucial incision and  then  cauterizing  its bottom, as Delpech did,
(Rev. Med., 1832,  t. II., p. 384,) is an objectionable process, which
would be applicable only to cysts of a benign nature.  The method of 
376          NEW ELEMENTS  OF OPERATIVE  SURGERY.

Jaeger  (Journ.  des  Conn. Med. Chir., t. I.,  p. 347), is too com-
plicated, and requires  too many instruments to find any advocates.
The previous ligature  upon the lingual artery, as practised  by M.
Flaubert, and which M. Mirault has made trial  of, would not be use-
ful except, if instead of the ligature en masse, we intended to make
the excision at  a  very remote point  upon the tongue.  It  is also
with difficulty that I can comprehend why M. Regnoli, (Gaz. Med.,
1838, p. 796,) in order to extirpate a tumor from the tongue should
have found it necessary to incise the entire supra-hyoid region and
to draw out the  tongue through this opening, though the young girl,
who was fourteen years of age, was cured.
  D.  When hypertrophy only exists, compression, as  employed suc-
cessfully by Freteau, (Bull, de  la Fac de Med., X. V., p. 264,) Del-
pech (Revue Med., 1835, t. I., pp. 330-337,)  and many others, will
almost always answer.  M.  Rey, (Ibid., 1835, t. I., pp. 330-337,)
who, in a case of this kind, states that  he was obliged to have resort
in one instance to the V excision, adds that the  operation of Mirault,
the father, was also performed for a hypertrophy, and not for a can-
cerous tumor.  It is quite remarkable that M. Harris (Bull, de Fer.,
X. XXVI., p. 93), and  M. Mussey, (Gaz. Med., 1838, p. 394,) who
believe themselves to have been the first who employed this process,
should also have been under the necessity of making use of the V
excision  to cure a  chronic tumefaction  of the tongue.  As to the
rest, every tumor,  whether scirrhous  or carcinomatous, which does
not penetrate  too  deeply and  which  projects  at the  periphery of
the tongue, may be readily destroyed by the  process of Faure or
Louis, that is to say, by means  of the scissors  curved flatwise and
the actual cautery.   Those on the contrary, wrhich, extending to the
muscular tissue,  are seen upon the surface or on one of the borders,
without reaching too great a distance posteriorly, and which have not
invaded either the entire  breadth or thickness of the  organ, require
the employment  of the  bistoury by the  process which I fraye pointed
out, and  which is somewhat analogous to  the method of P. le Mne-
monite.   If the  disease, though  much extended  on the surface, con-
tinues to be superficial, and that the tissues beneath it  are sound, we
must follow the indication given by Vallee and dissect and remove
everything which is  diseased, and respect  and  preserve everything
which is not so.  If it becomes necessary to destroy an entire half of
the tongue, including therein its  base, the ligature by  the process of
M. Mayor  becomes applicable and even appears to me to be prefer-
able to that of M.  Mirault, while, should it become requisite  to re-
move the whole tongue,  the  process  of Home ought  to have the
preference, as well as in all those cases in which excision, after the
manner of Boyer, is not sufficient for removing  the tumor and cen-
tral degenerescence.   It is necessary to be remarked  however, that
in the process of M. J. Cloquet or M. Mirault, as well as in that of M.
Maingault, there is no necessity of slitting up the whole length of the
tongue before strangulating its  base.  I will add, in the  patient of
the surgeon of Angers,  the ligature,  by embedding itself into the
tissues, became  imprisoned there by allowing  them to reunite over
it in place of mortifying them ;  the tumsr nevertheless was removed 
POSTERIOR FAUCES.
377
i   and the tongue remained entire.  As to the process of M. Regnoli, I
i   do not know what to say of it.
     E. Subsequent  Treatment.—It is extremely  rare,  as  has been
   shown by Tarbes, (Clin des Hdp., X.  II., p. 41,) that we are under
   the necessity, after these  different kinds of operations, of having re-
   course to the various objects of dressing.   If the contrary should be
   the case, the gusset (gousset) of Pibrac might become'useful.  Upon
   the supposition that there should  occur an unpleasant hemorrhage,
   or one  which the means  above pointed out cpuld not have effectu-
   ally arrested, we should then have to  have recourse to the ligature.
   In such  cases we should be obliged  to look for the lingual  artery at
   its passage above the os hyoides, unless that the carotid itself would
   not also have to be  included in the thread.  It would,  in fact, be
   advisable  to commence  there if the  tongue was to be  amputated
   near its root with the cutting instrument.

                            §  IV.—Palate.

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

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

                     § I.—Hypertrophied Tonsils.

      The  tonsils, after repeated inflammations, frequently remain so
    large as to interfere  with deglutition, hearing and respiration.  The
    induration they acquire at the same time, is the reason why for cen-
    turies past it has been believed that they had passed into the state of
    scirrhus.   But since the time of Claudinus,  and especially of B. Bell,
    the  falsity of  this  opinion, which I am surprised to see revived in
    some modern works,  has been generally acknowledged.   All  sur-
    geons  at  the  present time know that induration of the tonsils, with
    tumefaction, is nothing else but an hypertrophy,  and that it never, or
    almost never, gives rise to scirrhus  or cancer.  The treatment which
    has  been applied to it has greatly varied.  Without mentioning scari-
    fications,  eulogized by Asclepiades, Celsus,  Heister and Maurain, as
    well as by some of the moderns, and among others M. H.  Berard, 
378
NEW ELEMENTS OF  OPERATIVE SURGERY.
(Fabre, These,  No. 133,  Paris, 1832,) it has been attacked also by
cauterization, the ligature, extirpation and excision.
  A.  Cauterization.—Mesue,  who appears to have  been the first
who ventured to apply caustics to the tonsils, made use of the actual
eautery.  Brunus  adopted the same practice, at least when it was his
intention to  destroy the  whole disease.   Mercatus, who followed,
made  use  of a gold cautery moderately heated, and which he con-
ducted through a canula.   M. A. Severin, less exacting than Merca-
tus, contented himself with  an iron instrument, and  did not have
recourse to it  any more  than  his  friend Affisius,  except for  tonsils
with a large  base.   Wiseman,  after having mentioned that Ed. Mol
very successfully cauterized the tonsils by  perforating  them at seve-
ral  times with a red hot iron, nevertheless confesses that he prefers
the employment of escharotics, which Junker, Heister and Freind
also advise,  under various forms.   The lapis infernalis,  successfully
employed by Morand,  is also sometimes in  usage at the present day,
but it possesses no advantage any more than sulphate of iron, copper
or alumine, except in cases where the induration is  recent and of but
little extent.   MM. Perronneaux,  Roger,  Sarmento, Quotard, and
F. Hatin, who following MM. Bretonneau,  Toirac, Guillon  and my-
self, have proposed nitrate of silver against acute anginas, have also
devised for this  purpose caustic holders, which might  possess some
advantage, especially that of M. Sarmento.  The red hot iron, which
Louis  seems to prefer, and which should  be adopted if it was pro-
posed to cauterize  vigorously, is evidently applicable only to fungous
tonsils, and in cases in which we were fearful of having left behind
a portion of what we intended to have removed, and of seeing the dis-
ease repullulate and the blood escape in too large a quantity after the
excision.  But as these different circumstances, pointed out by Percy
and Boyer, are but rare exceptions,  it follows, even on receiving
them as facts, that cauterization ought scarcely ever to be resorted to.
  B. The  ligature, devised for the  purpose of avoiding hemorrhage
with greater  certainty, and giving less dread to the patient, and which
has been  a long time employed in  France,  had not, however, been
distinctly recommended by any person  before the time of Guillemeau,
who, in order to apply it, made use of  a sort of knot-tightening for-
ceps arranged with considerable  ingenuity.   F.  de Hilden  is the
second  author who recommends it.  The  canula, provided with a
canulatefl  ring,  and which he invented for this purpose, in order to
conduct and  tighten the thread, and which instrument has been re-
vived . as a new one by  M. Smith, (Journ. de Prog.,  etc.,  t. VI.,
p. 275,) has not been adopted any more than the instrument of Guil-
lemeau.  Cheselden, one of its principal partisans, applied it by means
of a simple sound in cases where the tumor is as it were pediculated.
In other cases, he passed a double thread through the gland by means
of a curved needle, in order to strangulate the two halves separately.
Sharp  operated exclusively in this  manner, which Lecat, following
Castellanus, Levret and Heuermann, has modified in this point, par-
ticularly that  from  the  color of his two strands of thread, being diffe-
rent, it is never possible to mistake  them.   Bell  made use of a silver
wire or catgut;  inserted it in a slightly curved canula, which he in-
troduced to the top of the pharynx through the corresponding nasal 
                       POSTERIOR FAUCES.                    379

fossa; extended its  noose with the finger, placed it around the ton-
sil, and used his canula  as a knot-tightener.  Desault was satisfied
with a Brittany thread conducted through the mouth upon a dou-
ble  erigne,  and fastened by means of his ordinary knot-tightener.
Before him Heuermann had maintained that the polypus instruments
of Levret are those which are the  best for this ligature, which, how-
ever, may be equally well applied by means of the chaplet instru-
ment of M. Mayor,  or after the manner of C. Siebold, by  means of
a silver wire introduced with the  forceps.  The inconveniences of
the  ligature, which had  already been noticed by Van Swieten and
Moscati, are so obvious to every  person, and are so inherent in the
operation itself, that no one now employs it, notwithstanding the suc-
cesses attributed to it by  Physick,  so  that it  becomes  difficult  to
understand  the efforts made use  of in  England by MM. Chevallier
and C. Bell to bring it  again into repute.
  C. Extirpation, which Celsus appears to have pointed  out in these
words: oportet digito  circumradere (tonsillas) et evellere, was posi-
tively recommended by Paul of Egina, ipsam totam (tonsillam)  ex
fundo per scapellum resecamus,  who performed it with  a curved
bistoury.   Ali-Abfcas had invented for  this purpose a sort of hook
which is called senora, and Abu'l Kasem a small knife in the form of
a sickle.  In the place of the ankylotome of Paul, J. Fabricius advises
that we should first isolate the  gland by means of an elevator, then
seize it with  the forceps and. draw  upon it adroitly in order that it
may yield without difficulty, he says, and as  it were of its own accord.
It would be  practicable, if it were necessary, to  tear out the tonsils
by enucleating them with the nail  and finger, as was probably done
in the lime of Celsus ;  but this would be unnecessarily augmenting
the  sufferings of the patient, and any person may comprehend that
such an eradication must necessarily be dangerous.  Moreover, ex-
tirpation of the tonsils  is; entirely useless, and excision has long since
been substituted for it.   If, however, we should decide upon perform-
ing  it, nothing would  be more simple.  An erigne, or the forceps
of Museux, to  draw and disengage the gland from between the pil-
lars of the velum palati;  and a narrow and blunt-pointed bistoury to
divide it at its root, would answer, as in ordinary excision.  Only
we  must take care not  to go beyond the lateral limits ofthe pharynx,
for then the venous plexus, or some vessels still more important, the
carotid, for example, which is  found  on the sides of this  muscular
funnel, might become wounded, and give rise to a formidable hemor-
rhage.
  D. Excision.—Though Aetius appears to have been the  first who
formally announced  that we must only remove the  prominent por-
tion of the tonsils, and never  extirpate them, excision nevertheless
had  been recommended before him.  The operation which Ascle-
piades designates under the name of homoiotome, cannot be any other
thing. Has not Celsus also described it in this phrase ? Si ne sic quidem
resolvuntur, hamulo excipere et scapello excidere.   Those who since
then have adopted it, have almost  all of them endeavored to modify
the process.  Rhazes says that we  should seize  the tumor with  an
erigne, and retrench the  fourth part of it;  but according to him, it is
an operation so dangerous that we  ought rather to recur to  broncho- 
380
NEW ELEMENTS OF OPERATIVE  SURGERY.
tomy.   Wiseman, instead of using the hook and ankylotome of the
ancients, or the curved bistoury and double erigne of Mesne, com-
menced by ligating the tonsil, and afterwards made use ofthe thread as
an erigne, while he was excising the gland with  the scissors.   Mos-
cati, who was at first a partisan of the ligature, which  had already
been proscribed by Cavallini, and who at  a subsequent period practi-
sed excision  with a curved  bistoury, fixed  upon a blade of  wood,
afterwards adopted another  process: he  commenced by making  a
crucial incision into the tonsil by means of a convex bistoury, after
which he excised its four flaps separately, taking care to leave an
interval of three or four days between each operation.   Maurain,
who properly censures the  method of Moscati,  recommends with
Levret  that we should remove with  a single cut the entire tumor,
by means of curved scissors made expressly for the purpose.   Lecat
went back to the double erigne of Heister, and recommended a small
concave knife with a blunt point, or curved  and blunt scissors.  At
the same epoch Foubert recommended that  we should embrace the
gland with a polypus  forceps, and make strong traction upon it in
order to contuse the vessels while we were excising  it with a single
cut of the bistoury.  Caque greatly extols the simple erigne, then  a
blunt-pointed knife with a cutting edge which is almost straight, and
bent into an angle upon its handle.   Louis asserts that the ordinary
bistoury will  answer, and that if we divide the gland  from below up-
wards, we shall be sure to prevent it from reversing itself upon the
opening of the larynx, and exposing the patient  to suffocation, as in
the cases which gave so much alarm to Wiseman and Moscati.
Museux invented for this operation the forceps which bear his name,
and maintained that when the tonsil is once seized hold of with this
instrument, it is no longer possible for it to escape.  Desault gave the
preference to the ordinary double erigne,  and the kiotome.  Desaulf s
instrument, though ingenious, is  no longer  employed.   The blunt-
pointed, straight bistoury is infinitely more convenient, and, as Boyer
has remarked, in every respect deserves the preference.   The reason
why authors  have varied so much  in  the  manner of performing so
simple an operation, is because, in intractable persons,  children for
example, and those whose mouth also is small and deep, or who open
it with difficulty, it  is sometimes attended with considerable embar-
rassment.  A glance at the stages which compose the operation will
enable me, I hope, to reduce to their just value the principal precepts
of the surgeons who have just been  cited.
  I. Speculum oris and depressors of the tongue.—The  first thing  to
be attended to  is to keep the mouth of the patient open, and to con-
trol  the movements of the tongue, from  whence comes the different
glossocatoches of the ancients, and the various kinds of specula, which
followed from the time of A. Pare down to our epoch ;  from  whence
also comes the chevalet, the handle of which, curved in  the shape of
an S, enabled Caqu6 to draw the labial commissure  backwards, and
to keep the jaws separated;  and the silver plate which was applied
on the tongue, while its handle, a little more elevated, rests upon the
lower dental arcade, which it permits us to depress ; also that other
instrument more complicated, proposed by M. Lemaistre, and after-
wards by M. Gamier,  and which, without interfering with the move- 
POSTERIOR FAUCES.
381
ments of the operator, has the effect to keep the mouth firmly open
and the tongue depressed ; the plate of box-wood, or of ebony, bent at
a right angle, and in other respects quite similar to the horn, which is
used for raising  up the heel of the  shoe  in putting it on, and which
MM. Roche and  Sanson consider very useful; from  hence  comes
also the instrument of M.  Colombat, the annular wedge of M. Saint-
Yves, and  the long handle with a  disc of M.  A.  Berard,  &c.   But
a myrtle-leaf, or a spatula, the handle of a silver spoon, the finger, or
a piece of cork, are full as good, and less embarrassing than1" those
ingenious inventions, when  we are actually under the necessity of
attending to the mouth or tongue in this respect.
  II. To secure  the  tonsil.—The previous ligature  of Wiseman is
evidently a method more fatiguing than excision itself.  As  to the
erigne, it is to be  apprehended, it is said, that  if it is single  it may
lacerate the tissues and escape ; that it is attended  w7ith  too much
difficulty to insert it on  the contrary if it is  double,  or  especially
quadruple, as in the forceps of Museux.  It is  also objected  to these
last, that they interfere by their size with the movement of the other
instruments, and that they are not easily  supported  by the  patient.
Finally, the erigne with three points, devised by M. Marjolin, would
be still more embarrassing if it was necessary to disengage it before the
end of the operation, than the instrument of the surgeon of  Rheims.
There can be no doubt that there is some  truth in these objections,
though most  of t,he  inconveniences pointed out  are  trifling.  After
all, the choice of the  erigne is not here a matter of importance; pro-
vided that that  which is single possesses a certain degree of solidity,
that it has an arc of a certain extent, and seizes the gland behind, at
the union of its outer third with its  two  inner thirds,  it will enable
us to make traction upon it with as  much force, and  with  as little
laceration of the tissues as a double erigne. Louis has had no reason
 to be dissatisfied with it,  and I on my part have found  it very useful
in practice.   The double  erigne also, which was still used by Desault
 and Boyer, has  no other inconvenience, in my opinion, than  that of
 being  a  little more  difficult to adjust.   The forceps of  Museux,
 though less easy of management, but preferred by Dupuytren,  pos-
 sess an advantage which is not found in the erigne of  M.  Marjolin ;
 which is,  of not  incurring the risk when we withdraw them, of
 wounding the different parts of the mouth.   The erigne-forceps of
 M. Ricord have no advantage over those of M. Marjolin.  The same
 may be said of  the polypus forceps of the  shape of an L of M. Chau-
 met, those of M.  Saint-Yves, and the erigne with four hooks of M.
 Baudens.
   III.  The  large blunt or  probe-pointed  bistouries, and which are
 curved or straight, with a spring or fixed handle,  being merely a re-
 production of the  ancient  instruments,  are  entirely unnecessary,
 though they have been proposed by MM.  Blandin, Amussat,  Ricord,
 Baudens, and myself.  As  to the cutting instrument, the only choice
 at the  present  day is  between the  scissors and the  probe-pointed
 bistoury.   With the first we are more certain, especially in selecting
 the scissors with blunt  or probe  points curved  on their  flat  side,
 particularly  the  scissors of M. J.  Cloquet, (Arch. Gen. de Med.,
 2e ser., t. II., p. 124,) of removing nothing which we wish to  pre- 
382
NEW ELEMENTS OF OPERATIVE SURGERY.
serve.   But the section which they make has less neatness, and they
occupy somewhat more space in the pharynx and mouth than the
bistoury.   The gland, moreover, when pressed upon between their
branches sometimes escapes from them, and compels us to make sev-
eral cuts before we can divide it.  In respect to the bistoury, if there
is no longer any  question except of those which  are terminated by
a blunt or rounded point, it is because that with the others we might
easily  wound the posterior wall ofthe pharynx, and with  much facil-
ity also perforate its outer wall.   Caque's knife is  too large, and the
straight and narrowest  bistoury is  unquestionably the best that can
be made use of.  If the kiotome had not  been recommended by a
man so celebrated as Desault, and had been represented in a less fa-
vorable light by M. S. Cooper, it would  scarcely have deserved to be
mentioned.
  IV.  The  instruments being once selected, it remains to know in
what manner the excision should be performed.  In making this ex-
cision  from above downwards, as some have recommended, it is to
be feared that the bistoury might end by wounding  the  base of the
tongue, and that if the gland holds  only by a pedicle, it may escape
and be reversed upon  the larynx;  but it would  then be so easy by
passing the finger into the throat  to bring it back into the mouth and
to complete its extraction, that this difficulty, which had like to have
happened to Wiseman  and  Moscati, is in fact rarely to be appre-
hended.  Louis, who  had a dread of it, says, that  by cutting from
below  upwards, there would be  no danger of such an accident, and
that the tongue itself would "thereby be protected from  any injury.
In acknowledging the justice of this  principle, Boyer and Marjolin
concluded nevertheless to adopt it only in part. According to them,
if we run no risk of wounding the tongue, it is not the same with the
velum  palati, and  to avoid  also this last inconvenience they follow the
recommendation of Richter, and  first incise from  above downwards,
then from below  upwards, terminating at the middle part of the tu-
mor.   I see nothing to censure in these precautions only that they are
useless.  M. Roux usually operates like Louis, and has no reason to
be dissatisfied with his  process.   Up to the present time I have had
no reason to find  fault with it;  provided we take care to make the
tonsil sufficiently prominent by drawing it towards us, and by slightly
pressing it with the flat ofthe instrument against the arches of the pal-
ate, as  if for the purpose of grazing its curve, we  obtain one of the
neatest and most rapid sections possible, without having in reality
any thing to apprehend.
  a. Ordinary Process.—The patient  being  placed upon a chair in
front of a window properly lighted, is to have the head steadied and
more  or less turned back by an assistant.   The  surgeon placed in
front, after having properly shaped a piece of cork, inserts it as far
in as possible,  and adjusts it vertically between  the molar teeth on
one side, in order to  keep the  jaws apart.  Having  caused  the
tongue to be depressed should it be in the way, and the commissure
of the  lips to be drawn backwards  and outwards, the tonsil is to be
secured and firmly embraced by the erigne  at  its postero-inferior
portion, with the left hand for the left side, and with the*right hand
for  the right side.  After having drawn it out and disengaged it from 
POSTERIOR FAUCES.
383
 between the arches, he takes  in his other hand the bistoury, which
 has been wrapped in a linen band up to within ten or fifteen lines from
 its point;  then passes it  between  the erigne and the tongue, under
 the base of the gland ; turns its cutting edge upwards, and cuts on its
 whole length  by saw-like movements, as  if in order to make it de-
 scribe the arc  of a circle,  which is to finish at the base of the uvula,
 and in this manner separates with a single cut  the entire hypertro-
 phied portion of the tumor.   Withdrawing at the same time the bis-
 toury, the  erigne and the excised mass, he immediately removes from
 between the jaws the cork which is fatiguing them, then makes the
 patient spit out and gives him cold water, or vinegar and water, to
 rinse  out his mouth and to gargle.   If  one of the tonsils only was
 affected the operation is finished.   When both are diseased  we wait
 a few minutes ; the blood ceases to flow, and we proceed after the
 same  precepts to the excision of the other.   We may in fact not re-
 move  them until  after an  interval  of some days,  should  the pa-
 tient be too much fatigued or absolutely desire it; but in general they
 prefer to be operated on at  the same sitting rather than have it re-
 peated after an interval of time, and the  pain that they experience is
 in general so trivial that they can support it without any very great
 dread.
   b. Process of the Author.—In tractable or reasonable persons, the
 process that  I follow  by preference, differs  from the preceding in
 these  particulars:—1.  I place nothing around the bistoury or between
 the teeth.   2.  I require no person to depress the tongue.   3. I make
 use of the simple erigne,  possessing some  degree of  strength, and
 properly curved into an arc or hook.   I  hold the mouth of the  pa-
 tient open, and depress his tongue with the forefinger if I find it neces-
 sary.   I then immediately  plunge the point ofthe erigne into the body
 of the tonsil, from behind forwards, and from within outwards.   The
 tractions I afterwards  make upon  the tumor to bring  it towards
 the side of the mouth and uvula, force the  patient to open his  jaws,
 by paralyzing  the contractions of the tongue.  Making use of it as
 a guide to the bistoury, which I glide in  flatwise, the back part first
 between it and the dorsum  of the tongue,  the erigne enables me to
 direct the  instrument with certainty, and  without having any need
 of seeing it as far back as' to the bottom of the pharynx, to elevate
 its cutting  edge when it is  properly adjusted, and to terminate the
 operation while the wrist  is  inclined outwards, in  as little time and
 with as little embarrassment  to the patient as possible.  It is  entirely
 useless to  wrap up the heel of the bistoury ; but if we should take
 this precaution, it would he better to make use of a strip of adhesive
 plaster than a linen band.
  c. Another process of the Author.—The operation  I  have  just de-
 scribed is so simple and easy, that I can scarcely see any reason for
 simplifying it more.   To effect this object however, new instruments
 have been  devised, which  may possess some  advantages.  In order
 to improve the kiotome of  Desault,  Physick, M. Warren, M. Fahne-
stock,  in America, and M.  Toirac in France, have each one  for the
purpose of dividing the tonsil, proposed a sort of guillotine, which is
constructed with a ring to embrace the gland, and with  a movable
blade  in the form  of a large arrow, in those of  MM.  Warren and 
^
384           NEW  ELEMENTS OF OPERATIVE SURGERY.

Toirac, and in form of a circle in that  of M. Fahnestock.  The one
which I make use of, after having modified it, bears a ring near its
handle, and also a shifting and sliding point, (pique a bascule et a
coulisse,) in order to raise up and fix the body which is to be excised.
This instrument being introduced open in the manner of a spoon to the
bottom of the  mouth, serves very well to embrace the tonsil, the
summit of which  is immediately transfixed by the point, which must
be made to slide an inch backwards; by pressing on the ring of this
point, we draw into the ring as much as we wish of the tonsil.  We
then draw rapidly the cutting circle of  the tonsillitome with one hand,
while we steady its shaft with the other, which terminates the ope-
ration.   This is an  instrument which should be preserved for chil-
dren, intractable persons, and those who open their mouth with dif-
ficulty, and also for surgeons who are not accustomed to operations.
  V. Subsequent Treatment.—If the  bleeding should not immedi-
ately cease, a solution  of alum, eau de Rabel, or any other styptic
liquor should be immediately given  as a gargle, or should be applied
naked to the wound by means of a forceps, if it were necessary to
make it very active or concentrated.   In cases of imminent danger,
the actual cautery constitutes a last resource, which must not be neg-
lected, and which  is  much more efficacious than the very compli-
cated mode of compression proposed by Jourdain, or the agaric hold-
er of M.  Hervez de Chegoin.  In an adult whom I operated upon in
the beginning of 1831, at the house  of Mad.  Reboul, the loss of blood
was  so considerable at  the  expiration  of two hours, that it became
necessary to apply powdered alum  immediately upon the wound.  I
have seen the same thing since in one of my patients, and in another
who  had been operated upon in'the medical wards at the Hospital of
La Charite.  If some inexpert person should have opened  the caro-
tid, as Tenon or  Portal, and A.  Burns, Beclard and  Barclay state
that  they have seen, the ligature  upon the primitive trunk  alone
would still offer some chance of recovery.   A  frightful hemorrhage
followed some scarifications which had  been made upon  the tonsils,
and the woman was dead when M. Champion came to visit her. In
respect to the  remainder of the  treatment, it consists of emollient
gargles and diluent  drinks;  and the diet of broths  and light soups,
and afterwards food that is  somewhat  more  generous.  In general,
scarcely  any fever supervenes, and at the fourth  or fifth day the
health is in a great measure re-established.

            § II.—Abscesses and  Incision of the Tonsil.

  The surgeon is sometimes called  upon to lay open with the instru-
ment abscesses which form in the substance of the tonsils, as the re-
sult of phlegmonous inflammation.  The sharp-pointed knife of Hip-
pocrates and Celsus, the long bistoury  and needle used by Leonidas.
the razor of Lanfranc, the small piece of polished wood of Platner,
the sagitella of Arcularius, the bird-beaked bistoury devised by Vigo,
the pharyngotome of J. L. Petit, that of Jourdain, and the  lancet of
Roger of Parma, are,  when it becomes advisable  to perform this
small operation, all advantageously replaced by the ordinary bistoury,
when it is required  to perform this  small operation.   Pressure with 
POSTERIOR FAUCES.
385
   the finger, a stroke with the nail, or an emetic properly administered,
   also very frequently answer.   We also hold the mouth and patient
   in the same manner as for the excision of the tonsils, and the bistou-
   ry is to be wrapped in a strip of plaster to six lines from its point be-
   fore we should undertake to plunge it into the abscess.   The laying
   open of collections which are sometimes formed in  the substance of
   the velum  palati, in the- uvula and walls of  the pharynx, or even at
   the base  of the  tongue,  is performed with the same precautions,
   and requires no other attentions.

                    § III.—Cancer ofthe  Tonsils.

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

                   § IV.—Excision of the Uvula.

    The elongation of the uvula, either by infiltration, inflammation
   or degenerescence, was  an  affection which  the ancients paid much
   more attention to than the moderns, and which perhaps, merits more
                                25 
 386          NEW ELEMENTS OF  OPERATIVE SURGERY.

 attention than is  generally accorded to it at the  present day.  In
 consequence of its contact with the base of the tongue, the apex of
 the uvula produces a most  unpleasant titillation (agacement) in the
 throat, causes sometimes symptoms which appear to be connected
 with  affections of a  much  more serious character, as for example,
 gastritis and phthisis, and which might lead to the commission of
 dangerous errors in the diagnosis, as well  as in the treatment, if the
 surgeon should be ignorant  of these circumstances.  Consequently
 it is important that we  should not wait too long before applying a
 remedy for the  alterations  of the  uvula, and  that we should not
 forget that its ablation is frequently, as  Physick and Beckern more-
 over have  shown, the only means of curing certain obstinate symp-
 toms, which might lead to the supposition that there existed a serious
 malady.
   A.  Cauterization.—Its inflammation even  when acute, should it
 have  yet  made but little progress, very readily yields to cauteriza-
 tion with nitrate  of silver.   I have  used it like  M. Toriac in many
 cases, and have had every reason to be satisfied with it.  The melange
 eulogized by Demosthenes, and the caustics proposed by Galen, are
 at  most applicable  to cases of serous infiltration.   The  gold or
 iron cauteries made use of by Montagnana and  Arculanus, the nitric
 and sulphuric  acids employed by Vigier and Nuck, are very pro-
 perly abandoned.  Nobody  at the  present day would  venture to
 imitate the absurd advice given by Mesue, and  afterwards revived
 by Nuck and Bass, that is to say, to make traction upon the hair of
 the head  to  such degree as to tear  the skin from the cranium, after
 having  tied them with a ribbon  near their roots, and united them
 together into a topknot.
   B. Astringents.—Sal-ammoniac and the gall-nut according to S.
 Largus, the green shell of walnuts according to Galen,  burnt alum
 mentioned  by Rhazes, and pepper or  ginger still recommended by
 Purmann,  are  scarcely in use at the present time, except  by old
 women and country people, who, when the  uvula is down,  believe
 also that they can  raise it up by placing under it a silver tea-spoon
 heated to a very considerable degree.
   C. The ligature applied to the base of the uvula by means ofthe
 canulated ring .of Castellanus, as  Pare recommends, or by the liga-
 ture-holder of F. de Hilden  and  Scultetus, or in any other manner,
 though not as dangerous as  Dionis considers, is  nevertheless useless,
 and excision with a cutting  instrument is  the only means, which at
 the present day is  resorted  to for the chronic  lesions, which have
 caused the elongation, or what is called the falling down of the uvula.
   D.  Excision.—It is moreover an operation which has been per-
 formed  at  every  epoch,  and in  quite  a  great variety of  modes.
 Hippocrates  treats of it  and recommends that it  should be done
 with address; Celsus and Galen  followed the same process.  Paul
'had instruments expressly made for it; a staphylagrum to hold the
 organ, a staphylotpme to divide it, and a staphylocaustum to cau-
 terize the wound.  He also  speaks  of  another  instrument invented
 by Serapion.   Mesue, who  proscribes  the entire removal of the
 uvula, excised it with a gold  bistoury heated at the fire, after having
 secured it  in the  ring of a  sheath made expressly for this purpose. 
POSTERIOR FAUCES.
387
In place of this sheath, G. de Salicet recommends that we should
make use of a tube of elder, in which he placed the uvula in order
to divide it, either by means of the  hot iron  or with  the common
bistoury.   Guy de Chauliac recommends a forceps or  an  erigne, a
concave bistoury or scissors.  The scissors, without forceps or erigne,
answered with J. Fabricius, who afterwards cauterized the wound
in order to  re-excite  its  vitality.  A  Norwegian  peasant named
Thorbern,  devised an instrument somewhat similar to that of Mesue
and  Arnaud, that  is to say, a species of kiotome, which is  opened
in order that the  uvula may become secured in a circular perfora-
tion  placed near its extremity, and which it  is only necessary to
allow to shut up  of itself for the excision to be instantly effected.
Job-a-Meckren, who has  seen the uvula extend as  far as the lips,
considers that we  can use  nothing more convenient than the scissors
with long  blades.  Thorbern's instrument, improved by Raw, and
soon after revived by Bass, under the  form of a spatula  provided
with a cutting tongue, did  not prevent Fritze from attempting still
another modification to it since.  Levret, who was also  an  advocate
of the ligature, has eulogized scissors  with a concave cutting edge,
the same as for the tonsils and also polypus forceps.   Richter found
that  scissors with a  blunt point answered the purpose very  well,
and B. Bell had adopted a  curved blunt-pointed bistoury nearly simi-
lar to that  of Pott for hernia.  The, scissors of Percy, however, foi
the excision of the uvula are those which have been constructed with
the most ingenuity and simplicity; a prolongation of three to  four lines
bent into a right angle  terminates one of their  blades, and prevents
the uvula from making its escape from them, as soon as it  has been
secured.   The only objection to them, as well as  to  most of the
inventions  mentioned above, is that they are not indispensable, and
can  be made use  of only for this purpose ; from whence it follows,
that  the new  staphylotomes proposed by MM. Rousseau and  Ben-
natti are also useless instruments.  A slender ring-forceps with very
long handles, and  with its  beak armed with three mice-teeth, is  pref-
erable to all the others.
  E. Operative Process.—The patient is placed in the same manner
as for excision of the tonsils.  The surgeon having in his left hand a
fine erigne, or a dressing, or polypus, or the claw forceps which I have
described,  secures the uvula, inclines  it forwards and a little to the
right, and  then with  a straight and blunt-pointed scissors divides  it
with a single cut at some distance from its base.
  F. It is  not under  the  idle pretext of preventing it from falling
into  the larynx that we endeavor, in  the first  place, to secure the
uvula, but  because from its being supple and very movable it might,
without that precaution, escape from the  blades of the  instrument.
Oribases,  Rhazes,  Avenzoar, &c, were wrong in saying that its
entire ablation is dangerous, and that it always alters the respiration
and voice.   S. Braun  is still further from the truth in asserting that
it constantly produces loss  of speech.  The case cited by Wedel,
and which tends  to prove  that the aliments and the  drinks then
ascend through the nose,  is evidently only an  exception.   The ob-
servations of Scheffer, Becken, Myrrhen, and Physick, and those of
my own, satisfactorily prove that the loss of an organ like this rarely 
388
NEW ELEMENTS OF  OPERATIVE SURGERY.
produces any disturbance in the organism.  It is better even to take
awav too much than too little, in order that we may not be obliged
to repeat the operation; moreover the disengorgement which soon
takes place, causes the uvula, whose base was more or less concealed
in the velum of the  palate, ultimately to become much longer than
would  have been at  first supposed.
                      § V.—Staphyloraphy.
   Abnormal divisions  of the velum palati are,  as  in the lips, some-
times congenital and sometimes acquired.   If  the first are almost
always situated upon  the median  line, it is  generally because the
cavity of the vault of the palate has not filled up posteriorly, and that
its two halves are not united at that part at the usual period.  They
are, however, sometimes found  a little to one  side, but they have
never  yet been seen double.  The second, (or acquired,) which are
ordinarily  the  result of traumatic lesions, and  more especially of
syphilitic ulcerations, are  encountered to the  right and to the left as
well as in the middle,  and under the form of notches, the  depth of
which  is usually limited by the border of the vault of the palate, while
the congenital extend often to the  dental arcade, and to such degree
as to be continuous with the simple or double harelip should the patient
be simultaneously affected with that.
   A. History.—Nothing in the ancients  indicates that  they ever
undertook  to cure  this malorganization.   Roland, Harnemann, and
Tenon, who have mentioned  and seen it, do not speak of  its treat-
ment.   The moderns, more enterprising or more skilful,  have en-
deavored to fill up  this void,  and their efforts  have been crowned
with the most fortunate results.  In casting the eye upon a fissure
of the uvula, the idea of staphyloraphy  must have frequently pre-
sented itself to the mind.  The trials which M. Colombe states that he
made of it in the year 1813 on the dead body, and  which he wished
to repeat in 1815 on a patient who refused to submit to it,  have not
been known to the public.   That of which M. Graefe published the
details in the Journal  of Hufeland for 1817, and which he  dates at
the end of 1816, not having  succeeded, has  also passed unnoticed.
It is therefore  to M.  Roux for whom  it was reserved to call atten-
tion to this  subject.  In 1819 a young physician, M. Stephenson, pre-
sented  to him  the first opportunity for this1 operation.  It succeeded
to his wishes, and M. Stephenson himself made known his  cure in a
thesis, supported at London  in 1821.  In 1822. the  following year,
M. Alcock was no less fortunate than the surgeon of Paris.  It was
then that the rights  of M. Graefe to priority were appealed to by his
countrymen.   There  is every reason, however, to believe  that sta-
phyloraphy had been practised in former times.  Robert, in fact,
says in his memoirs on various medical subjects, published in 1761:
k< A child had  the  palate cleft from the velum  to the incisor teeth.
 M. Lemonnier, a very skilful  dentist,  endeavored  and succeeded  in
 reuniting  the two borders of the cleft, first inserted several points of
 suture in order to keep them approximated, and afterwards abraded
 them with a cutting instrument.  An inflammation supervened, which
 terminated in  suppuration, and was followed by the reunion of the
 two lips of the artificial wound.   The  child was perfectly cured. 
POSTERIOR FAUCES.
389
The words: child, a cleft, suture, the abrasion, the approximation, and
the cure,—all this, notwithstanding the somewhat  obscure language
of Robert, scarcely permits us to  doubt that his  dentist must have in
reality had  recourse to staphyloraphy,  and not to the suture of a
simple perforation of the vault of the palate.  This operation there-
fore is, in every point of view, a discovery entirely French.  It is
one, moreover, which is so frequently required,  that up to the pre-
sent time, 1839, M. Roux has himself performed it nearly one hun-
dred times.   M. Jousselin of Liege has  obtained two cures and M.
Baubien a third.  M. Caillot of  Strasbourg has published a fourth,
and in 1828 M.  J. Cloquet a fifth.   M. Morisseau has published a
sixth, obtained by him at Sable, in a young girl aged twenty years.
Bonfils communicated another about the same time to the  Society of
Practical Medicine at Paris.  MM. Smith, Hosack, Stevens and War-
ren, in America,  M. Dieffenbach  and others in Germany, and MM.
Philippart, A. Berard, (Arch. Gen. de Med., 2e ser., t. IV., p. 629,)
A. Thierry and Baraduc, (private communication,) in France, have
had every reason to be  satisfied with it.  I have myself been no less
fortunate  in one  instance.  M. Roux performs it at the present time
in the  same manner  that he did  in 1819.  In Germany, in place of
the word uranoraphy, which M. Graefe proposed, others have wished
to substitute the terms velosynthesis, kyonoraphy,  uraniskoraphy,
&c.   MM. Doniges, .Ebel, Hruby,  Dieffenbach, Wernecke,  Lesen-
berg,  Schwerdt  and  Krimer, have all endeavored to simplify  the
instrumental part of it;  and in England M. Alcock himself no  longer
follows the method of M. Roux in all its particulars.  All  the  stages
ofthe operation have been discussed, and deserve  to be so.
  I. Abrasion of the Cleft.—Cauterization by means of muriatic
and sulphuric acid, or caustic potash, as attempted by M.  Graefe, or
with the tincture  cantharides, lapis infernalis,  and even the hot iron,
as proposed by MM- Ebel, Wernecke and Doniges, answer a no bet-
ter purpose for abrading the fissure of the velum palati than that of
the lips.  Excision is  indispensable  in both  cases.  M.  Roux,  by
means of the dressing forceps, somewhat concave and slender,  suc-
cessively seizes the two halves of the  uvula or of its division near
their free extremity, taking care to include only  a very small portion
of their border ; then detaches from them, by proceeding from below
upwards or from behind forwards, a strip of tissue a line thick, which
he prolongs as far as  their angle of reunion, and even  a little be-
yond,  if the bony vault  remain  intact.   For that purpose  a straight
blunt-pointed and very  narrow bistoury,  moved in the manner of a
small  saw, appears to him preferable to the scissors, which are bent
into an angle upon their handle near their heel, and which he  at first
proposed, and which he even still sometimes uses to commence this
excision.   In the beginning M. Graefe, in order to carry  out  the in-
dication in question, made use of, first,  a long forceps, curved back
laterally near their points and  terminating  in a, double erigne;  se-
cond,  of an  uranotome, which  is too complicated for me  to attempt
to describe here.   Dr.  Hruby  has found that curved scissors,  like
those of Museux,. terminated in the form  of crutches, firmly  secure
the  velum  during the  time of the  excision.    The  forceps  of M.
Graefe. with or without hooks, have appeared sufficient to M. Dief- 
390           NEW ELEMENTS  OF OPERATIVE  SURGERY.

fenbach, who, for the abrasion properly so called, has contrived a
small knife, a good idea of which would  be conveyed by a lancet
which was narrow at its heel  and mounted upon a long handle.  Fi-
nally, M. Schwerdt differs only from  the  preceding  authors in not
having his forceps bifurcated at their extremity.
   II. Approximation.—The interrupted suture,  the only one which
in these cases can enable us to keep the two abraded edges in con-
tact, are nevertheless applied in different ways.
   a.  The needles of M.  Roux, which are  short,  flat and curved, in
the manner of a hook, are nevertheless broad at their heel, upon which
as in all other  needles  is placed  a  large  square eye.  The liga-
ture which he threads them with is composed of four or five strands,
properly waxed and about two feet long.  His needle-holder, already
known in the arts, is a sort of forceps having a groove on the inner
side of its branches, and which are tightened or relaxed at pleasure
by means of a ring.
   b. Those which M. Graefe made trial of in 1816, represent very
nearly the half of an ellipse.  They are of less breadth but greater
length than those of M. Roux, but their eye is much more elongated
and  perforates them  at  the side,  as in the ancient suture needles.
The forceps designed for inserting them is not traversed by any stem.
Two rings, which are two inches apart, and which support two late-
ral uprights,  open  or shut it by gliding towards its extremity or its
handle.   At the present time  the  needles  of M. Graefe are almost
straight  and terminated  in  a  spear point.   He has, moreover, bent
his former needle-holder into an angle near its point, in order that when
the needles are fixed by their border into the root  which the branches
of this instrument present, they may transform it into a  legitimate
hook.  Finally, M. Graefe has dispensed with the rings of this needle-
holder, which at the present day consists only of a jointed forceps, the
movable  branch of which is vibrating  as in the concealed lithotome.
  c.  The needles  of Ebel, which  are  straight, sharp  pointed, and
broader in the middle than at the heel, have, like those of M. Roux,
a square  opening  to  receive  the thread.   Those of M. Alcock are
curved into an elongated circle, and are almost round.  M. Dieffen-
bach  has devised some which resemble a small punch.  They have
no eye,  are straight  or slightly concave, hollow in their posterior
half, and may receive a leaden wire,  which their inventor prefers to
any other substance, and which they  readily draw after them.  His
needle-holder,  still more simple than that of M. Graefe, is in fact no-
thing more than a ring forceps, whose branches, which are a fourth
part  only of the length of the handles, are  bent  almost into a right
angle in  front near their point.
  d.  The needle and needle-holder of M. Doniges, make but one in-
strument.  It  consists of a long stem  supported  upon a handle of
ebony, slightly bent pdsteriorly, and terminated in front by a needle
hook pierced near its point and hollowed on its convexity to receive
the thread.  That of M. Lesenberg differs from it only in this, that
it is formed of two parallel branches,  which are separated or approx-
imated by the same mechanism as the first needle-holder of M.Graefe;
in such manner that all that is  required is to open it after it has perfo-
rated the parts, in order that the  thread that it  has conducted may 
POSTERIOR FAUCES.
391
be free, and that we may withdraw the needle without acting upon the
ligature.  M. Schwerdt, in adopting this needle, has proposed that we
should attach to it the bascule branch of the last needle-holder of M.
Graefe, in order to curtail it of the shifting rings of M. Doniges.
  e. M. de Villemur has contrived some which are altogether differ-
ent. His, while being retained in the needle-holder, are straight.  Issu-
ing from their sheath, from which a central stem enables us to expel
them,  they assume the curvature of the needles of M. Roux.   As we
push them from before backwards, they fall naturally into the pharynx,
from whence  they are  to  be withdrawn  gradually by means of a
dressing forceps.  The two ends of each thread being brought for-
ward  and  knotted out of  the mouth,  transform  the ligature  into a
great  circle, the  noose  of which it suffices to draw by its side, to
make  its broad  portion  slide backwards into the pharynx, after
which we untie the knot and terminate as in the other methods.
  III.  To knot the threads.—The ligatures being once adjusted, every
thing is not yet finished ; they are  also to be knotted and fastened.
In France  it would be difficult to comprehend why for this part of
the operation it would be necessary, as M. Graefe recommends, to
add other instruments to those already mentioned : 1st, a  small hol-
low cylinder, pierced upon  its  sides ; 2nd, a forceps bent into an
angle  on its back near its handle,  andhollowed out with two grooves
on the outer surface and each side of its point; 3d, a screw,  or species
of stopper, modelled after the preceding ring ; 4th, a second forceps,
straight, and with a  handle like the ordinary caustic-holder for  the
lapis infernalis ; and 5th, a long  steel  stem, mounted upon a handle,
dilated and cut into a square shape at its free extremity, where are
situated two openings to receive  the two halves of the ligature and
to form in  itself a  legitimate knot-tightener.  This display  of useless
objects is sufficient of itself to make known their inconveniences, with-
out the necessity of my particularizing  them.   M. Doniges in propos-
ing the surgeon's knot as a substitute for the instruments of M. Graefe,
a sort of crutch, cleft at the two  ends  of its transverse piece to  re-
ceive  the two ends of the  thread which are to be drawn  with one
hand,  while with the other we push this instrument towards the su-
ture, has doubtless forgotten that  the fingers would attain this  object
infinitely better.   Nor can I see what advantage in reality M. Krimer
can find in the employment of gold screws, rather than those of iron,
like those of M. Graefe, of black threads rather than white, and those
that are oiled in preference to those that are waxed.   The method
of M. Roux is still more simple and more natural.   This surgeon, after
having seized and passed the two ends of each ligature one into the
other,  makes a simple knot, which the forefingers directed to the bot-
tom of the mouth, enable him to tighten as powerfully as he wishes.
An assistant immediately embraces this knot with a ring forceps, and      (
holds it firmly, in  order that it may not be  relaxed, while the  opera-
tor is occupied with fastening it definitively by means of a second knot      ,
formed in the same manner, and outside of which we are afterwards
to divide by a cut of the scissors, each of the superfluous portions of
the threads of the ligature.                                             !
 B. Operative Process.Staphy loraphy, properly speaking, is not either      *
a difficult or a painful operation ; but being long, delicate, and fatiguing,      i
{ 
392
NEW ELEMENTS OF  OPERATIVE  SURGERY.
it requires much  endurance on the part of the patient, and even on
that of the operator.  Consequently it  cannot be performed except
upon those who desire it, who are are fully sensible of its importance,
and who have made up their  minds to  submit to it.   It rarely hap-
pens, therefore, that it is attempted in children under the age of from
12 to 15 years.  It exacts no precautions of regimen; only that the indi-
viduals should in other respects be healthy.   Diseases of the gastro-
pulmonary passages would especially  compromise its success, from
the cough,  sneezing, and necessity of spitting, which so frequently
accompany them.
  I. The different instruments, and which are to be prepared before-
hand, are composed of: 1st, six flattened regular and pliant ligatures;
2nd, twelve needles, one threaded at each end of the ligatures ; 3d, an
ordinary needle-holder, or that of M. Dieffenbach, if the needles of
M.  Ebel, which are almost straight, should be preferred ;  4th, a good
pair of dressing forceps, the branches of which being a little concave,
should not touch each  other exactly when they  are  shut, except at
their point, or better still, the claw forceps; 5th, a  straight, blunt-
pointed bistoury,  narrower than that which  is generally carried in
the surgeon's case,  or a very sharp-pointed and very narrow straight
bistoury ; 6th, excision scissors, and straight scissors, for dividing the
ligatures ; 7th, corks hollowed out into a gutter at each each extrem-
ity, to accommodate themselves to the form of the dental  arcades;
8th, a spoon intended for depressing the tongue in case of necessity;
9th, a number of towels,  an  aleze, cold water,  a glass, basin, and
also a small quantity of vinegar.
  II.  Situation.—The patient, provided with an aleze, and  wrapped
in a napkin and seated with his head supported by an  assistant,
should be placed in  a powerful light, as  for  the excision of the tonsils.
A second assistant stands ready to hand, as may  be required, the ba-
sin  and the water as well as the instruments.
  a. First  stage.—The  operator  being placed in  front and on a
chair, properly elevated, first  introduces the corks between the mo-
lar  arcades on either side ; then seizes the  right  border of the divis-
ion, by means of a forceps, in his left hand ; directs the needle-holder,
which has been threaded, into the pharynx with his right hand ; brings
it forwards and endeavors to make its point fall at three or  four lines
outside of and near the lower  part of the fissure,  in order that it may
perforate the velum.  Seizing hold of this needle by its point with the
forceps  transversely, after it  has  penetrated as far as possible into
the mouth, he detaches its heel  at the moment when the assistant
opens the needle-holder, and  without exercising the least movement
upon it;  he then  removes this last instrument, takes the forceps  in
his  right hand, draws the needle entirely towards him and brings it
out of the mouth, while it fetches the ligature after it.   The patient
being fatigued, is  under the necessity of spitting and of reposing for an
instant.  The jaws are then  freed of the corks by which they were
held apart, before proceeding to do on the left side with the second
needle and the other end of the thread,  by changing hands, what
has already been done on the right.   In order that they may not be
confounded with those which  are to follow, it is advisable to knot the
free extremities of  this first ligature  and to  depress  its noose  a little 
POSTERIOR FAUCES.
393
into the bottom of the throat, in order that it may not interfere with
the application of the others.  The two extremities of it are drawn to-
wards the commissures, and brought up by the assistant on the sides
of the head.   The surgeon then  places the  second and  afterwards
the third ligature, if he deems  it  necessary, with the same precau-
tions and in the same manner, leaving between them nearly the same
interval.
  b. Second stage.—After  having depressed,  to  one or two inches,
the noose of each thread while  pushing them backward, in order not
to run the risk of dividing them with the bistoury or angular scissors
(ciseaux coudes), the operator embraces the left lip of the  cleft at the
end of the uvula; commences  with the scissors  the excision  of the
thin strip which he intends to  remove, and  which the forceps is not to
let go of, while he continues to separate it with the bistoury as high up
as the bony vault; performs the  same manoeuvre on  the right lip
with the left hand, and returns to the use of the scissors, in order  to
regularize this abrasion, if  the bistoury has not been made to act in a
uniform manner on all the  points of the  abnormal division.  The
blood flows out, obstructs the pharynx and very frequently collects
in clots about the threads.  The patient requires to be relieved from
it, and to gargle  and to  remain tranquil for some moments.   In
other respects  the most  difficult  part of the operation  is  now com-
pleted.
  c.  Third stage.—The ligatures are to be now identified and to be
arranged in order, that they may be readily found again, and then suc-
cessively knotted, commencing  with that below. , When the separa-
tion is  considerable, and its coaptation appears to be attended with
difficulty, M. Roux detaches each of its lips from the posterior bor-
der of the palatine bone by a transverse incision of from four to  six
lines in depth.   The two  halves of the velum being then no  longer
restrained by the  hard parts, yield and approach each other with an
astonishing facility.  It is the mode of preventing all dangerous trac-
tion on the part ofthe threads,  and the new wound which has been
made, afterwards spontaneously closes without necessarily giving us
any uneasiness.   In order to remedy the same  inconvenience,  M.
Dieffenbach finds that a longitudinal incision at four lines external to
and on each side  of the abnormal fissure, is infinitely  preferable to
that of M. Roux, as it possesses  all its advantages without  having
any of its  inconveniences; thatiit also heals up of itself, and without
interfering with the relations  of the palatine vault,  admits of a very
decided elongation throughout their whole extent, of the flaps that
we wish to bring  together.  These  two modifications  are not unim-
portant, and should  be adopted;  the first when a separation of  the
bones is complicated with a fissure of the soft  parts; the second,
which is more common, when we have only to overcome the resist-
ance of these last, and the retraction of the muscles of the palate.
  C. Subsequent Treatment.—After the ligatures are  once knotted
the operation is finished;  no dressing  is required ; the patient is  to
remain quiet, without  speaking, and be careful  not to laugh,  cough,
vomit, spit or sneeze, and to take  only broths or light soups, until  the
suture has acquired  some degree  of  solidity.   On the fourth day  the
first thread, that is, the middle  one, may be removed ; the second or 
394          NEW ELEMENTS OF  OPERATIVE SURGERY.

highest on the day after, and the third not until the sixth day.   It is to
be understood that they are to be left one or two days longer should
the agglutination not appear to have been completed  at the ordinary
period.   It need not be remarked also that, in order to relieve the
tissues of them, we are  to confine ourselves to dividing  them upon
the side of the knot, which is to be held and  then withdrawn with
the forceps.   Nevertheless the operation quite frequently fails.  A
young girl, whom I saw at the Hotel  Dieu, was operated upon for
it five times  without  success.  Many patients of M. Roux have
succumbed  in consequence of it, and  I have  seen  a  certain num-
ber that this surgeon had operated upon without any  benefit.  Other
practitioners have procured a still smaller amount of successful re-
sults  than M. Roux, so that it is not  prudent to undertake it except
under favorable circumstances,  and  in patients, for  example, who
are in good health, tractable and  between -fifteen and fifty years of
age.
   D.  Modifications.—If  reunion  has  been accomplished  only to-
wards the uvula, as  frequently happens  when the fissure is prolonged
upon  the median line of the jaw, it should not be the source of any
anxiety.   Quite frequently the opening which  results from it disap-
pears without any other treatment, alter the expiration of a greater
or less length  of time,  which result moreover  is to be promoted by
inflaming the edges with the  lapis infernalis,  as I  have done and
seen M. Roux do, or with the nitrate of mercury, as has been suc-
cessfully done by M. J. Cloquet.   After all, the patient would be rid
of his trouble with an aperture  only, if there were not other re-
sources, and if palato-plasty was not at  our command for an accident
of this kind.
   I. Cauterization.—There is another method  yet, which is repeated
cauterization at  the superior angle of  the fissure, either  by a small
bird-beaked cautery, or  the  nitrate  of silver, as  proposed by M.
Henry de Lisieux, which method has  been successfully employed by
M. J. Cloquet, in  order to entirely dispense with, or  as a substitute
for, staphyloraphy.
   II.  Modifications.—Process of the  Author.—In place of beginning
by adjusting the threads, I commence with rawing the borders ofthe
fissure ; for that purpose I seize  its left free border  either with the
claw  forceps or  that which I have pointed out  as the one to be pre-
ferred, in speaking of the excision of the uvula, in order  to cut off a
strip from it and afterwards to operate in the  same  manner  on the
other side.  As the small knife of M. Dieffenbach might, if necessary,
be replaced by a keratotome or by a lancet of some  length, secured
by being wrapped in a strip of plaster, or even  by a common straight
bistoury, and which has no other inconvenience than that of incurring
the risk of wounding the posterior wall of the  pharynx, I should not
hesitate to make use of it in place ofrthe blunt-pointed bistoury; but
a straight, very sharp,  and very narrow bistoury is much better still.
Being plunged through the velum palati from the mouth towards the
pharynx, and very near the fissure which is to be excised, and after-
wards conducted parallel to this fissure, at first in front or towards
the bones or from  below upwards, then towards the  uvula, a  strip is
readily separated from it, the extremities of which, being the last that 
POSTERIOR FAUCES.
395
 are detached, evidently render the excision of the whole more cer-
 tain and more easy by furnishing a double support to the instrument
 up to the end of the operation.   I  now wait a few minutes, and, as
 soon as the blood no longer flows, I adjust the ligatures with the flex-
 ible needles and needle-holder of M. Villemur,—that is to say, from
 the mouth towards the pharynx, or from before backwards, as is pre-
 ferred by M. Berard, (Arch. Gen. de Med., 2e  serie, t. IV., p. 629.)
 The rest of the operation requires  no particular directions: I suc-
 ceeded in this manner, in 1837, in a young man at the hospital of
 La Charite.  M. A. Berard  was  no less fortunate in another case.
 But  in a young girl whom I operated upon in the same manner in
 February, 1839, the reunion  did not continue.
   III. An instrument furnished with  straight needles, carried from
 before backwards, and which secures the  velum by embracing it,
 and brings back the needles  and the thread  at the same time through
 the fissure,  would  simplify every step ofthe operation, and has lately
 been  made, at  my request, by MM. Chopiniere and Foratier, pupils
 of the hospitals.  M.  Beaumont, (Med.-Chir. Review, Oct.,  1838,
 p. 148; Enc des Sc. Med.,  1838, p. 119,)  with the view of more
 readily applying the suture to vesico-vaginal and recto-vaginal fistu-
 las, also makes use of a sort  of needle-forceps, which enables him to
 introduce and draw the thread  through the staphyloraphy in one
 movement.
   IV. In a boy eleven years of age, in whom a fissure was made in
 the palate by  a  piece of wood, M. Fristo succeeded completely by
 making use of a blunt-pointed  bistoury to excise the  parts, and of a
 long dissecting  forceps, provided  with a sheath, for a needle-holder.
 A small hook, mounted upon a leaden handle, answered the purpose
 with M.  Philipart; and M.  Smith,  rejecting the  complicated appa-
 ratus of M. Hosack, finds nothing more required to introduce all his
 threads than a hook-shaped lance, (lance a crochet.)
   V.  M. Montain's clasp is  too fatiguing to be generally adopted.
 Finally, if the  fissure should continue near the incisor teeth we might,
 as M. Sanson (Diday, These de Concours, 1839, p. 25) did in one in-
 stance with success, shut it up by means of a flap borrowed from the
 upper lip.
   [Staphyloraphy.—From a recent  elaborate work of the celebrated
 Dieffenbach, (Die Operative  Chirurgie, Leipzig, 1845—see also con-
 densed abrege of this work in the Dublin Journal of Medical Science,
 Nov., 1845, No.  LXXXIIL, vol. XXVIIL, p. 227—249,) it would ap-
 pear that this  surgeon now dispenses with the usual preparative pro-
 cess of familiarizing the parts to the touch of the instruments, fin-
 gers, &c, before proceeding  to the operation, from having himself
 found it impracticable, and also from patients being so  averse to it.
 He however approves of it where it is practicable, illustrating its ef-
 fects by the fact, that those  who suffer from chronic  ulcers in  the
 throat, lose altogether the sensibility of these parts by frequent,  gar-
 gling and pencilling.   He uses short curved needles, the blunt ex-
 tremities of which are formed into hollow tubes for holding  the
 pointed ends  ofthe leaden wires used for  the  sutures.   The  lead
 wire should be of new drawn lead, as the old is brittle.  The clots
of blood are removed by a small piece of globular sponge, fixed in a 
396
NEW ELEMENTS OF  OPERATIVE SURGERY.
delicate forceps.  The patient may take water in the mouth after
the margins are excised, but not  gargle, as this excoriates the abra-
ded parts.  When the cleft is not wide, and after the clots of blood have
been thoroughly removed, the  lead  stitches, the upper one of which
is to be inserted first, are to be twisted close together, so as to bring
the edges of the excised cleft into perfect and intimate  contact, so
much so that the lead rings (i. e.  sutures) become covered  with the
mucous membrane.  But all this is not to be done until the whole num-
ber of sutures have been inserted, and which are only to be gradually
approximated at first.  Prof. Dieffenbach makes his excisions with the
hook and  bistoury.   The side incisions through the velum, (and which
we should say, ought to be made after excising the edges of the fissure,
and inserting the sutures loose,) he deems of vast importance. One is
made on each side the  cleft, plunging the bistoury in half an inch dis-
tant from it, and half an inch distant also from either end of this cleft.
The bistoury, with a sawing motion, is then carried directly upwards
to the bony palate.   Considerable blood flows, and the mouth must
be washed frequently with cold water.   The good effect of these in-
cisions is seen immediately, the still-strained palate hangs down lax,
like a damp curtain,  and  the wounds on the sides appear like two
oval clefts, which would admit two fingers.  The painful and strain-
ing sensation, which  penetrates into the ears, also ceases immediately,
and the air passes freely in and out  through them.  They are espe-
cially necessary and before finally tightening the wires and closing
the cleft, when the fissure is wide  and ascends high up; in such cases
the lateral incisions have to be made through the palate, as near the
cheek as possible.  The  patient must remain in  bed, rather in a sit-
ting than in a recumbent  posture, and the mucus which collects in
large quantities about the stitches, is to be frequently cleansed off by
the sponge, as mentioned  for removing the blood.  Only water  and
mucilaginous drinks  are to be given, as  lemonade and acids oxidize
the wire.  On the third  day the mouth may be washed  with tepid wa-
ter or elder  tea, and on the fourth, the agglutination  being ascer-
tained to be complete,  by probing it  with the camel's-hair pencil, the
first ligature may be removed, and on  the fifth and  sixth days the
others.  Frequently, in fact in many cases, M. Dieffenbach has thus
succeeded in uniting the entire cleft.  The shorter the cleft, the nar-
rower it is, and in these, two or three stitches only will ansWer.   If
the stitches cut through and  the cleft opens, they are  to be  speedily
removed.  Sometimes they suppurate, leaving only one.  In that case
they must also be removed without delay, except that one which is leit
for the support of a bridge. At the next operation, the edges being by
this bridge found more approximated, will require an abrasion ol  a
straw's width only. The preservation of union in the lower half is still
more fortunate.  If  all the stitches cut through,  the  next operation
should be  deferred at least a year, as the scars will not have become
soft till then.  Frequently, M. Dieffenbach  has succeeded completely
in his subsequent operations.  In  a young lady,  he met with entire
success, though other surgeons had failed  antecedently in three dif-
ferent attempts.  The  side incisions close without any aid from art.
If after their closure  any granulations  protrude,  they are to be
touched with nitrate of silver.  The closing up a cleft in the hard or 
POSTERIOR FAUCES.
397
bony palate by the distinguished professor's method, is probably more
easily described than accomplished.  He first punches a hole through
each edge of the cleft, and inserts a thick soft silver wire, which is to
be  drawn upon  and  twisted  as  close  as it  can  be, after  having
first cut down upon,  and then separated or cut through the palate
bones on each side where they join the alveolar processes, by means
of  a  thin,  smooth, concave  chisel.   The  flesh wound  thus  left
soon cicatrizes, and an advantage  is gained  as  to approximation of
the cleft, by exciting its edges  with the hot iron or tincture of cantha-
rides, so as to produce suppuration and granulations upon them.
  After the bony cleft is  sufficiently closed,  the  cleft in  the soft
parts is to be sutured,  and  the side slits are to be made as  before.
The rest of the operation consists in covering over the bony cleft with
mucous flaps, detached from each side, and drawn over and pressed
into the cleft, and  united at their free borders with fine  leaden su-
tures.  The abraded surface left by these flaps fills  up  with granula-
tions, which prevent the mucous operculum from  retracting again
entirely, should some of its stitches cut through.  It sometimes be-
comes necessary to cut entirely through a sound soft palate, in order
to reach and extirpate  or to cauterize  steatomatous tumors, adherent
to the posterior  portion and to each side/ This cleft is  to be left
open for free respiration till the cure is effected, and then reunited in
the manner already described.
  Small openings that remain in the palate after it has  been stitched,
or which come  from  ulcers, are found to be  more effectually closed
by  concentrated  tincture of cantharides,  than  by nitrate of  silver,
which latter Professor  Dieffenbach says  causes the loss of a layer of
the organized mass, while the  process of granulation which follows,
produces an  insufficient  deposit of fibrine,  so that the hole  gene-
rally, actually increases in size.  This, if  accurately true, is a most
important point  to be remembered  in all such apertures, since it is
well known that they have  hitherto been almost exclusively treated
by  cauterizations  with the lapis infernalis.   If these  apertures are
large  and oval, their edges  are to be regularly excised and brought
together by a sufficient number of lead wire  sutures.   If we endea-
vor to cut round apertures  into oval ones, there  is risk, as the open-
ing becomes larger if we  fail.   Their edges should be abraded howr-
ever, and one or two stitches inserted, which are to be tightened after
making a crescentiform incision through the palate  on  one side only
of the hole, or if the hole is of considerable size, we  should make one
of these incisions on  each  side  of it.  The  lateral  incisions  are to
be stuffed with lint, which causes  them  to  keep open, after which
they gradually fill up  with granulations.  Small holes in the hard
palate may also  be healed up by excising their edges, also by means
of tents of lint saturated  with concentrated tincture of cantharides,
kept in for an hour  at  a  time  and prevented from being swallowed
by a strong thread attached to the tent  and fastened outside the
mouth.  For large openings the professor recommends an artificial
palate to cover the same,  but not to project into it, and  which instru-
ment should itself be covered on its outside with a thin layer of gum
elastic, and fastened by means of flat wife-beams to the cheek teeth.
This does not prevent attempts at a radical cure by taking out the 
1
398          NEW ELEMENTS OF  OPERATIVE SURGERY.

palate daily, and moistening the borders of the instrument with the
tincture of cantharides.  In this manner he has  frequently seen aper-
tures that a finger could enter, finally closed up.
  In all his operations on cleft palate, he gives the preference to lead
wire sutures, because they can all  be gradually tightened to the same
degree so as to make uniform traction ;  whereas waxed silk and
thread ligatures cannot be tightened uniformly, and some of the su-
tures will draw more than others  and some even cut through.   The
hook and bistoury in making the excisions is far less irritating to the
palate, and more commodious, he  says, than the scissors.  He says
the suture is much more difficult,  if we adopt M. Roux's mode and
adjust that before making the side  incisions.  The side incisions also,
even if we do not succeed, give us a better chance for success  after-
wards, for nature  compels them to close up with new granulations,
which of course in the same proportion diminishes the  width of  the
cleft.  M. Dieffenbach strongly  condemns the cylinders  used by
Villemur's method to introduce the needles.
  The wearing of any kind of obturator, that goes entirely through
the aperture or the bony palate, as for  example sponge  or metallic
substances,  must necessarily  defeat its own object  in a measure,
by enlarging the aperture  itself.   M.  Dieffenbach has  thus seen an
aperture of the size of a quill increased so much as  to admit  the
finger.   There is no apparatus for clefts or holes  in the soft palate,
nor imitation  velums and  uvulas  which can be employed without
danger.   In small  apertures of the velum with  callous edges, we
may, until we  operate, allow  the  patient  to wear a double elastic
plate, which represents a  kind of  caoutchouc stud, until it is practi-
cable to operate.   This  is the invention of M. Dieffenbach.  The
intermediate portion must be  so small in diameter as  not to touch
the edges.  [Quere.  Why could  not this  ingenious contrivance of
M.  Dieffenbach be used also for large apertures  and wide fissures
in the hard palate, and  thus  avoid the danger of increasing their
diameter ?  T.]
  In applying it the patient stands before  a glass, and pinching the
inner plate  with a forceps inserts it  through the  hole,  when it is
immediately adjusted  by  its  own elasticity.   It is to be removed
three or four times a week in order to cleanse it, and also to  touch
the edges of the opening  with the tincture of cantharides should
there be  a prospect of diminishing the aperture  by this means.
  In  children, where  the  cleft goes  through the entire roof of  the
mouth, an apparatus made of  a steel keel which goes over the head
and  has  circular plates  attached, which constantly press on both
cheeks at once, will, if worn for some time, sensibly diminish the fis-
sure by the compression it makes on the jaws.
  In conclusion, to restore a destroyed velum is next to impossible;
but in partial destruction of one side only  we may make trial of the
lateral incisions, excisions, and  sutures, as  above described.   When
through scrofulous ulcers or other  affections, the posterior surface oj
the  velum has  become agglutinated to the  pharynx, thus completely
cutting off and isolating the nares  from the throat, closing up the eu-
stachian  tube and causing deafness, it becomes exceedingly difficult
to separate  the parts.   This  is  to  be done by  a  cross incision, and 
*
                       POSTERIOR FAUCES.                    399

then detaching the soft parts from the posterior pharynx, and aiding
this operation by a suitable spatula passed through the nose.
  Mr. Fergusson of London, (see British and Foreign Medical Re-
view, April, 1845, No. XXXVIII., pp. 415, 416,) by dissection ofthe
cleft  of the soft  palate, and a careful  inspection of its movements
during life, comes to these conclusions : 1, that the flaps are slightly
drawn upwards and to the sides, when the levator palati contracts ;
2, that when the levator palati and palato-pharyngeus act strongly
and together, the flaps are so forcibly drawn from  the  mesial gap,
that they can scarcely be distinguished from the sides of the pharynx ;
3, that the flaps are  forced together, and the edges  come into con-
tact when the  superior constrictor muscle contracts during the  act
of deglutition ; 4, that the circumflex palati  possesses but a feeble
power  over the  flaps; and  5, that  the  fibres of the palato-glossus
were very imperfectly developed in  the specimen in his possession.
  Based upon these  principles, he proposes a new  process, which he
has in  two instances  applied with entire success.  This consists of
the division of those muscles of the  palate, which have the. effect of
drawing  the flaps from each  other, and widening the gap between
them when  they contract, so that the stretched velum may be  in a
state of repose, and  the joined edges may not be pulled  asunder by
any convulsive action of the parts during the process of union. That
is, as an  accessory  to the operation, he advises a division  of  the
levator palati  and palato-pharyngeus  muscles, and  if requisite  the
palato-glossus.   This  is intended to effect methodically, by  the  ap-
plication  of  myotomy to  staphyloraphy, what-- probably is more
thoroughly  attained by M. Dieffenbach s large side-incisions through
the velum.
  Our countryman. Dr. Mutter, states that by the mode in which he
has proceeded for staphyloraphy, he has succeeded in giving relief to
all but two  cases out ofthe twenty-nine he has operated upon.  (Re-
port  on the  Operations for Fissure  of the Palatine Vault.   By T.
D. Mutter,  M.D.  1843.)  Dr. Mutter, like Dr. Mott, has found great
advantage in the preparative familiarization of the parts to the instru-
ment, finger, &c.  So decided  was this effect in one  case, that Dr.
Mutter could dispense with all  means  for keeping  the jaws open
or the  tongue in place.  He uses the  hook, and seizes  the lowest
angle of one edge of the cleft first; then plunges a thin, narrow-bladed
knife into this part, and like Dieffenbach, excises rapidly upwards to
the bone.   The strip is then  drawn tense and detached downwards.
His needle is small  and curved, and fixed in Physick's forceps, and
the thread is waxed silk.  Unlike Dieffenbach, Dr. Mutter puts  the
lowest suture in first.  We have noted the principal points in which
the steps  of  Dr.  Mutter's process  differs  from  that  of others.
He has never  met with any serious accidents.   If severe griping
should follow the operation, and which symptom he attributes to  the
swallowing of  blood, he recommends as the best resource, injections
to  be repeated every hour till  the  blood is brought away, or if re-
quisite an anodyne enema.
  Sir Philip Crampton's  process differs  from most  others  in  two
peculiarities, (Dublin Journal  of Med. Science, vol. XXII., 1843, p.
320, &c.):  1, in  securing  the  ligatures, which are of the ordinary 
4
400           NEW  ELEMENTS  OF OPERATIVE  SURGERY.

kind, by passing down upon them, as suggested by Mr. Maclean of
Dublin, a small metallic bead,  which, when it reaches  the  edges of
the cleft and has  drawn them together  to  the degree required, is
compressed by a forceps, and  thus makes a knot unnecessary ; 2, in
discarding  the starvation system of some, and allowing the patient
to eat all kinds  of  lubricating soft food,  as  jellies, custards, soups,
&c.   He  had at the period mentioned performed the operation by
his process in two  cases, one a boy aged 12, and also on a young
lady aged  16, in both with entire success.
   At the sitting of the Paris Royal Academy  of Sciences, March 17,
1845, (see  Arch. Gen. de Med.. 4e ser., t. VII., April, 1845, p. 507,)
the commission, composed  of MM. Pariset, Roux  and Arelpeau,  re-
ported in the most favorable terms of a new artificial substitute for
perforations through  the vault of the palate,  lately invented by
M. Stevens.   This obturator is remarkable for its nice adaptation to
the parts, without  the aid  of springs, clasps  or hooks ;  also for its
lightness, delicacy and strength, and the ease with which it may be
adjusted  or removed.  In  the case to which it  was  applied, a
superior officer  of  the  army in Africa, there was a large opening
from  the nasal  fossas into the buccal  cavity, causing all the usual
annoyances as to  deglutition,  articulation, &c, all  of which were
perfectly removed by the apparatus. T.]
                        CHAPTER  IV.

                 THE OLFACTORY APPARATUS.

                   Article I.—Nasal Fossae.

                     §  I.—Foreign Bodies.

  A.  Foreign bodies of all kinds  are  found in  the nares.   Khern
(Planque, Bibl. Med., X. XXL, p. 568,) saw there a calculus of the size
of a pea, and which was ejected  by sneezing, after the continuance,
for a year and a half, of  pains between  the two  eyes.   In  another
case (Gaz.  Salut., 1768, No. IV., p. 3,) the concretion was almost as
large as a nut.  M. Graefe speaks of a calculus that had formed upon a
cherry as its nucleus ; also of  another in a gouty  person, which was
friable.   A nasal calculus mentioned by Wepfer  (Jourdain, Mai. de
la Bouche, X. I., p. 519, obs. 19,)  and which was an inch long, rested
upon the root of the only tooth which the patient  had remaining.  It
is  to be remarked, also, that  stones  have  in  this manner been
very frequently  ejected  from  the nose.  A girl  ejected, first, seven
stones of the size of a pea, some  of which were of talc and others of
granite ; second, four other fragments of the size of a filbert and ir-
regular  in shape ; third, another stone ; fourth, three more stones ; and
fifth, three  small bladders, according to  the report of a curate (Gaz.
Salut., 1761, No. X., p. 3,) who was the dupe of this personage.  Two
small girls who were brought  to Deschamps (Tr. de la Taille, t. II., 
NASAL  FOSSAE.
401
p. 131, obs. 47)  by their mother, one seven years of age  and the
other eight, pretended to have been throwing out stones from  their
nose and ears during the space of several months ; some of the stones
exhibited to the surgeon left  him in no doubt as to  the deception;
one was a  piece of wall plaster, the other a very small flint;  the chil-
dren  confessed the trick.
  B.  Apea had assumed in the right nostril the appearance of a poly-
pus;  Renard (Gaz. Salut., No. 51, 1761, p. 4,) extracted it  with the
tenaculum  in presence of five of his confreres, who had been deceived
by it.   Dumoustier mentions  two dry peas which had been intro-
duced into and had become swollen in the nose during  the space of
two days.   It became necessary  to  extract them  in fragments, by
means of a gimlet, (Obs. et Reflex, sur quelques  Corps etrang. etc.,
Strasb., 1810, p. 8, obs.  3.)  Meckren (Obs. Med.  Chir., chap. 14,)
even speaks of a polypous excrescence containing  within it a fragment
of wood, which a child three years of age had secretly thrust  up
its nose, and which had  been the cause of the suppuration  and ex-
crescence.  An earwig which got into the nose and occasioned there,
according  to Sandifort, (Exercit. Acad., 1788 ; Gaz. Salut, 1786, No.
51, p. 83,) excruciating pains, was expelled during fumigation with tepid
water, and was, followed by the evacuation of  a fetid pus.   A leech,
which had been swallowed and become attached to the nasal fossas
in the druggist Lalouette, (Rec. de Mem. deMed.-Chir. et Pharm. Mil.,
t. X., p. 406,) kept up in this  manner an  epistaxis  during the space
of three weeks.  Bleeding, astringents and topical applications had
no effect;  a tampon of lint, wet with  eau de Ravel, succeeded  no
better.  The blood began to flow again when it was  taken  away in
the morning ; the patient finally blew his nose  and the leech was ex-
pelled.  Thos. Etbrun (Gaz. de Med., p. 288, t. II., 1761,) also mentions
that a leech, whose head and tail had become attached to the poste-
rior cavities of the nose, produced an epistaxis  and  spitting of blood,
during the space of from 18 to 20 days, which resisted every remedy
and several bleedings ;  the inhalation  of saline  vapor through the
nose  caused the leech to drop  off behind the uvula, where it was
seized with the  forceps.
  C.  A cherry nut, which had caused an obstinate pain in the head,
spontaneously came out  through the mouth, after having remained a
long time  in the nose.  A similar fact is mentioned by Verduc, (Tr.
d'Oper., p. 229.)  A young lady in this manner ejected calculi of the
size and shape of dates, according to Bartholin, (Planque, Bibl. Med.,
t. XVIIL,  p. 97,) and of the dimensions and length of the finger, ac-
cording to Water, (Coll. Theses  de Haller, X. II., p. 230.)  A peasant
girl had a  stone  in her right nostril, which shut it entirely up and occa-
sioned an  extensive tumefaction of the nose.  A  fetid sanies con-
tinued to ooze out from  thence during  the  space of 17 years; and
the septum had become pushed towards  the right.  M. Rittmeister
(Journ. d'Huff eland, 1817, et  Bibl. Med.,  X. 62, No. 185, Decembr.)
succeeded in extracting  the stone from it by means of the forceps.
It weighed two gros and a half, and was an inch  in diameter.
  D.  M. Champion  has found  the  best  means  of extracting such
bodies to be the black pin with two branches, or the hair pin fastened
upon a cork.  I  have procured the  same  success with an  ordinary
                                26 
402          NEW ELEMENTS  OF OPERATIVE  SURGERY.

probe, curved into a hook near its blunt point.   Madame D. called on
me, in great trepidation, with her child, three years of age, who  had
just introduced  into its right  nostril a flint which  could not be ex-
tracted.   It was a smooth stone in the form of a sugar  plum, and of
the size  of a large almond.   The  small  hook readily relieved  the
little girl of the difficulty.  We may in this manner  remove peas  and
the pits  of fruit  and  other uniform bodies ;  if the  substances were
stems, or angular or adherent bodies, the forceps would be preferable.
For living animals and insects it would  be necessary to  have  re-
course to injections of various kinds of liquids.  Making the patient
sneeze and  blow his nose also is an auxiliary means which he is  not
to neglect.
   [Foreign  bodies—Nostril.—Dr. P. F.  Eve of  Georgia extracted
from the right posterior nares, by means of his forefinger introduced
into the mouth, a tailor's thimble which a little girl  aged six years
had got  up her nose while playing with it, and where it had remained
deeply impacted for  two  weeks, without  however  producing  much
inconvenience,  (Amer. Journ.  of the Med.  Sc,  Philad., 1839, vol.
XXV., p. 494.) T.]

                § II.—Hemorrhage and Tamponing.

   Whether the bleeding which  comes from the nose be  the result of
a traumatic lesion or sanguineous congestion, as soon as it yields no
longer to revulsives, cold topical applications, styptics and  astrin-
gents, or that its duration and abundance  give room for anxiety,  the
surgeon  should without hesitation have recourse to the tamponing of
the nasal fossas.
   A.  This operation, which is  as simple as it is easy, is performed in
the following  manner:  We first prepare a  roll  of lint sufficiently
large to shut  up the  posterior  opening  of the nostril, around  the
middle of which is tied a double waxed-thread, and to this also a long
common thread.   Other  rolls, which are  of smaller  size or merely
made with  coarse lint, are  also to be prepared  beforehand.  The
operator passes into the pharynx, through the bleeding nostril, either
a gum  elastic catheter or catgut, a leaden or silver wire, or even a
stem  of flexible  wood, or if it  is practicable  Bellocq's sound, and
proceeds in such manner as  to bring to the outside,  through  the
mouth, the extremity of one of these objects, either by seizing it at
the bottom of the throat with one or both  fingers, or by pushing  the
spring of the sound, if it is this that he employs. Then attaching  the
double thread  to this extremity, he draws upon it in  order to  bring
the roll of lint into the  posterior fauces,  carrying with it the single
thread.  He then removes the  guiding instrument, which has now
become  superfluous:  again draws upon the plug of lint and forcibly
secures it from behind forwards in the diseased nostril, which is thus
found closed up  posteriorly;  separates the  two extremities of  the
ligature  which  come  out through the nose;  passes  between  them,
from  below upwards and before backwards, the other rolls or coarse
lint, until the front portion of the nasal cavity is entirely filled  up by
them; afterwards crosses the threads as  if for the  purpose of knot-
ting them, and tightens them with all the force that he judges neces- 
NASAL  FOSS.E.
403
sary upon this last mentioned tampon, in such manner as to push it
backwards, at the same time that he acts again upon the other with
equal force in order to bring it forwards.   By this means we may
easily fill up  the nostril with lint, close up at  least its two openings,
and present  an  insurmountable obstacle to  the  hemorrhage.  The
two ends of the thread which come out of the mouth and nose are to
be raised up  and attached to the cheek,  or fastened to the night-cap
of the patient, until the period arrives when the dressing is to be re-
moved.  It is at this time only that the single thread is to perform
its office, unless  the surgeon has been forced to withdraw and to re-
place the posterior nasal tampon before definitively adjusting it pre-
vious to removing the  whole, which should never be done before the
complete  cessation of the  molimen hemorrhagicum,  or seldom, at
least, before  the second or third day.   He then divides or  unties the
anterior knot and withdraws through the nose, by means of the for-
ceps, all the  lint, with the  exception of the first plug, which is re-
moved from  the pharynx, by the  mouth, by making tractions upon
the posterior thread.
   B. We are indebted to M. Martin Saint-Ange (Lapeyroux, These,
No. 314, Paris,  1836,) for a  process still more convenient than  the
preceding.   A canula opening at one end into a small sac, and  pro-
vided upon the  side of its other extremity with a faucet, which may
be opened or shut at pleasure, composes the entire instrument, which
the author denominates a rhinobion.   It is introduced, shut up, into
the nose as far as to the pharynx.   It is then opened,  ai.d  air blown
or water injected through  the canula into the little sac;  it is  then
shut up, and the distended sac drawn  towards us from behind  for-
wards, and the  whole fastened upon a tampon of lint  in front of the
nostril.   This  instrument,  which Bell and M. Miquel-d'Amboise
(Ibid.) had mentioned, has also succeeded upon  the patients treated
by M. Martin  Solon  (Bull, de Therap., X. XII., p. 20,) and  the  in-
ventor.
   [Epistaxis.—M.  Negrier (Arch. Gen., 4e ser., t. II., p.  354, 355)
recommends as a curative means in  nasal hemorrhages, to keep the
two arms raised up above the head, while the nostrils are  to be held
shut.   He has known two persons who were in the practice of this
method, to stop a  bleeding  of the nose which they were  liable  to.
The curative action is ascribed by him to the retardation which is
thereby effected in the return of blood to the head. T.]

                   § III.—Polypi of the Nose.

   Polypi of  the nose may be cured by exsiccation, cauterization, the
seton, excision, tearing them out, and the ligature ; but these different
therapeutical methods are far from being always equally efficacious or
deserving the same degree of confidence.
   A. Exsiccation, for example, is evidently applicable only to mucous
polypi taken at their  commencement;  it is even doubtful then if the
results which  it procures will  be  very satisfactory.  Moreover, at
the present day it is only occasionally employed, either subsequently
to, or as  an  auxiliary to the excision or tearing out of the polypus
Notwithstanding what Aetius, Alex de Tralles and Actuarius, and a 
404
NEW ELEMENTS OF  OPERATIVE SURGERV.
multitude of ancient authors have said of the powder of Teucrium
marum, and the apparent success which M. Mayer states he has had
with it, this does not, in my  opinion, appear calculated to throw any
doubt  upon this judgment.  I would  say the same  of compression
by means of a kind of tamponing eulogized by M. Lamauve, (St,c.
Med. de Mont pellier, X. IV., p. 129,) after having made trial of it in
one instance with success.
  B.  Cauterization is  somewhat more worthy of attention, and I
should not be surprised if the future should reverse the unfavorable
verdict which the moderns have given on it.  Hippocrates, who had
already praised it, used the hot iron by preference.   Arsenic, and ace-
tate  and sulphate of copper,  were, according to Galen, preferred by
Philoxenes, while Antipater and Masa also made use  of vermilion of
Sinape.  Sandarach, pimento, burnt lead, the root of the ranunculus,
quick-lime, and potash, lauded by Archigenes, S. Largus and P. de
Bairo, have since been replaced by butter of antimony, (which Garen-
geot used only after he had protected the sound parts by placing a phis.
ter between the polypus and  corresponding wall of the nose,) nitrate
of mercury, nitric and sulphuric acids, or the nitrate of silver.  These
different catheretics were applied te the disease by means of meches,
tents, or rolls of lint, pieces of sheet-lead, metallic tubes, &c, in order
to touch its prominent  part and destroy it by degrees.  Afterwards
they substituted for these, injections of lime-water, solutions of  alum
or vitriol, astringent or styptic decoctions ; finally, the whole array of
desiccative medicaments ; and the history of medicine shows that many
radical cures of polypus have in fact been obtained in this manner.
  I.  Process of Jensch.—In 1827 M. Wagner published some remark-
able  cases which, if authentic, are worthy of attracting public atten-
tion.   He succeeded in discovering  the secret of a German empiric
named Jensch, who had acquired in his province the reputation ot
readily curing the most obstinate polypi.   Having gained possession
of this secret nostrum,  which is nothing else than a melange of sul-
phuric acid,  butter  of antimony and  nitrate of  silver, M. Wagner
(Bull,  de Fer., t. XVI., p. 96,) was desirous of putting it to the test.
by following out exactly, moreover, the rules laid down by the char-
latan.  Now, according to his representation, its effects have been
almost miraculous.  The following  is tRe  process which  he gives:
A metallic stem, in the form  of  a long pin, and having a head of the
size  of a large  pea, is the only instrument required.   After having
placed upon the head a layer of caustic of greater or less thickness,
it is directed upon  the projecting portion of the polypus, and this
application is repeated from two to five times.   The operation is
daily renewed until the tumor faljs or is destroyed.   An injection of
alum is  thrown up  an hour before and an hour after the cauteriza-
tion.   When the principal mass is detached, we  confine ourselves to
touching the remainder with lapis infernalis.  The  injection should
be continued during the space of two months ; and in order to restore
to the sense of smell any defect that it may have sustained, we pre-
scribe to the patient powder  of nap eta (Teucrium verum)  in the form
of tobacco.   Moreover, I see no objection to making trial of this treat-
ment,  at least in timid patients, or where the polypus, being found as
difficult to extract as it  is to tie, is greater in its breadth than its pro- 
NASAL  FOSSiE.
405
truding part.  It would not, moreover, be the first time that ignorance
and gross charlatanism have suggested the idea of an advantageous
medication to the art of treating diseases methodically.
  II. The actual cautery, which  naturally inspires somewhat more
confidence than  the  potential cautery, and which, according to the
Arabic physicians, it suffices to apply on the forehead to prevent the re-
production of polypi;  which has been so warmly extolled by Roland of
Parma, who applied it to the disease through a canula; by D. Scacchi
and P. de Marchettis, who had the courage.to repeat this application
successively  for twenty days ; by Purmann, who succeeded in three
instances by means of an iron wire  heated  to a red heat; and by
Richter  and  Acrel, who were  careful to wrap the conducting  tube
in wet linen, the better to protect the surrounding tissues, is never-
theless at the present day almost totally abandoned.   It is only occa-
sionally that we may  still have recourse to it in rare instances, as for
destroying some  of the remains of the polypus which  have been left
after the other  operations,  to remedy the hemorrhage which some-
times  succeeds  to  its extraction,  or to  attack organized  (vivaces)
or malignant polypi.  None of these cases even absolutely deruand,
it.  In the first case,  escharotics, which are less alarming to patients,
are justly preferred to it.   Tamponing  replaces it perfectly well in
the second  case.  In the third case, the knife,  hot iron, and  other
applications, are almost,  equally  dangerous,    The kind of polypi,
which bleeds upon the slightest touch, frequently even without being
touched, and which produce  a  remarkable change in the features of
the patient, and  are  accompanied with lancinating pains,  do not in
fact yield to any remedy, and form a true noli me tangere.
  xii. Appreciation.—The  operation, moreover, is easy, so long as
the polypus is not situated too deep within.  During the space of some
days the anterior orifice of the nose is to be dilated if the cautery is to
penetrate through it.  A speculum nasi afterwards enables us to as-
certain precisely the situation of the tumor.  After these preliminaries,
the surgeon takes a canula, attached at an angle at its base to a  han-
dle, or to the ends of a species of forceps, unless he prefers making use
of a simple tube secured by a dressing forceps; wraps it in wet linen,
and directs it upon  the polypus,  which may then be  burnt by means
ofthe reed or olive-shaped cautery heated to a white heat.  Through
the mouth, that is to  say for polypi in the posterior fauces, it would,
in most cases, be impossible to use this means, which, even in other
instances, is frequently followed by intense  cephalalgia  and very
severe cerebral accidents, as Sabatier has repeatedly observed.
  C. The seton is a  resource of another kind.  Three  distinct ob-
jects, might,  if necessary, be obtained by this.
  I. The packthread arranged  with  knots, first proposed by Paul
or rather by Rhazes, afterwards  by Avicenna, and  especially by
Brunus, in order to saw through  the polypus, is a species of seton
constructed with considerable ingenuity, but which must act, to say
the least of it, as much on the Schneiderian  membrane as on the
morbid tumor.   Nor is the silver wire, surrounded  with a brass
wire  running round  it  spirally  and sustained by two handles, the
one fixed and the other immovable, as  recommended by Levret, in
place of the seton of  the ancients, found any longer in practice. 
406           NEW  ELEMENTS OF  OPERATIVE SURGERY.

  II. The idea of Le Dran was more natural.  This surgeon, by pass-
ing a hook through  the nostrils, in order to seize a meche of cotton in-
troduced into  the pharynx by the forefinger, or by inserting a catgut,
which he brought to the exterior through the mouth, in order to attach
this meche to it and to draw it  afterwards from-behind forwards into
the nasal  fossa, succeeded in  destroying a polypus, many ofthe roots
of which at first had escaped from him.   It was then easy for him to
introduce daily into the nose a roll of dry lint at first, to remove the
foreign  matters ;  and in the second place rolls of lint saturated with
digestive  or catheretic ointment, calculated  to favor the separation
of fragments  from  the polypus, and  to cleanse the wound.  It  was
also for this purpose and  to obtain this  object that Hippocrates and
Loyseau  (Observat. de Chir., &c, p. 67), and some others have also
extolled the seton.
  III. Goulard, with the  intention of simplifying the process of Le
Dran, has in reality only complicated it still more.   The hook shaped
like the nasal fossas, which he  prescribes instead of the catgut,  and
the fork, which enabled him to introduce the seton behind the velum
palati,  instead of using the  finger, are evidently  less  convenient.
After all, at the present  day  we introduce the seton  through the
nostrils  in the same  way as  for tamponing its cavities.  It  is a
method  the  advantages of which consist in enabling us to introduce
medicated substances upon any point whatever of the nasal fossas.
  D. Excision appears to go back as far as to the time of Hippocrates,
or at least to Celsus, who mentions a  species of cutting plate (spa-
tha), by which it was practised.  Paul cut out the polypus by means
of his spathapolypica, one of the extremities of which had attached
to it a chisel, and tore out the rest by apolypoxista.  Abu'l Kasem
commenced by depressing the tumor by means of a hook, in order
afterwards to  excise it with a cutting  instrument.  Others, Scacchi,
for example, operated  with the simple  bistoury, or, like Hutten, with
a species  of syringotome,  or again after the manner of Nessi, with a
curved  and  blunt-pointed bistoury.  J.  Fabricius censures these in-
struments and warmly extols a kind of forceps in the shape of a dou-
ble cutting spoon, which M.  A. Severin accuses him of having bor-
rowed   from  Nicollini, without  acknowledging it;  an  instrument
which Glandorp, V. Home and Solingen have successively modified,
and which Dionis, Percy and B. Bell have considered should not be
entirely rejected  from practice.  Le Dran, Manne and Levret, who
also under some circumstances excise polypi, employed no other in-
struments than the ordinary bistoury or curved scissors.   M. Wathely,
however, has  in latter times returned to the use of  the  syringotome,
that is to say,  of a bistoury prolonged  into the beak of a sound, con-
cave on its cutting edge and enclosed in a  sheath, in which it can
be readily made to  glide either towards  its point or handle.  When
the polypus possesses a certain degree of solidity, and approximates
very near to the exterior or to the pharynx, there is no doubt that by
the process of Abu '1 Kasem with a bistoury, or better still, the com-
mon scissors or those that are curved flatwise, we may succeed very
frequently in removing it; and that the cutting forceps of J. Fabricius
may also  attain this object in the depth of the nasal fossas, under cer-
tain circumstances.  Nevertheless excision is an uncertain method, 
NASAL  FOSSAE.
407
which almost always requires to be assisted by one of the preceding
processes if we do not wish to see the disease  repullulate, and one
which consequently ought not  to have the preference but in certain
exceptional cases.
  E. The tearing out of the polypus (arrachement), which has been
generally substituted for excision, is a method not less ancient and in
other respects very important.  It  is doubtless from having con-
founded the cutting pliers with the ordinary  pliers, that the moderns
have ascribed the first suggestion of it to  Pare, or rather to, F.
ab Aquapendente.  It is found distinctly mentioned in the works that
Sprengel ascribes  to Thessalus  and to Dracon, the son of Hippo-
crates.   There existed, even at that epoch, two modes of performing
it.  In one there was introduced by the nose a piece of sponge firmly
tied and  fastened by four threads; after which, by means of a long
needJe, they endeavored  to conduct these threads  into the posterior
fauces, and to make traction above them by means of a forked instru-
ment, and thus tear out the polypus.  The  other consisted in first
tying  the tumor with a catgut  surrounded with a thread, and in ex-
tracting it afterwards through the pharynx.    Paul  and Rhazes also
speak of this last process as one in common use.
  I. Brunus recommends that we should remove the fleshy excres-
cence by means of a hook, and G. de Salicet had already advised the
forceps.  Aranzi, who had contrived a kind that are very long, found
great advantage  in  directing the  light so that it should fall into the
nose through a hole in  the  window, or through  a glass globe filled
with water.   Whatever may have been said in praise of hooks, by
Job-a-Meckren. it is nevertheless to  Dionis that we are indebted for
the first circumstantial  details  upon the subject of employing them
methodically.  Since adopted by almost all practitioners, they have
been modified  by Sharpe, who sometimes employed such  as were
curved ;  by B. Bell, who pierced, or made an aperture through their
branches, and by Richter, who for large sized polypi invented a kind
whose branches could be adjusted separately, like those ofthe [uterine]
forceps.  The straight  forceps are the best wherever the situation of
the tumor allows of their application.  By  making them turn upon
their axis, we  act  upon the polypus with a  degree  of force which
cannot be applied with the curved forceps.   These last are reserved
for tumors which we wish to attack  through the throat and bring out
by the mouth.  As to the shifting forceps, they possess a decided ad-
vantage, when the  mass to be extracted is  too voluminous for the
common hooks to embrace  it with facility in the depth of the nasal
fossas.  Whatever, moreover, may be their dimensions or general form,
it is important that their extremities should  be pierced, or concave
upon their inner side like a  spoon, and provided with small  points,
called wolves'  teeth, in order that they may have a firmer grip.   It
is also advisable to give them as much solidity as possible ; otherwise
we should very often incur the risk of their bending.
  II. The tearing  out  of a polypus, moreover, after the manner of
the ancients, has  never  been entirely laid  aside.   Theden, for exam-
ple, first introduced a ligature  upon the pedicle  of the  polypus, by
means of a forceps, which formed by their union at the point a ring
dentated upon  its convexity, and pierced with an  eye at each of its 
408
NEW ELEMENTS OF  OPERATIVE SURGERY.
free extremities ; after which he made use of his thread to exercise
tractions upon, and to tear out the tumor.   Although Vogel has used
with success the forceps of Theden, M. Cooper, who. when he can,
also tears out polypi by  means of a ligature, has nevertheless deemed
it advisable to reject their employment, and no one at the present dav
would venture to maintain that they are indispensable.  In admitting
that this kind of extraction may have, as M. Cooper alleges, the advan-
tage of incurring less  risk of hemorrhage,  and of removing at the
same time the entire root of the polypus, and the fibro-mucous mem-
brane which has given origin to it, it would nevertheless  possess the
serious inconvenience of exacting two operations in place of one, of
being applicable only to hard, pediculated polypi, and of not being
susceptible  of application but with  difficulty in the depth of the
nostrils.
   III. When the tumor does not exceed  the  size of a nut, and that
it is solid, and without a pedicle of too great a thickness, Monind
has  been indebted for some  successful  results to the following pro-
cess :—The two forefingers are introduced into the nose, one in front,
the other behind, and as  far  as the polypus, upon which  traction is
then made  by pushing it alternately towards the pharynx and the
face, in order  that it may be finally detached and forced to come out
by the passage which  presents to it  the least  degree of resistance.
This is a process, moreover,  which, after  the manner of Dupuytren,
it would be advisable to combine  with the employment of hooks.
There can  be no doubt, in  fact, that by  pressing  with  the  finger
through the pharyngeal  opening of the nasal  fossa upon the tumor,
we should be able to effect its extraction  with more certainty and
facility by means of the  forceps, which draw  upon it in the opposite
direction.
   IV.  Operative Process.—This mode by arrachement requires no
preparation, unless we should think proper to imitate G.  de Salicet,
by gradually enlarging the anterior opening of the nares by means of
a sponge, or any other dilating means.  Cold  water, oxycrat, one or
more basins, an aleze and napkins, lint, and all the articles necessary
for tamponing the nasal fossas, an erigne, scissors, a blunt-pointed and
ordinary bistoury, dressing forceps, the forceps of Museux and seve-
ral pairs of  polypus forceps, as they may be required, should  be ar-
ranged upon a table or a' broad board.  It is also advisable to have
several  rolls of lint sprinkled with colophane, and even one or two
cauteries in case of obstinate hemorrhage.
   a. The patient with an aleze around him, and seated in front of a
window with  his head  supported by an  assistant, should have his
hands free if he is an adult,  in order that  he may be enabled to use
the gargle at pleasure ; or his hands should be surrounded and cov-
ered by the  aleze, oh  the contrary, if he is a  child. The operator
being placed in front, and standing up, introduces his hooks through
the orifice of the nose; recognizes with this  instrument the precise
seat ofthe polypus, which he seizes as near as possible to the pedicle,
while taking care also  to embrace it to  a very great extent; draws it
gently towards him ; seizes it a little higher up, if it elongates, with a
second forceps, without abandoning the first; then with a third, if he 
                          NASAL FOSSAE.                       409

 is still fearful of tearing  it without removing it by the root, and thus
 endeavors to extract it entire at the first operation.
   b. When  the tumor, from being situated too far within, or not suf-
 ficiently distensible to enable us to bring it to the exterior without
 having lacerated it, it is  more advisable, as soon as we  have seized
 hold of  it, to turn the forceps upon itself two  or three times without
 oscillating it, while at the same, time we draw upon it until the poly-
 pus yields and is detached.  During  these efforts the instrument is
 held by means of its rings with the right hand, and near its entablure
 with the left, in order that we may direct its movements better, make
 it act in certain cases in the manner of  a lever of the first kind, and
 to incline its spoon-shaped grip with all  the force  necessary,  up-
 wards, inwards, or outwards.
   c. If  the whole of the  tumor is not extirpated  at  first, or if there
 are several of them, we immediately recommence, and always in the
 same manner, until we are  certain that there is no longer any foreign
 body in the nasal fossa.   In  this respect, when we  are  desirous of
 knowing the exact condition  of things,  and that  the  eye no longer
 affords us any assistance,  it suffices to make the patient  blow  out
 with force while we hold the sound nostril shut.  So  long as the air
 finds  difficulty in passing  we may be  satisfied that some  portions
 of the polypus have escaped the action of the instruments.   If on
 the contrary nothing interrupts  it, and it comes in freely to  the
 respiratory passages with  a clear and  full (nette  et franc) sound,
 it is useless to make any further researches and  the  operation is
 terminated.
   V.  Appreciation.—Mucous  polypi  are  too  soft and adapt them-
 selves too readily to the parts which surround them, for the narrow-
 ness of  the  nasal opening  to interfere  seriously with their extrac-
 tion.  With  hard  polypi  it  is different;  the irregularities which
 they are covered with in order to adapt  themselves to the form ofthe
 passages, the prolongations  that they sometimes send  off, either back-
 wards or forwards  or into the maxillary sinus, or, as I have seen in
 one instance, into the zygomatic fossa  through the  spheno-palatine
 foramina, two other instances of which  have also been seen, one by M.
 Blandin and one by M. Cazenave, (Bull. Med. de Bordeaux, p.  25,) ren-
 der it in certain circumstances extremely difficult to draw them to the
 exterior.   Inasmuch as the bones in the body of the  nostrils do not
 present  any great degree of resistance  to them, they depress them,
 push the septum in one direction, separate the turbinated and ethmoid
 bones in another, and very easily depress the vault  of the  palate;
 while posteriorly the pterygoid process, the body of the sphenoid and
 the thick border of the vomer present  a much more considerable
 resistance to them, while in front the ascending process of the maxil-
 ary bone  also presents an obstacle to  them  for a  greater or less
 length of time.
  a.  They are especially arrested by the circle or fibro-cartilaginous
 border of the facial opening of  the nostril.   Owing to its great elas-
ticity and its want of distensibility this  circle has a constant tendency
J° ret"m tf^ ^s natural limits, and makes infinitely greater resistance
than the  bones to the force directed upon it.  If then it should appear
tnat the,  extraction of a polypus  of somewhat large dimensions would 
410
NEW ELEMENTS OF OPERATIVE SURGERY.
 be thereby  rendered too difficult, we ought, rather than have re-
 course to the dilatation of G. de Salicet, to slit up the ala of the nose
 from its free border as high as  to the triangular cartilage, as Dupuv-
 tren recommends, as I myself have done in two instances, and as M.
 Serre  (Compt. Rend, de la Clin,  de Montpellier,  1837) has also
 practised with success.
   b. When  the  tumor extends  beyond the posterior opening of the
 nasal fossa, it  is rarely practicable  to extract it entire through the
 nose.   It is  under such circumstances that the curved hooks become
 indispensable for seizing it  through  the  pharynx, as  has  been done
 also  by M.  Bermond (Bull. Med. du Midi; Gaz.  Med., 1838, p.
 442) with success.  If in  this position it should have acquired a great
 volume, or if in consequence of any particular arrangement  it had
 crowded downwards and forwards the posterior half of the palatine
 vault to so great a degree as to contract the arches of the palate, the
 method of Mau.ne or of Nessi, indicated  by Hippocrates, Guy de
 Chauliac or Garengeot,  adopted in  practice by Loyseau, (Obs. de
 Med. et de Chir., p. 66,) Petit  and  Hulterus, (Percy, Mem. sur les
 Ciseaux, p. 70,) and which consists in slitting open from above down-
 wards  the velum  palati  with a curved bistoury, would not be un-
 worthy^of adoption.   Heuermann and Morand had every reason to
 be satisfied with it;  and  I myself have tested its value in a similar
 case.   The objections that Schumacher makes to it prove only that
 it was  not indispensable  in  the case he mentions.  It is literally a
 debridement which is effected without any fear of wounding an artery
 of any dimensions.  The reunion afterwards took place spontaneously
 in one of the patients upon whom I operated. The polypus, which
 may be then  embraced and torn out, if not entire, at least in fragments,
 by means of the forceps or  fingers, might also be excised with the
 curved scissors or the  cutting hooks of M.  A.  Severin.
   c Finally, there are cases  where it  is necessary that these different
 operations should be united  and  skilfully combined, where after hav-
 ing extracted a  large portion of the tumor  through  the nose, and
 another through the pharynx, as is seen in  the example that M. Chau-
 met has given,  whether  we  have detached it or not in front or be-
 hind, enough still  remains to which the process  by ebraulement of
 Morand might also become applicable.
   d. In whatever manner it is performed,  the patient should be per-
 mitted from time to time to wash out  his mouth and nose by furnish-
 ing to him  simple cold water  or vinegar and water.  Should the
 hemorrhage become too abundant, every manipulation should cease,
 and  further attempts put off to  an interval of some days.  When
 however it does not cease spontaneously, it is arrested by tamponing,
 which renders the application of caustics or hot iron almost always
 unnecessary.  Nor should we proceed  so far as this even until we
 have unavailingly made use of inhalations of the eau de Rabel, or a
 solution of alum or some other styptic.
  VI.  Torsion.—The extraction of polypi, and especially of mucous
polypi,  is almost  always  effected by torsion.  The surgeon having
embraced the tumor well  and properly adjusted the hook or forceps,
turns it while drawing upon it as if upon its axis, and thus incurs less 
NASAL  FOSSiE.
411
risk of having the instrument relax its hold, and the polypus crushed
and broken into fragments before yielding at its root.
  VII. Subsequent Treatment.—The tearing out of polypi  is rarely
followed  by serious accidents.   It is  rare that  any  fever  super-
venes, or that the patients  are under the necessity of restricting
themselves to diet during the space of two or three days.   It is, ne-
vertheless, a method which is far  from always succeeding, or of be-
ing susceptible of employment under all circumstances without in-
convenience.   It is particularly well adapted to mucous and fibrous
polypi, which have one root only, and to  all those whose base is not
extended over too large a surface, or which, in a word, it is practica-
ble to extract entire.   The  sarcomatous polypi, whose cancerous de-
generation  commences  at  the  projecting part, would also be ap-
plicable to it  if, as Dupuytren alleges, we could distinguish  them
from the others  before proceeding to the operation ;  but according
to Boyer, it would in other cases only hasten the development of the
accidents, and lead to dangerous transformations.  Here also, more
than in any other cases, the operator ought to recollect the anatomi-
cal arrangement of the nasal cavities, in order that he may not pinch
up and tear out for polypi the turbinated bones which are  external
to it, nor shatter the septum which is on its inside, nor the cribriform
plate of the ethmoid which is above, nor mistake a simple engorge-
ment of the mucous membrane, or some  deviation in the bones, for
an abnormal production, nor fail at any stage of the operation in al-
ways guiding the forceps in a proper direction, nor be ignorant also
that there may exist in  the nose tumors, whose root  is in the frontal
sinuses,  as in  the  patient  operated on by M.  Hoffman, or in the
maxillary sinus, in  the interior even of the cranium, or in the ptery-
go-maxillary fossa  for example, as  in the  patient  mentioned by M.
del Grasco, and in whom the supra-maxillary nerve was transformed
into five enormous masses of a polypoid appearance.   In a patient of
M. Janson, (Compt. Rend, de I'Hotel Dieu de Lyon, p. 64, 1822,) the
polypus, which occupied the two nares and the maxillary sinus, made
its appearance in the mouth through an opening in the dental arcade,
partially issued through the ulcerated lachrymal sac,  projected into
the orbitar cavity,  from whence it had thrust  out the globe of the
eye upon the cheek, and obstructed the pharynx to such degree that
it became immediately necessary  to separate certain portions of it
by means of the ligature and knife in order to prevent suffocation.
In a boy  16 years of age in whom I had removed one  lobe of it, and
who died of small-pox,  the  polypus protruded at the same time out-
side of the  nose, into the pharynx, into the cheek through the sinus
maxillare, into the orbit and  temporal fossa, and also into the cranium,
the base of which had become softened and worn away by it.
  P.  Ligature.—The ligature, like  most of the  preceding  methods,
goes back to the remotest antiquity.  The Greeks and Arabs, never-
theless, rarely proposed it, except  as an auxiliary  to excision or  ar-
rachement.  We have  to come down  as far as  to  the 16th  and
17th centuries before we find it  clearly described and formally indi-
cated.  Fallopius applied it by means of a brass-wire, a noose of
which he directed around the polypus by means of a silver canula.
F. de Hilden has not  described his  process.  Glandorp, who  paid 
412
NEW ELEMENTS OF OPERATIVE SURGERY.
 particular attention to it, applied the ligature by means of a kind of
 needle shaped like a hook, and  having an eye near its  point, which
 was furnished with a  silk thread.  It was in the course of the last
 century  especially, that it became the subject of a multitude of in-
 vestigations and modifications.
   1.  First process of Levret.—Thus  Levret proposes to conduct a
 silver wire  by means of a sound upon the root of the tumor, to make
 its two extremities afterwards pass through a double canula, in order
 to twist  them by turning it on its axis, after having fastened them to
 the rings which it has on  its free  extremity.   Pallucci, in place of
 two tubes, soldered together at their sides in form of a double sound,
 states that  he had invented a simple  canula like that of Fallopius,
 but which was divided into two portions near its nasal extremity, by
 a small  septum.   Levret himself made  use of this instrument, and
 published an account  of it before Pallucci spoke of it.   It is neither
 perceptibly more or less convenient than the preceding, of which it
 is to be  considered as a  simple modification.   The  same may be
 said of the instruments of Nessi, Hunter and Kluge.
   II. Second Process.—Levret not being  enabled to reach polypi
 in the posterior  nares with his double  canula,  contrived for this
 purpose  a species of ring-forceps or  ligature-holding forceps, with
 long branches slightly curved, dilated at their extremity, and hollowed
 out, but which surgeons have not adopted  any more than they have
 those of  Theden, which undoubtedly suggested them.
   III.  Process of Brasdor.—The difficult point in the first process
 of Levret, is to secure the  polypus in the middle of the noose, which
 the metallic tube conducts  to it.  Brasdor  proposed to remedy this
 inconvenience by making use of a Coupelle silver wire  doubled so as
 to form a noose, drawn in  the  same way that plugs of lint are from
 behind forward, when we wish to tampone the  nasal fossas.  When
 the two  extremities of this  ligature are once brought out through
 the nose, the surgeon  seizes- them with one hand, draws them gently
 towards him, while with two fingers  of the other  hand  introduced
 into the pharynx, he endeavors to pass its  noose upon the root of
 the polypus, then introduces  them into a  knot-tightener, and imme-
 diately proceeds to the strangulation of the tumor.   A  simple thread
 is moreover fixed upon the  middle portion  of  the  silver wire, and
 left free  in the mouth, in order to be  enabled to draw the ligature
 backwards,  and  to replace it should it not be  found  at first  to be
 properly adjusted.  This, it  must be  confessed, is  a  real improve-
 ment ; but as we cannot tighten the metallic ligatures but by twisting
 them  upon  themselves, and  as  they consequently frequently break
 before having cut through the pedicle of the tumor,  many persons
 have always preferred to these the use of ligatures of hemp, flax or silk.
 The only advantage, moreover, which can  be claimed  for them  is
 that they form a noose, which easily keeps itself open without bending,
and which consequently is better calculated than  that of scft liga-
tures to glide upon the root of the polypus.
  IV. Process of Desault.—Desault, reasoning upon this hypothesis,
at first confined  himself to adjusting a  ligature of thread in place of
the silver wire used by Brasdor.   Subsequently, in order to obviate
the difficulty of forcing the tumor to become embraced in the noose 
NASAL  FOSS^!.
413
of a ligature so pliant, he adopted another course.  His last process
is performed by means of three distinct instruments: first, a canula,
slightly curved, terminated  in a  dilatation, (en larme,)  and having a
lateral ring at its other extremity;  secondly, a stem of iron or steel,
which is  a sort of knot-holder, which  is shut up, and  which glides
without difficulty into a second canula, and when  it is open repre-
sents a forceps, while when shut its beak forms a true  ring; third, a
knot-tightener, which is another metallic stem, one of the extremities
of which, bent at a right angle upon its axis, has upon it a rounded
opening, and the other  of wThich forms a cleft plate.   One of the
extremities of the thread is attached to  the ring  of the canula, which
it also has passed through.  The other is then passed into the ring
of the ligature-holding  forceps, which is immediately shut up  by
drawing it into its sheath.  The surgeon  then directs these  two  in-
struments  together upon the polypus,  and even a little beyond it,
endeavors to apply them above or below,  or to the right or to the
left  of the pedicle of the tumor, seizes  the knot-holder  with  the left
hand and stops it at this point, while with the other hand he causes the
canula to  pass around the whole circumference of the polypus, and
brings it to the point diametrically opposite, in order  to embrace the
pedicle accurately; glides once or  twice, one around the other, the
canula and the  knot-holder, in  order to  transform the noose of the
thread into a true circle; withdraws these instruments; leaves the
ligature in its place;  passes its extremities into  the ring of the knot-
tightener, which he  pushes backwards  with more or  less force, with
the  view of strangulating the morbid'mass ; fastens the extremity of
the  ligature upon the cleft plate,  and proceeds to attach it to the cap
of the patient, in order to maintain the whole in the nasal fossas.
The constriction is afterwards augmented gradually by drawing each
time with greater force upon the knot-tightener, and in the space
of a few days the section of the polypus is completed.
  V.  Another process of Desault, less embarrassing than the prece-
ding, is that which consists in introducing the noose of  a long thread
into the pharynx through the nostril by means of a gum elastic sound
or bougie.  The  operator proceeds to seize hold of this noose with the
finger as soon as it appears above the velum palati; brings it to the ex-
terior through the mouth; detaches from it the guiding sound, which
he withdraws through the nose ;  fixes to it an ordinary thread intended
for  the same uses as in the process of Brasdor;  makes  it ascend into
the posterior fauces in supporting it with two fingers, while an aid draws
its two extremities, which have remained free, to the anterior opening
of the nose ; after which they are introduced into the knot-tightener in
the manner described above.  If the fingers were not sufficiently long
to follow the noose of the ligature as far as the posterior opening of
the nares, two threads in place of one attached  to this ligature, at an
interval of an inch apart, and each of them afterwards passed into a
canula could be  advantageously substituted.
  VI.—This process was still further  modified by Desault himself,
with the view especially of more readily applying it to polypi of the
pharynx.   After having brought from the mouth and throat  outside
of the nasal fossas, the extremity of one ligature, and the two ends
of a noose of thread of a different color, he introduced into his canula, 
414
NEW ELEMENTS OF  OPERATIVE SURGERY.
which is slightly curved, the extremity of the ligature which was
left in the mouth ;  penetrated with this canula to the bottom of the
pharynx; made use of it  to pass the  thread around the polypus;
then caused to be passed upon it the noose of the accessory thread,
which an assistant is afterwards directed to draw through the nos-
tril, and whose object is to bring through this passage, after the man-
ner of a hook, the second head of the ligature, which is immediately
introduced as well as the first, through the ordinary  knot-tightener.
  VII.—Boyer, who approves of these different methods, and has
made trial of the greater part of them with success, has nevertheless
found  it advantageous, under  many circumstances, to substitute a
catgut, to the cord of thread  recommended by Desault.
  VIII.—A. Dubois, (P. Dubois, These, Paris, 1821,) with a view of
preventing the  noose of the  ligature from  becoming  effaced before
having arrived upon the root of the  polypus, recommended to  hold
it enclosed up to that point in a piece of elastic sound, of about three
inches long, which was afterwards drawn to the outside through.the
nose  by means of tractions so applied, as if we intended to turn
this ligature upon a pulley,  while acting temporarily upon one of
its  extremities  only.   The sound having  been removed, we draw
upon the other end of the ligature, in order to bring  them out upon
the same line, and insert  both into a knot-tightener.   Unfortunately
this  piece of the sound  does not always follow the direction we
would wish to give to it   It  slips and escapes, sometimes to one side,
sometimes to the other, and frequently does more harm than good;
so that contrivances still continue to  be devised  for holding the lig-
ature open  in a  proper manner until it reaches to the top of the
pharynx.
  IX.  Process of M.  Rigaud.—In the  month of January,  1820, two
new instruments were proposed for this purpose.  One which its in-
ventor, M. Rigaud, calls a polypodome is composed of three stems
of steel susceptible  of being moved, advanced, and withdrawn sep-
arately or together in a strong canula.   Being curved into an arc at
their  extremity, they form a kind of  forceps, with  three branches,
which are opened or shut at  pleasure.  Each one has a  bird's-eye at
its extremity;  the middle portion of  the ligature is passed into these
openings, and its extremities are immediately brought through the nose
by means of Bellocq's sound.  The  forceps with its three branches
approximated, are then conducted into  the posterior fauces.  In that
part they are separated to a greater  or less degree, according as  it
becomes requisite to give to the noose more or less considerable ex-
tent.  Afterwards their summit is elevated in the same manner as it
we were using the polypus forceps.   In order  to  disengage the
thread, it suffices to draw with a certain degree of force  upon the
extremities which hang out of the nose.  The  two halves of their
terminal cleft, being sufficiently elastic to retain the noose, which is
in no way drawn upon, allow it to escape  immediately upon the
pedicle of the tumor.  The rest of the process has nothing par-
ticular.
  X. The other, which is that of M. Felix Hatin, (Mim. surde Xouv.
Instrum., fyc, et supp., 1830,) is  a plate of  polished metal curved
near its pharyngeal extremity ; being dilated and rounded upon its 
NASAL  FOSSAE.
415
convex surface, it may serve two purposes or fulfil two indications.
In fact, its horizontal portion depresses the tongue exceedingly well,
while the other obliges the ligature to glide upon it until it meets the
polypus.  It is an instrument of very simple construction, which its in-
ventor uses with success, and which I myself have made trial of in two
instances ; but which could, if necessary, be replaced by a tea-spoon
bent forwards towards the root of its handle.   The polypodome of M.
Rigaud occupies less space, conceals the parts less, and is better cal-
culated to conduct the ligature  where, and as  we wish, and could in
fact conduct it advantageously without passing through the  mouth,
upon certain polypi  in the anterior portion of the nasal fossae, but it
has but little solidity, and is more inconvenient than I had at first con-
sidered it.
  XL The knot-tightener itself has attracted the attention of a great
number of practitioners.   Bichat recommends that it should be joint-
ed (brise) in order that we may, if necessary, give it a greater or less
degree of length, without displacing it.  That of M. Graefe, which is
composed of two pieces, one of which is made to slide upon the other,
enables  us to strangulate  the polypus  with  force, without  disturbing
the extremity of the threads.  But the most ingenious of all is the one
which Roderick succeeded in constructing to  cure himself of a poly-
pus which had resisted all the efforts of the surgeons of Brussels.
(See Ligature en masse.) The chaplet, which it  makes, perfectly
accommodates itself to the curvatures of the nasal fossas, and fatigues
them incomparably less  by its presence than any  other.   Its  balls
may be made of wood, bone, or metal, and M.  Sauter constructs them
out of the point of the horn  of ruminating  animals.   M. Mayor re-
commends that they should be made  of silver, tin, &c. ;  finally, in
place of a winch, M. Bouchet makes use of a small  barrel, while M.
Levanier (Arch. Gen. de Med., X. II., p. 467,) confines himself  to a
simple clapper (cliquet.)   M. Braun has also deemed it necessary to
modify this instrument, which had already been suggested by Girault
or Riolan.
  XII.  Appreciation.—The process described by Dionis, and which
is intended for the adjustment upon the pedicle of the tumor by means
of a crow-beaked forceps  of a running knot, one ofthe  extremities of
which is afterwards made to pass through the nostril by means of a
long needle of lead  or brass, in order to bring it  out through the
mouth, while the other remains at the extremity of the nose, is scarce-
ly ever  applicable.   That of Glandorp, as modified by Gorter, after-
wards revived by Heister, who, in order to adjust his ligature, success-
fully employed, on a woman 70 years of age, a curved  needle mount-
ed upon a handle, pierced with an eye near its point, and which is
quite similar in every respect, moreover, to the needle invented by
Goulard, in order to tie  the intercostal artery, cannot however  be
reasonably made trial of  except in those cases where the polypus has
approached very near the opening of the nose.  As the  anterior na-
sal opening descends below the palatine  wall of the nares, the  liga-
ture necessarily acts with force against the  facial border of this  wall,
when we draw upon it through the nose, and  tends constantly to cut
into it, or at least to excoriate it.  It was to remedy this defect that
Levret proposed to  add a sleeve to the two ends of  the seton, which 
416
NEW ELEMENTS OF  OPERATIVE SURGERY
he sometimes recommended to be used.   It was for the same object
that M. Felix Hatin recommended a  small  plate, which was to be
kept vertically behind the lobule ofthe nose, where it was to fulfil the
office of a pulley, but which plate  could be perfectly well replaced by
a steel stem pierced with an eye for the passage of the thread.  Fi-
nally, the ligature is not adapted to polypi with a large base, nor to
those that  are  vesicular.  In whatever  manner it  may  have been
applied, it is necessary to tighten it daily up to the time of the separa-
tion of the  body which it embraces.   It. is no longer applied at the
present time  as formerly, with the simple object of rendering the ex-
cision or tearing out of  the polypus more easy or less dangerous, or
with the intention of protecting' us  against hemorrhage.  But it is
with the professed intention of  producing mortification of the poly-
pus by intercepting the passage of the fluids through its pedicle, which
result moreover it effects by ultimately cutting completely through
it.   Consequently we should be prepared to find that the tumor has
become engorged immediately after  the  operation, then shrunk  or
decomposed,  and requiring  the employment of the  forceps or some
kind of hook when its root has been  divided.  On  the  other hand,
injections of  vinegar and water, alum  water, or any  styptic  or
antiseptic solution whatever, are in such  cases auxiliaries not to be
neglected.  Prudence also suggests  that  the  patient should be con-
stantly kept with his head inclined forward, in order that  the putrid
matters may not descend into  the digestive passages.   Should the
polypus moreover be about to fall  into  the  pharynx, it would be
important to  introduce  into it  beforehand a  thread by  means of a
needle.   Otherwise, it might  pass towards the opening of the larynx
in becoming detached, and give rise to the apprehension of suffoca-
tion.  After this separation, it is well  to  continue still for the space
of a week or  two the detergent, astringent, or styptic injections,  so
long in fact as the nostril  shall not have entirely  ceased to suppu-
rate. Having pointed out while speaking of these different methods.
the  merits of each one of them  in  particular, it would be deemed, I
presume, altogether unnecessary to compare  them  here in their en-
semble in order to appreciate their relative value.  As  there is no
one of them which can claim the preference in an absolute manner,
it must be to  the judgment ofthe surgeon that the choice is to be left,
of the process which is  best  adapted  for employment in each case
considered  separately.
  XIII. Polypi of the Velum Palati.—It may happen that vegeta-
tions, small polypi and  pediculated tumors, will develop themselves
upon the nasal surface of the free  border of the velum palati.  This
is a  disease of which I have seen  three instances.   There would be
no objection to  treating  it by the ligature or arrachement; but excis-
ion   would  be evidently better adapted  to it.  Securing the tumor
with one hand  by means of an erigne or claw forceps, the surgeon
excises it with the other with a strong pair of scissors or straight bis-
toury.  The two patients whom I operated upon in this manner found
themselves cured on the following day.
  [Calculi in  the  Nasal Fossa.—Case of an Osseo-calculous  or
Bony circular  Plate in the Diaphragm.—We avail ourselves here,
chiefly of a very learned and complete paper on calculi in the nasal 
NASAL  FOSSAE.
417
 fossa, by M. Demarquay, in the Archives Generales of Paris (4e
 ser., t. VIII., Juin, 1845, p. 174 et seq.)   Though this subject  has
 been long neglected; cases of this description of calculi  have been
 noticed by J. M.  de Gardi, (Pratica, Venise, 1502, post  2, cap. 14,
 p. 308,) Thos. Bartholin,  (Histor. Anat. Rara, centur. 1, hist.  13, p.
 47,1654,  et Histor. cent. 4, p. 404, historia 85,) Clauder, (Ephemer.
 Curios., dec.  2, an. 13, obs. 78, an.  1685,) Kern, (Observ., 46, dec. 3,
 an. 5 and 6;  Ephem.  Cur. Nat., p. 100, an. 1700,) Vitus Reidlinus,
 (Ephem., dec. 3, an. 9  and  10, obs. 145,  p. 268, an.  1706,) Wepfei*
 (Observ., 192, p. 905, an. 1727,) Ruysch, (Obs. Anat., Amsterdam,
 obs. 44, p. 42, an. 1733,) Plater, (De Olfactus Lesione, lib. 1, cap. 9, p.
 264, an. 1736,) Horn, (in Smuker, obs.* 22, p. 289, an. 1788,) M.  Savi-
 ales, (Bull, de la Fac  de Med., X. IV., p. 44,  an.  1814,) M. Graefe,
 (Annates d'Oculistique, X. VIII., 4th  and 5th liv., p. 203,) Thouret,
 (Arch. Gen. de Med.,  t. XIX., p. 27, an. 1829,) M. Brodie (Ann. de
 Therap.,  Med. et  Chir., No. 2, May, 1844,) and  M. Blandin.
   M. Graefe  has  properly given them the name of rhinolites, and
 the earthy and saline materials of which they are composed are rea-
 dily explicable by the elementary composition of the secretions from
 which  they are  derived, viz: chiefly from those of the Schneiderian
 membrane, lachrymal  apparatus, &c.  There is no doubt, however,
 in our  minds  that earthy and  saline calculous concretions may be
 formed in any of the cavities, passages and surfaces of the  entire
 organism, and also in the substance of any  of the tissues.  Thus, at
 the Seamen's  Retreat Hospital, New York, while the writer of this
 was at the head of that institution, a robust, tall, corpulent old sailor,
 aged 70,  every  way of good constitution and well formed and erect,
 and laboring under no other disease but an extensive sore  on the leg,
 caused by intemperate habits, and of the character of those so famil-
 iarly known  as "rum-legs,"  in  a fit  of despondency threw himself
 from the  piazza of the hospital, eighty feet,  which caused his imme-
 diate death.   In examining the dead body, in which we found every
 rib on one side fractured and extravasation into the pleura, ventricles
 and base of the brain,  &c.; we  found also, on inspecting the dia-
 phragm, a large regularly formed flat *osseous or earthy plate, which
 was completely  circular,  and about  two inches  in diameter and a
 quarter of an inch thick in every part of it, flat on both sides, and
 perfectly imbedded, or  as it were  sewn into the middle of the  mus-
 cular fibres of the  diaphragm, its two  planes corresponding precisely
 to, and being  accurately covered by, those of this  partition.
  It is to be  remarked, as  suggested by M. Graefe, that where  an
 arthritic or lithic  diathesis  exists, earthy  deposites and calculous
 concretions may be expected to be found more extensively and in
 every part of  the body.
  M. Demarquay,  after his  investigations,  comes to  these conclu-
 sions:  1.  Rhinolites may be found alone or in considerable number
 in the nasal fossas, and especially in the lower part  and lower meatus
 of these fossas; 2.  In the frontal sinus, and from thence descend into
 the fossas, or into the sinus maxillare, or they  may be developed in
 the antrum of Highmore, as  mentioned by Lanzoni (Ephem.  Cur.
 Nat., deca. 3, an. 9 and  10, obs. 143, p. 267); 3. They may shut up the
nares and incline the septum to one or the other side, or destroy it in
                              27 
418          NEW ELEMENTS  OF OPERATIVE  SURGERY.

part; 4. That they vary from the size of a bean to that of a pigeon's
egg; 5. That they may be isolated, as is usually the case,  or envel-
oped in a shell; 6. That they are  of a blackish, greyish, or whitish
color, and have  asperities or a  chagreen aspect on their surface •
and 7.  That they may  be homogeneous  or  may be  formed on a
nucleus, as on the kernel of fruit, the root of  an incisor tooth, &c
   Exposed as the nares  constantly are to the  introduction of foreign
bodies,  and the more  so  in inspiration, it is easily conceived that cal-
culi might be formed  entirely by aggregation of particles of dust or
fine pulverized earth inhaled  from without, without any distinct nu-
cleus, and thus by admixture with  the  solid depositions from the
secretions of the nares,  sinuses, &c, give rise to the supposition of
an organic process from within the system.   This idea does not ap-
pear to have occurred to M. Demarquay.
   The analysis of these calculi, as given  by  Axman, Prout and M.
Bouchardat,  is:
Animal matter (albumen, mucilage, fibrine, fat  and osmazome), 0-35
Phosphate of lime,    -----      0*8
Carbonate     "          -       -       ....   o-22o
Carbonate of magnesia,        -      -       -       -      0.125
Traces of soda, muriate and carbonate of soda, and oxyde of iron.
Mucus.
Phosphate of magnesia.
   Thus they constitute,  as M. Demarquay says, an exaggeration  or
excess of the normal secretions of  the  parts.   Differing from M.
Graefe,  he imputes their formation not so much to an arthritic dia-
thesis as to a chronic  inflammation of the nasal fossa and lachrymal
gland, causing a vitiated or altered  state of the secretions  of those
organs.   Also an  abnormally contracted condition  of the passages
may have an influence, by the obstruction it would create to the free
escape of the secretions.  Among the symptoms to be noted are, a
sensation of dryness and weight in the passages, obtuse  and  some-
times acute pain, occasionally  periodical cephalalgia, &c, and finally
inflammation  of the  parts encroached upon, erosion, caries, foetid
purulent discharges, &c.
   They may be sometimes diagnosed by a metallic  sound imparted
to the exploring instrument.   The treatment,  when their volume re-
quires the aid of  surgery, is the  same as that for the extraction of
polypi, together with a more careful attention  to detergent injections
and general remedies  to  change the morbid action.
   Successful removal  of  Polypi from the Frontal Sinus.—One ofthe
most extraordinary surgical cases on record, and one also of the most
extraordinary instances  of the triumph of surgical  art, is that of a
boy aged ten years, operated upon  by Dr. C.  C. Wuth, (British and
Foreign Med. Review, January, 1846, p. 186,) for a remarkable en-
largement of the left frontal sinus, with frightful protrusion and dis-
organization of the entire left  eye; both of which had existed nine
years, and caused constant severe pain in the  head, loss of rest, ema-
ciation,  &c.   Many practitioners had been  consulted and  various
remedies used, but no one it  appears had ever suspected  the true
diagnosis, until  Dr. Wuth  suggested  that the whole tumor and
deformity arose from  polypi within the frontal sinus.   It is proper to 
NASAL  FOSS.E.
419
state that the socket of one orbit had become so much displaced for-
ward by the internal  pressure, that the left eye was almost entirely
extruded from it, presenting a most hideous aspect.  The globe in
fact lay on a level with the back of the nose, and projected laterally
over the cheek bone on the left side, while downward it reached to the
point of the nose. The lids for three years had ceased to cover it, and
the protrusion of the ball was the greater from the orbicularis acting
now as a powerful sphincter, excited into this forcible antagonism, Dr.
Wuth thinks, in order  to resist the pressure of the tumor from within.
The cornea was partially  ulcerated, the vessels of the conjunctiva
varicose, and a  constant flow of tears came  from the parts.  The
regions of  the frontal and  nasal bones were greatly protruded, and
the left side and  the back of the nose formed a flat surface by  reason
of the pressure, so that the nostril on that side was  nearly closed.
The skin was thickened and doughy to the touch, and  the left eye-
brow deviated upwards at  a great distance from the right, and had
at its outer and  under part a small opening, from whence there con-
stantly oozed out a whitish mucous fluid.  An attack of measles is
supposed to have been the  cause of this terrible mischief.
  Dr. Wuth proceeded to operate as follows:  first by a vertical incis-
ion two inches long, from the root ofthe nose upwards through the soft
parts, and  a horizontal one  from this of the same length, close above
the eyebrow. Dissecting off the triangular flap thus circumscribed,
he next proceeded to trephine the  frontal  sinus, remarking  in  the
middle of  the superciliary arch a  small  hole in the bone,  which
accounted  for the mucous discharge already mentioned, [and but for
which salutary drain probably death would have long before ensued.
T.] This  oozing however had caused, in the soft parts ofthe neigh-
borhood, a considerable degree of inflammation and  a fungoid condi-
tion of the tissues, wrhich gave rise to some  hemorrhage.  On tre-
phining into the frontal sinus by two openings, an immense quantity of
polypi protruded, being connected together like grapes, and covered
with a milk-white fluid.   The greater part of these were removed
by the  scissors.   Internally they were yellow and semi-transparent,
and each had two or three vessels in them, radiating off branches in
all directions.  In the upper portion of the sinus the polypi were of
a mucous or cellular texture, and softer to the feel, but firm.   Out of
these could be made too ooze, by pressure, a white slimy fluid.   In
the middle of the abnormally dilated sinus the morbid product was
denser and more opaque;  and posteriorly and towards the parietes
it was  of  a fibrous  structure.  The cavity terminated towards  its
inner and outer  sides  in small sinuses or cellular spaces, in which the
polypi lay  firmly imbedded.   As the surgeon found  the osseous  par-
tition which separated the  sinus from the brain, so thin in fact that it
yielded to pressure  and imparted  to  the finger the  pulsations (the
diastole and systole) of the  encephalon, great caution was required in
detaching the morbid  growths from it, or in the application afterwards
of such cauterizing means as would not cause too much irritation.
He now bored through the osseous parts from the cavity of the nose
to the frontal sinus, as the  ethmoid cells, conchas, &c, and intro-
duced a silver canula, so that the fluid collected in the sinus might
flow off unconfined ;  and also to remedy the flow of tears over the 
420          NEW  ELEMENTS OF OPERATIVE SURGERY.

ball, perforated the nasal bone from without inwards, so as to meet
the artificial canal previously made, and inserted in this second also
a silver tube.  This last was removed and closed when the tears had
reacquired their natural passage.  The first  canula into the sinus was
also afterwards removed, and the parts firmly cicatrized in the space
of twelve months ; by which time the globe  and the bones had almost
resumed  their natural  dimensions and  position; the ulcer of the
cornea also having healed and left only a  leucoma, but the sight much
improved.  From the first night the patient enjoyed such sleep as he
had not had for years.  The first six weeks  he spent chiefly in sleep-
ing and .eating, which soon repaired his exhausted constitution.  The
cure in fact has  continued complete and perfect, now embracing a
period of some years.   To  overcome the  adhesions  of the polypi,
and to restrain new growths on the parietes of the  sinus, Dr. Wuth
properly declined the use of the  nitrate of silver and  employed
laudanum, Goulard's  extract  and  creosote, pencilling the parietes
with a mixture of equal parts of the two  former, and then applying a
salve composed of an ounce of zinc ointment and ten drops of creo-
sote spread on lint.
  Dr. Wuth, from the above highly instructive case, the  successful
operation for which does him so much honor, deduces very naturally
the following conclusions:  1. The power of vision to continue under
general  traction and  elongation of the optic nerve.  2. The frontal
sinus may be enlarged to an enormous extent, which, in  this case,
was equal to the volume of three hen's eggs!  3.  The return of this
osseous  cavity almost to its normal form.  4. The complete division
of  the  supra-orbital and frontal  nerves  without  injuring vision.
5.  Pain is not a pathognomonic sign of the  malignant or  benignant
nature of a swelling—a fact illustrated also by cases  of induration of
the mammas and other organs, which, by their spontaneous disap-
pearance, show their non-malignant nature.
  There is a case of a  gentleman now  living in New York, aged
about 55, who has been  frequently seen by Dr. Mott, myself and
others, and in whom, in fact, there  has existed for many years such
a frightful  protrusion of the socket and  balls of both  eyes, and the
whole of the lower portion of the frontal bones and  outer angles of
the orbits, as to have  excited remark among all who have ever wit-
nessed this melancholy deformity.   The sight of both eyes is now
entirely lost, as both  are  amaurotic, though both balls can yet be
covered  by the lids, not  however without difficulty.  The organiza-
tion of  the substance  of the  tunics of  the globes is not  materially
altered,  though they both, and especially one, stand out on a level
with the cheek.   Is it not probable  that  this case is one of polypi in
the frontal sinuses ?  Some fifteen years ago it was seriously stated,
that one day, in  a  violent fit of sneezing, one globe  actually came
out of its shallow socket, and hung  upon  his cheek by its optic nerve
until replaced by a physician who happened to  be present!   This
does not now  seem in the least marvellous,  after reading the case of
Dr. Wuth, above. T.] 
SINUS MAXILLARE.
421
               Article II.—Sinus  Maxillare.

                      § I.—Perforation.

  The maxillary sinus is frequently the seat of diseases, to relieve
which perforation has repeatedly been resorted to.   The worms,
which Bordenave, Fortassin, Heysham, &c, state to have encoun-
tered here, would unquestionably exact this operation if it were pos-
sible to recognize the existence of these animals during the life of the
patient.  The same  remarks apply to peletons  of adipocire, which,
as it has been stated, sometimes form in this part, also to balls which,
as Ravaton (Chir. d'Armee, p. 114) and M. Petit (Journ. Hebdom.,
t. II., p. 47) have seen, may get caught here and remain even as long
as 25 years ; but it is especially with the view of removing abscesses,
hydropsy, ulcerations, and fungus, fibrous, and carcinomatous tumors,
also polypi, necrosis, and caries of the cavity, that this  operation is
had recourse to.
  A. Jourdain, who about the middle of the last century so strenu-
ously insisted upon  the utility of medicated injections  through the
natural opening ofthe sinus, and  upon the  inutility of its perforation
in almost  all  its diseases, has not succeeded,  notwithstanding  the
numerous arguments which  he advances, in convincing practitioners,
and his doctrine at the  present day is  advocated by no one.   On one
hand it has been found most frequently, whatever  may have been
said on this subject, that  it  is extremely difficult to discover, at the
middle of the median meatus of the nasal fossas, the entrance of the
sinus by means of a  sound;  and on the other hand that this opening,
which is more frequently obliterated in consequence of disease than in
any other manner, would afford no assistance even though it should
be re-established, and  that  taking all things into consideration, the
artificial perforation, which  is less difficult and more certain, ought
to have the preference.
  B. Perforation of the Alveoli.—Of the different methods of effect-
ing the opening into  the sinus maxillare, the  most ancient is not, as
is generally believed, that which  consists in penetrating through the
alveoli of the molar  teeth.   Molinetti, who wrote in 16^5, says, that
in a patient who was tormented with agonizing pains, a crucial in-
cision was made into the cheek, and that by means of  the crown of
a trephine  they penetrated into the  antrum highmorianum,  which
was the seat of an abscess.   It is also an error to attribute the honor
of this operation to Meibomius.  Zwingler had, after the extraction
of several necrosed  and loose teeth, cured  a caries of the maxillary
bone,  by  dilating  the diseased  alveolus  with  prepared sponge.
Ruysch naakes the remark that Vanuessen could not succeed in curing
a polypus until after having extracted  several molar teeth and cau-
terized their alveoli with a  red hot iron, so as to be  enabled to pass
the  finger into the  maxillary sinus.  Some years subsequently* W.
Cowper, in 1697, according to Drake, who has formally recommended
it, perforated the alveolus of the first molar and penetrated into the
sinus with a kind of stilette, in order to be enabled to inject liquids into
it.  Moreover Meibomius, whose researches were published in 1718,
is so far from having  invented this method, that he limited himself 
422
NEW ELEMENTS OF  OPERATIVE SURGERY.
 to  the  extraction of a tooth, in order to give issue to the matters
 accumulated in the sinus, with the perforation of which he appears
 to be wholly unacquainted.   It was also the practice that Saint-Yves
 followed with  success, in  a patient who for a long time had had a
 fistula,  accompanied with destruction of the floor of the  orbit; so
 that it  was not until Cheselden had  revived  this operation that the
 attention  of practitioners  was  directed  towards it.   This surgeon
 recommends that we should rather extract  the  third or the fourth
 than  the first or the socond molar  teeth, as indicated by Juncker,
 and that  if there exists an osseous  fistula we should content our-
 selves with enlarging it in place of piercing through  the bottom of
 the alveoli.  Since that epoch the perforation of the alveoli  has been
 modified by different  authors.   Heuermann, who also 'prefers the
 alveolus of one ofthe last teeth, recommends, if the pus does not im-
 mediately  escape, to perforate the sinus with a  probe, and  to place
 in the opening  a canula, in order to prevent its too speedy oblitera-
 tion.  Bordenave judiciously remarks, that, with  the exception ofthe
 first,  all the molar teeth correspond to the  sinus, and that conse-
 quently if there is one of them carious or more painful than the others,
 it is this which should  be removed by preference, but that  it is ad-
 visable  to  extract the  third if  they  are  all equally sound.   On the
 other hand he recommends that we  should extract all those which
 are altered, provided that they can no longer be of any service.  A
 canula of lead appears to him to be more suitable for keeping, during
 a  certain  space of'time,  the aperture open, than the sound and
 bougies, and he does not think, moreover, that the  process should be
 the same in all  cases.   Desault, who adopted the recommendation
 of  Bordenave,  commenced  the operation with a perforating tre-
 phine, mounted upon a many-sided  handle, and terminated it with
 another instrument of  the same kind, but the  point  of which was
 blunt, in order not to wound the opposite wall of the sinus.   Accord-
 ing to B. Bell, if we have our choice  we ought to extract one of the
 posterior teeth, and in  the interval between  the dressing keep the
 opening shut by means of  a stopper  of wood.   Richter perforated
 the alveolus with a trochar : he cautions us against leaving the canula
 which is plaCed there open, because  portions of  the food might get
 into it and  be introduced into the  sinus.  Deschamps recommends
 that we should leave  this canula  permanently  in, fastening it by
 means of a thread round one of the teeth.  In conclusion, the method
 called that of Meibomius, which possesses the advantage of placing
 the opening at the most depending  point of the sinus, of leaving no
 visible cicatrix  at the exterior,  the execution of which, moreover, is
 as simple  as it  is easy, and preferable to every other when there
 exists a carious tooth,  ought, in my  opinion,  to be rejected under
 contrary circumstances, and where the alveoli have for a long time
 been divested of their small bones,  and become entirely obliterated.
  C. Method of Lamorier.—Lamorier recommends  ip such cases
 that we should  penetrate into the sinus maxillare, immediately below
the zygomatic process, between the cheek bone  and the third molar
tooth.   This is the  point which corresponds  to the summit of the
cavity,  where  the walls of the  sinus present the  least degree  of
thickness, and where it may be reached  with  most facility.   An as- 
SINUS MAXILLARE.
423
 sistant, provided with a blunt  hook, draws the labial angle outwards
 and  upwards.   The operator incises the  fibro-mucous  membrane
 which covers the  bone, at the point  designated, by means of a scal-
 pel or good  bistoury; then perforates the  osseous wall with a solid
 pointed instrument; enlarges  the opening as much as he judges ne-
 cessary, and finishes by introducing into it a tent of lint.
   D. Method of Molinetti.—Other surgeons, going back to the ope-
 ration of  Molinetti,  have recommended that we should first divide
 the cheek between the projection of- the malar bone and the suborbi-
 tal* foramen, then  to penetrate through this wound into the  interior
 of the sinus; but  unless we are forced  to  do  so by circumstances,
 we should avoid this division of the external soft parts.
   E. Method of Runge.—In place of perforators, one sharp-pointed
 and triangular, the other  blunt,  invented by Desault for this  kind of
 operation, Runge,  who had performed it in  the year 1740, made  use
 simply of a strong scalpel, which, in order to enlarge his first punc-
 ture, he took care  to turn four or five times upon its axis.  The tre-
 phine which  C. Bell uses  for the same purpose, has neither more nor
 fewer inconveniences  than the  scalpel of Runge or the perforating
 trephine of Desault.
   F. Method of Gooch.—In a patient who  had no longer any molar
 teeth, the idea  occurred  to Gooch of perforating the antrum high-
 morianum on its nasal wall, and of inserting therein a leaden canula.
 01. Acrel had already made use of a process very analogous: that is
 to say, that after  having operated in the manner of  Cowper, he in-
 serted through the nose  another canula into the sinus, which had a
 fistulous opening upon that part  of it.
   G. Method of Ruffel.—A buccal fistula of the sinus maxillare sug-
 gested to  Ruffel the idea of penetrating that cavity with a trochar,
 and of compelling it to come out above the  gum, in order thereby to
 establish a counter opening.   A seton was then introduced and kept
 in this passage during the space of six weeks, with such benefit that
 success crowned the enterprise of the surgeon.
   H. Method of Callisen.—Callisen, who adopts the seton of Ruffel,
 and imitated in this by Zang,  thinks  with reason that if the fluctua-
 tion should become perceptible at the vault  of the palate that the ar-
 tificial opening should be established there.  Busch and Henkel have
 perfectly succeeded by means of a meche introduced through a fis-
 tula in the floor of the orbit, and brought into the mouth  through an
 opening in the alveoli.  Bertrandi proceeded in the same manner, with
 the exception of not using the seton, in a patient who  could not open
 his mouth and who also had a  fistula in the orbitar wall of the sinus.
   I. Method of Weinhold.—In  the  process which is  attributed to
 Weinhold, the surgeon first directs his instrument to the upper and
 outer part of the  canine fossa,  directs it obliquely downwards and
 and outwards, carefully avoids the branches of the suborbital- nerve,
 perforates the sinus  and  then  places a roll of lint in the wound.  If
 the sinus  has no other issue, Weinhold recommends  that we should
 perforate it through and  through, either by pushing  the first instru-
 ment through the  palatine vault into the mouth, or  by means  of a
curved needle above the alveoli, when we  wish to place  the coun-
ter opening external to the gum.  An eye which both instruments 
424          NEW  ELEMENTS OF OPERATIVE SURGERY.
have, enables us at the same time to pass through the sinus, the con-
ducting thread of a meche of lint destined to perform the duty of a
seton, and which is besmeared with any ointment that may be suit-
able.
  J. This is a method, as we perceive, which is quite similar to that
of Ruffel  or Henkel, and which may be made trial of as well as that
of Desault or Lamorier.   It is also analogous to that of Nessi, who,
after having freely laid open the sinus through the mouth, perforates
it with a trochar and proceeds to destroy also its anterior wall to a
considerable extent below  the cheek bone, or in the  canine fossas.
  K.  Appreciation.—In conclusion, the perforation of the maxillary
sinus  is performed at the point of election  or at that of necessity.
The first  may vary according to the taste  or ideas  of  the operator.
The other,  on  the contrary, is determined by circumstances.  In
cases of abscess,  hydropsy, fistulas, and ulcerations, we almost  al-
ways operate at  the point of election.  In such  cases,  however
slightly one of the molar teeth may be diseased, it is to be extracted
as well as the neighboring tooth ;  we then divide the gum down to
the bone ; outwardly, inwardly, posteriorly, and  in  front, as if for
the purpose of forming  thereby  a  square-shaped  flap,  and then iso-
late it entirely from the surrounding tissues ; after which the alveoli
are to be  perforated by means of the instruments of Desault, and  an
opening made sufficiently  large  to enable  us  to  penetrate with the
finger into the sinus.  Boyer, who  follows  this process, insists with
reason upon the  necessity of never making the  dimensions of the
opening too small.  Should all the teeth be perfectly sound, or should
the patient have lost  them for a long time,  and the  alveolar border,
rounded  off and  smooth, should have preserved all  its solidity, the
method of Desault or Lamorier  would deserve the  preference.  Upon
the supposition that this would not succeed, there  would  be plenty
of time to adopt that of Meibomius, which it cannot  be denied is
incomparably more painful and more formidable to the  patient.
  L.  The Author.—If, as  happens frequently, and  an  example  of
which has been published by M. Sauve, (Bull, de la  Fac. de Med., t.
V., p. 9,) the sinus is distended by any liquid, its anterior wall, swol-
len out in the form of a border under the cheek, is in general so soft
that a bistoury or scalpel perforates it without any  difficulty.  The
operation  is then extremely simple.   Having freely incised the supe-
rior part of this border transversely between the cheek and the ma-
lar bone, I excise its inferior portion with a second cut of the bis-
toury.   The loss  of substance  thus made remains fistulous, and pre-
vents  the sinus  from filling up  a second time.  The three patients
whom I treated in this manner were promptly cured.

                 § IL—Foreign Bodies.—Polypi.

  It is also through  the  anterior wall of  the sinus that we  must
penetrate  if we have to extract only  a foreign body,  as for exam-
ple, a ball, or shot, or some splinters of bone.  When, on the con-
trary, we wish to remove a polypus,  fungus or necrosis, prudence sug-
gests that wTe should attack it at the point towards which it appears
to have naturally inclined, or which it has most seriously altered.  Du- 
SINUS MAXILLARE.
425
 bertrand found that he could succeed in this manner in extirpating a
 polypus of this kind, by uniting two alveoli  by breaking  through
 their septum, and  then  removing  the  fragments of carious bones;
 while Caumont was obliged, in a patient who had undergone a
 similar operation  without  benefit, to  attack  the  tumor where  it
 showed itself at the canine fossa, and  Chastenet on the other hand,
 found it necessary in the case cited by him,  to destroy almost the
 half of the maxillary bone with its palatine process, in order to ef-
 fect the same object.  However this may be, when the antrum high-
 morianum is opened with the sole  view of giving a ready egress to
 the matters which it  secretes or  exhales, the requirements of the
 operation are reduced to simple detergent, astringent, antiseptic or
 dessicative injections, until the bottom of the wound is covered with
 cellular granulations.  Should there exist at the same time necrosed
 osseous fragments, these are to be destroyed.   In such cases it  fre-
 quently becomes advantageous to  prolong the incisions, to enlarge
 the openings, and to have recourse to the chisel,  the saw, cutting
 pliers, gouge and mallet.   The same thing takes place in  cases of
 exostosis, and every other alteration  of the osseous tissue.   When
 the sinus  encloses a polypus, the  tumor is  to be treated in the same
 manner as  if it  were  in the nose, with  this difference,  that  the
 tearing of it out, which is almost always  applicable, rarely fails to
 effect our object, and that we cannot perceive at least what advan-
 tage would  in this case  be presented  by  the  ligature, which was
 still employed by Sylvi,  (Soc de Sante de Lyon, p. 121, 1798,) for
 a polypus, which projected at  the same  time into the mouth, and into
 the zygomatic and temporal fossas.
   After having isolated  and denuded its periphery,  and laid bare its
 pedicle or base, it is then to be secured by a polypus forceps, or if
 we should  find it more  convenient, by the forceps  of Museux,  fre-
 quently used by Dupuytren.   We then  tear it  out by drawing it to-
 wards  us, or what is  as well, by twisting  it upon  itself.   Should it
 not possess sufficient firmness to resist  the  action of the forceps, we
 remove it by excision after having forced it to  yield as much as pos->
 sible; and if any bridles or osseous lamellae should  interfere with its
 extraction, they should  be divided without hesitation, unless, how-
 ever, there should be some danger in  meddling with them.   When
 it has more breadth than prominence, when instead of a polypus  we
 find fungosities or any other degenerescence, we are  sometimes
 obliged to remove them, layer  by layer;  either by means of the ordi-
 nary or blunt-pointed bistoury, by the scalpel with a truncated, short
 and broad point, somewhat curved on its  flat side, like the knife of
 P. de Hilden, or that devised  by  Pelletan  and  eulogized  by Boyer,
 or finally by means'of any other  appropriate instrument, as for  ex-
 ample, by a kind  of cutting scoop, like that of Bartisch.   On  the
 other hand, should the tumor be of too large  a size to  be readily
 extracted at the maxillo-labial groove, it would be necessary to  lay
 open the lip freely throughout its whole height,  or one of its  commis-
 sures in the direction which was most suitable.   The twisted suture
in a wound of this kind renders agglutination so easy a matter, that
we should be really culpable in neglecting it whenever it should  ap-
pear that the operation would  be thereby simplified.  Sylvi, by cut- 
426           NEW ELEMENTS OF  OPERATIVE SURGERY.

ting into  the  temporal fossa, in order  to  extract  and cauterize a
remaining branch of a polypus in the  sinus,  lost his  patient at the
expiration of three weeks ;  but  Cartier,  (Soc de Sante  de Lyon, pp.
122. 123,) after a similar operation, had  the good fortune to cure his.
Caustics may be used to destroy whatever arrachement and excision
have not  enabled  us to remove.  The  mineral acids,  the butter of
antimony, and better than all this, the nitrate acid  of mercury, intro-
duced  by means of  a  pencil wrapped in rolls of lint,  have the ad-
vantage of not transmitting their action to a distance like the actual
cautery, which at  this point in particular is to be especially dreaded,
because of the proximity of the eye.   It is however important not
to be forgotten, that Garengeot could not succeed in curing a fungous
mass in the antrum which  had resisted repeated excisions, extirpation
and  chemical  escharotics, except  by destroying it  by means of the
red-hot iron.   Nitrate of silver,  alum, sulphate of iron or copper, and
all those substances which are rather styptic than really caustic, are
scarcely applicable,  in fact, except to vegetations, small ulcers and
tumefactions ; in a word,  to alterations  disconnected with the bones,
and  which have no  malignant character.   It is unnecessary to say
that, should any deviated tooth  be the cause of the disease, it would
be necessary to proceed in search of it and to extract it  immediately.
The triumphs of art contain in this respect facts that are extremely
curious ;  such, for  example,  is that which Dubois has published.
This practitioner, supposing that he was cutting  down on a fungous
tumor,  saw issue out nothing but  a liquid and thin  matter from the
maxillary sinus, which he had just freely laid open above the dental
arcade.  The wound soon closed up, but the tumor remained.  With
the assent of  Pelletan, Boyer, &c, Dubois extracted three teeth, re-
moved  a  large  portion of the  alveolar border, thus laid open the
antrum in its whole  extent, and found  no fungus,  but  perceived in
the upper part of the cavity, in  the substance of its anterior wall, a
white point, which was no  other than an incisor  tooth, the root of
which was found to be rivetted as it were into the sinus.
   M. Blasius (Arch.  Gen. de Med.,  3rd  ser., t. II., p. 98,)  also suc-
ceeded  in curing a hydropsy of the sinus maxillare by extracting an
abnormal tooth.   A  tooth of this kind, which had  become imbedded
in the ascending process, gave rise to the production of an enormous
tumor in a patient  of M. Gensoul,  (Let.  Chir., 1833.)   As to hemor-
rhage,  these different manipulations  sometimes render  it sufficiently
copious to oblige us  temporarily to  suspend the operation.   Should
it not cease spontaneously, the eau de Ravel, oxycrat or tamponing
wTith small balls of lint sprinkled with colophane. or even if neces-
sary, the iron  heated to a  white  heat, are at the command of the sur-
geon and  will always enable us to apply an efficient remedy.  It is
also  for cancerous  and  osteous-sarcomatous tumors  of the maxil-
lary sinus that exsection and amputation ofthe upper jaw have been
most frequently performed.  In addition to the examples which I
have elsewhere related, (see Exsection ofthe Jaws, Vol. II.) it is neces-
sary to mention also that  of M. Bonjour, (Arch. Gen.  de Med., ser.
2nd, t.  IV., p. 476,) that of M. Blandin,  (Ibid.,  t. V., p. 1(52,2nd ser.,)
that  communicated to me  by M. Chaumet, that of M.  Laugier, that
of Le Sage, (Bull, de la Fac de Med.,  X. V.,p. 258,) and one which 
SINUS MAXILLARE.
427
belongs to myself.  In this last, (Gaz. de Medecins, Prat. t. I., Nos.
1 and 2,) after having incised the soft parts, as has been mentioned,
(see Exsection of the Jaw, Vol. II.,) I divided the zygomatic arch, the
external orbitar angle, the ascending  process, then the dental arcade
and the nares in  the mouth, with a cultellaire saw, and  removed
the  entire maxillary bone  together with the cancer.

                    §  III.—Osseous Cysts.

  Osseous  tumors, tumors filled with a thin serosity, as in grenouil-
lette, or with pus, or of a fibrous, fatty or fungous nature,  or com-
posed also of many of these elements at the same time, have been fre-
quently noticed outside of the sinus maxillare, and  even in the sub-
stance of the bones of the face.  I have seen, like Chaussier, exostoses
in  the  lower jaw.  M.  Diday (These de  Concours, 1839, p. 32,)
mentions one situated in the vault of the palate.   M.  A.  Cooper
saw one which  caused suffocation by pressing upon the epiglottis.
Runge, who was one of the first that spoke of these tumors, states
that his father and himself have met with osseous tumors in both jaws,
and that they frequently derive their origin from the  point of the
root of a tooth.  It is also probable that those alleged lymphatic con-
gestions whose walls  were found  as thin as parchment, and which
M.  Brodie,  (S. Cooper, Surgical Dictionary, p. 201, 7th ed.) as well
as Kirkland, places in the antrum highmorianum,  also belong to the
same description of disease.  Has not Callisen committed a like error
in  speaking of  those tumors with separate  compartments, which,
according to him, require the extraction of several teeth 1  Siebold,
who saw an osteo-sarcoma between the laminas of the sinus, and who
exsected it without causing any pain,  and cured his patient, has dis-
tinguished- better  than  his predecessors  the  actual  location of this
disease. In fact Runge, who in other respects describes it sufficiently
well, and does not omit to mention that by pressing it with the finger
it yields, but immediately reacquires its dimensions with a bruit,
ranges it among diseases  of the  sinus.   Sprengel also  charges him
with several times having inserted in his dissertation, through inad-
vertence without  doubt, lower jaw for upper jaw.  In  this  respect,
the learned historiographer was evidently deceived.  It is certainly to
the lower jaw that Runge has reference when he designs to speak of
it.   Only he has made use, erroneously and improperly, of the term
sinus, to designate tumors which are  situated external to these cavi-
ties.  These isolated facts, moreover, had not attracted  the attention
of any one,  and it is to Dupuytren  to whom we are  indebted for
having been the first to give in his clinical lectures exact notions on
the disease in question.   I have now seen a great number of exam-
ples.   Though  the  tumor may be situated outside of the sinuses,
since it is  more frequently seen in the lower than in the upper jaw,
and in the ascending process as  well as in the substance of this last,
nevertheless almost always has certain relations with a diseased con-
dition of the teeth.   M/Diday, (These de Concours,  1839, p. 36,)
adopting this idea, seems even to think that osteo-serous cysts of the
face almost always proceed from a dental follicle, and that the greater
part of them are disconnected with the substance of the jaw.  Though 
428           NEW  ELEMENTS OF OPERATIVE  SURGERY.

they are similar in form and external appearances to carcinomatous
or fungous tumors, they differ from them especially in this, that they
are readily cured by surgical means.  Analogy authorizes us to sup-
pose that the various  kinds  of treatment extolled for lesions of the
maxillary sinus would be equally applicable to them ; that by extract-
ing the carious teeth in the neighborhood and opening  into them at
the inner side of the lips or cheeks when they are so situated as to
allow of it, we should effect the cure of a great proportion of them;
so that there would be no great mischief from confounding them with
polypus or  other tumors  developed in  the  antrum highmorianum,
as happened to the father of Runge and to Dupuytren himself.   But
up to the present time at least, I have always found it to suffice, as
Dupuytren also did, to incise them freely in the mouth or through the
cheek, then to throw up injections, and to insert daily a meche or tent
of lint in the wound, in order to bring about their diminution and
resolution.
                        CHAPTER V.

                     AUDITORY  APPARATUS.

                  Article I.—External Ear.

                        § I.—Otoraphy.

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

                   § II.—Tumors of the lobe.

  The lobe of the ear may be the seat  of tumors  of a large size;
those that are pyriform, indolent, homogeneous or somewhat granu- 
EXTERNAL ear.
429
 lated, fibrous or elephantine.   A woman had one of unequal size on
 each ear ;  having removed by a V incision into the sound tissues, that
 of the right side, which was ofthe  size of a nut, I was enabled to re-
 unite the wound  by two  points of suture, and to cure the patient in
 three days.  It would appear, moreover, according to M. Campbell,
 (Arch. Gen.  de Med., 2d  ser., t. VI., p. 110,)  that this description of
 tumors, which frequently  originate from  the  helix, is apparently
 endemic at Nipel.


          §  III.—Deformities of the  Meatus Auditorius.
  A. When atresia of the passage of the ear is complete, and that
 its source lies in the temporal bone itself, a double example of which
 I saw in the dead body of a child four years of age, and a second
 instance on  one  side  only in  another child  of  from ten  to twelve
 years of age, it  is incurable, and yields  to no kind of medication.
 To whatever degree, on the contrary, the contraction may have pro-
 ceeded, even though  it scarcely admits  of the passage  of a needle,
 as was seen  by Lametrie, or that the coarctation is trifling and occu-
 pies only one point of the passage, or has invaded the whole extent
 of the  canal, we  should make an attempt to remedy it by  dilatation.
 Caustics, which were preferred by some ancient authors,  might under
 these circumstances become dangerous and would rarely effect the ob-
 ject in view.  The canulas, sounds  or  tents of larger and larger size,
 that are used, should be still continued  a long time after the cure, and
 even sometimes during life ; for the wall of the canal retains almost
 always a  great  tendency to contract again.  In certain  cases  the
 walls of this canal, when simply' lying in juxtaposition to each other,
 cannot be effectually  separated  except by  a metallic  canula of a
 diameter corresponding to that of the auditory passage in the normal
 state.  If the  deafness depended evidently upon an anomaly in  the
 curvature  of the  cartilaginous prolongation of the  ear, it could be
 remedied by placing a gold canula permanently in this passage, an
 example of which is related by Boyer in his practice.
  B. More frequently  the external  ear is shut up by a membrane or
 a sort  of diaphragm.   Unless  it should  be very remote  from  the
 pavilion, this membrane should be  laid open by a crucial  incision
 with the bistoury.  The flaps are afterwards  to be excised with  the
 same instrument  or a small pair of scissors,  while  they are  succes-
 sively raised up by means of a hook.  Others have recommended that
 it should be  perforated with a trochar, and its destruction completed
 by the  aid of dilating  bodies ;  but  this method is not as  good as the
 first.  Incision, which  Paul  of Egina adopts when the accidental dia-
 phragm is deeply situated, as in the preceding case, rejected by F.
 ab Aquapendente  under the pretext that it incurs  the risk of penetra-
 ting into the  internal ear,  is  not proscribed at the  present day, except
 in cases in which it appears to touch the membrane of the tympanum.
 In these cases we  follow  the precepts of J. Fabricius,  and have
recourse to caustic, and the best without contradiction  is the lapis
infernalis.  Leschevin recommends that  it should be inserted in a
piece of quill, and applied  to the bottom of  the passage through a
silver canula.  Three  or  four  cauterizations, at  intervals  of two or 
430
NEW ELEMENTS OF  OPERATIVE SURGERY.
three days, are generally sufficient.   If, however, the septum should
be very thick, it would be better, after the manner of Leschevin, to
perforate it at whatever depth it may be situated, by means of a very
short trochar, whose stilette passed but a very slight distance beyond
the end of the canula.
  C. It is by the same treatment that we should attack every kind
of atresia, complete or incomplete, which is imputable only to defect
of conformation of the soft parts, and which is not purely membranous.
As soon as the instrument has passed beyond the obstacle which the
sudden removal  of  the  resistance indicates, the trochar  alone is to
be withdrawn,  in  order  to  use its canula for the introduction of a
bougie to the bottom of the auditory passage, which is to be renewed
daily, gradually increasing its  size.

                     § IV.—Foreign Bodies.

  A. An infinite number of varieties of foreign bodies may become
introduced in the auditory passage, and an infinite number of means
have been proposed  for their extraction.  Archigenes, in compelling
the patient to hop on one  foot, and  to take sternutatories, had the
same intention  as Celsus, who recommends us to press his head  upon
a table and to shake it with force, either by raising him up by the feet
or striking his sound ear, or letting suddenly fall again, after having
raised  it, the body which supports him.  Alexander of Tralles has
suggested the idea of sucking upon them with a tube; and Mesue,
who has revived this, like J. Arculanus, has devised for this purpose
another instrument,  destined exclusively to pump out liquid matters.
The suction pump,  the  instrument  invented by M.  Deleau, and
which can serve to withdraw the air, serosity, pus, &c, as well  as
for injections into the  ear. are  referable  to the  same  principle.
Leschevin, who alledges  that the air contained in the canal of the
external ear is the ordinary cause  of the buzzing sound and tingling
in the ear, had been anticipated by Reusner, who, in order to remedy
this inconvenience, recommended a small silver canula left perma-
nently in the auditory passage.
  B. Hardened wax is dissolved very well by means of oil of sweet
almonds, as is remarked  by Avicenna, and better still  by means  of
tepid soap and water, or even in pure water, if we believe in the
experiments  of Haygarth, who rejects oils  as less  serviceable.  A
solution of sea salt, as eulogized by J. E. Trempe], also dissolves it.
Consequently, when  deafness is produced, as  so frequently happens in
persons of a certain  age, by the accumulation of this material, we
cause to be  introduced several times a day into the ear one  of
these liquids, either by means  of a syringe, or upon cotton which has
been saturated  with it, and when it has become softened or detached
it is removed by means of a scoop,
  Duverney, (Traite de Forgone de VOuie, 3d part, p. 156,157,1683,)
states that he had seen in eight or ten instances the wax  so inspis-
sated as to resemble  plaster, and filling up exactly the bony and carti-
laginous passage of the ear.  Distinguished  surgeons had communi-
cated to him  more  than thirty similar examples.  This species of
deafness,  according  to him, is the most common and the most  easily 
EXTERNAL EAR.
431
cured.  A famous surgeon of Mons who obtained  so much  renown
for the cure of deafness, undertook only the treatment of this form
of the disease.  In a  patient who had been affected with deafness
for a long time, the cavity of the tympanum had become excessively
dilated, and  the  petrous  portion of the temporal bone  absorbed.
These two  singular affections  were produced, says M. J. Cloquet,
(La Clinique des Hopit., X. IV., No. XXI., and Seance Acad. Med.,
1829,) by the development or accumulation  of  a ceruminous matter
which had become indurated in the interior of the cavity of the tym-
panum, and which was thrown off in scales, forming a species of false
membranes.   In  another  case  noticed by M. Jobert, (Revue Med.,
June, 1830,  p. 414,) the cerumen which  filled uprthe cavity of the
tympanum, had transformed the petrous portion into an osseous dila-
ted cavity, in which there remained no vestige of the conformation
belonging to the middle and internal ear.   The woman mentioned by
Bartholin, (Act.  Haffn., t.  I., obs. 45, p. 82, and Planque, t. XVIII.,*)
experienced severe pains,  especially in the petrous bone.   In clean-
ing the right ear  she extracted from it, together with fetid matters,
a quantity of sand, and then experienced no more pain.
  C. Should bugs, earwigs, and other insects, (Wolckamer, Rayger,
Lieutaud,(Sauvages, Nosol.,&,c, X. IV.,  p. 232,) Alteyrac, DelaMotte,
Drouin, and Acrel, have noticed worms here ; M. A. Severin, Drouin,
and Planque, caterpillars ; Ravaton and  Wolckamer earwigs ; Binnin-
ger and Schenk, the larvas of flies,) which sometimes get into the bot-
tom of the auditory passage, not become entangled in the cotton and
pitch, as had already  been  recommended by  Hippocrates, or in a
piece of lint saturated  with turpentine, which are  introduced, in or-
der that they may become caught in it, we may after the manner of
Hameck, endeavor to  kill them by pouring into the ear the oil of bit-
ter almonds, or like Rhazes, a decoction of peach-leaves.   The de-
coction of Sedum palustre, used by Acrel, would produce the  same
effect.  But it is useless at the present day to combat with Verduc, who
thought that the pippin apple possessed the property of drawing them to
the outside ; or with Leschevin, who boasted of the half of a potato
being a special antidote for the  earwig.  It is nevertheless true that
that  milk appears to possess the property of attracting an  earwig,
and that M. H. Berard, as well as Alteyrac, succeeded in effecting the
expulsion of worms from the auditory passage, by holding a piece of
meat upon the ear. It  is to.be mentioned also, that whether living or
dead, we should  endeavor to seize hold of these insects and extract
them by means of the  forceps.
  D. As  to  solid foreign bodies, of a certain volume, and  which
Paul  of Egina has properly ranged into two Classes, namely, those
which absorb humidity, and may become distended in the parts,  and
those which are impermeable;  (MM.  Betbeder, Begin, and Cham-
pion, speak of oat-seeds and  barley-ears ; Dupuytren, of a piece of
pencil; De  la Motte,  of a pea ; Saucerotte, of beads of a  rosary ;
F. de Hilden and MM. Dumoustier, Champion,  Faber, and M. Mau-
noir,  of cherry-pits,) they  demand all the attention of the surgeon.
Acute inflammation, abscesses, caries ofthe bones, cerebral accidents,
and violent pains of the head may be caused by their presence.  At
the opening of the dead body of a patient who  died in this manner, 
432           NEW ELEMENTS OF OPERATIVE SURGERY.
 Sabatier found the os petrosum perforated, the dura mater inflamed
 and an abscess, together with  a small  ball of paper, which was the
 cause of all the difficulty, in the substance of the bone  itself.  In a
 young girl  who had suffered  for a long time paroxysms of convul-
 sions, and all kinds of nervous accidents, F. de Hilden (Bonet, Corps
 de Med., X. II., p. 405, obs.  4)  effected a complete cure by extracting
 from the ear a foreign body which had been introduced  there seven
 years before.   An analogous observation was published in  1829, and
 scientific collections are crowded with similar examples.
   E.  M. Larrey  nevertheless remarks that  in a soldier  whom he
 treated, the foreign body had  remained in its place during ten years
 without producing any accidents.   It is well also not to forget that
 these different bodies, which  may be a bean, a small  ball  of bread,
 wood, shot, glass, iron, a small pebble, pin, needle, clot of blood, &c,
 sometimes  come  out of themselves  when the first  accidents  have
 passed over, after having produced a suppuration more or less abund-
 ant.   An important point to be noticed in practice  especially is this,
 that  patients frequently, as  well as  their friends, are  determined in
 persisting that there is a foreign body  shut up in the  ear when it is
 completely  free.   A woman greatly alarmed  brought her  child five
 years of age to one of the  public cliniques in the capital, in order
 that she might have removed from his ear a cherry pit which had
 been there  for  the  space  of twenty-four hours.   All kinds of at-
 tempts were made, and these  being uselessly repeated every morn-
 ing  for three  days, caused  excessive pain, inflammation and fever,
 until when  it became  hazardous to do anything more, and the idea
 suggested itself of ascertaining whether the organs of the little pa-
 tient actually contained the pit sought for, it was perceived that
 there was nothing there.  Such mistakes have frequently given rise
 to the most  serious accidents.   Boyer relates  two instances;  I have
 met with three or four, and  there  are  few physicians who  have not
 had occasion to witness the  same.
   F. If by  inclining  the  ear  downwards we  cannot extract these
 solid foreign bodies, we must  endeavor to reach them by means of
 the forceps when their form  is  elongated or flattened.   A small hook
 is sometimes the best instrument that can be used for removing those
 which have a certain degree of softness.   It is for these last also that
 it is advised to divide them and  reduce them into fragments by means
 of a narrow and elongated myrtle-leaf probe,  in order afterwards to
 withdraw them by piecemeah
   G. Fragile  bodies  exact  much  more precaution.   A  false pearl,
 says Boyer, which had become broken in the auditory passage, by a
 surgeon who was endeavoring to extract it, put the life of the  patient
 in danger, and caused a suppuration of  the tympanum and the loss
 of hearing.  We must therefore undertake their search by  means of
 a delicate scoop, which however is to be of sufficient solidity, by fol-
 lowing the lower wall of the canal in order to introduce it below the
body which is to be removed, and  afterwards making use of it as a
lever of the first  kind, by depressing its handle at the  moment of
 making the extraction.  The scoop modified by M. Leroy, which is
terminated by an articulated beak which is to be introduced straight,
and  which  is  to  be elevated   by  the  turn of a screw when it has 
EXTERNAL EAR.
433
passed beyond the foreign  body, almost always  succeeds in  such
cases. A noose of lateen or  brass wire, or a hair pin, much esteemed
by M. Champion, if introduced and brought out in the same manner,
would be equally efficacious.
  H. A  cherry pit which had resisted  all such manoeuvres, finally
germinated in the ear to such extent, if M. Donatus is to be  believed,
(De Med. Hist. Mirab., lib.  II., cap. 22, fol. 77,) that it then became
practicable to extract it by drawing upon  its  twig; but there  is no
necessity of pointing out the improbability of a statement of this
kind.  Verduc (Operat. &c, p. 224, 1721,) however, also states that
a pea had  germinated in the auditory passage, and  M. Dumoustier
(Rejlex.  sur les Corps Etrang., Strasbourg, 1810, p. 5,) makes the
same remark of an oat seed as Donatus does of his cherry pit. In
such cases the only  resources applicable  would  be to  oppose the
symptoms  with  energy or to prevent  them,  to as  great a  degree
as it was in the power of art to do, and then  to await the  suppura-
tion.
  I.  The process of F. de Hilden, as adopted by C. de Solingen, and
which has been  properly rejected, consists in  introducing a first ca-
nula down to the foreign body, then through this last a second canula,
intended to secure  this  body by means  of the teeth which are pla-
ced upon  its  extremity, while a kind of screw-ring  or gimlet is in-
serted to extract the whole at the same time.   That which the scoop
could not do would not be more advantageously effected by this ap-
paratus, which is much better calculated to force  the  foreign body
into  the cavity of the tympanum than to bring it to the  exterior.
The eyed ear-picker of F.  de Hilden, Ravaton's  hook,  Brambilla's
scissors, Leschevin's  hook, the flattened  probe of Andrieux, and the
curved  forceps of Dupuytren are not as valuable as the forked pin
of M. Champion,  and the articulated scoop of M.  Leroy.   In two
instances M.  Begin, (Elem.  de Pathol., 2nd edit., p. 521,)  has  suc-
ceeded without any difficulty in extracting cherry  pits which  had
got introduced into the bottom of the auditory passage, by means of
a small  slender iron rod  slightly curved in the form of a  scoop:. a
vibratory movement made upon the instrument caused the expulsion
of the foreign body.
   J. In  difficult cases Paul made a semilunar incision behind the
concha,  in order to penetrate to the bottom of the passage,  by open-
ing through the cartilage  from without  inwards, and to be thus ena-
bled to force out the foreign body from within outwards, by means of a
suitable  instrument.   This operation,  again recommended by Dionis
and  Verduc,  is now wTholly abandoned.  It  should not, however,
perhaps, be entirely rejected when the danger presses, and  all other
means have been fruitless.
   K. Injections thrown in with some force* eulogized by M. Dumous-
tier (These, Strasbourg, 1810, p. 5,) and M. Mayor, (Journ. des Conn.
Med., X.  III. p. 13,) already  employed at the time of Celsus, and cen-
sured by Scultetus, and which had been used with  advantage  by  a
surgeon  of the acquaintance of Morgagni, (Lettre XIV., p.  334. Art.
XIII.) would  be applicable if the foreign body had but little size, or
was light.   It is  however obvious that the douche and injections
through  the Eustachian tube, as recommended by M. Deleau, (Gaz.
                              28 
434           NEW  ELEMENTS OF OPERATIVE SURGERY.

Med. de Paris, 1835, p. 303,) could not succeed unless the membrane
ofthe tympanum was ruptured.  We must always, moreover, before
commencing the operation, and whether we  use this or that  instru-
ment, instil some drops of oil into the ear, in order to render the parts
smoother, and less irritable.   Afterwards, nothing remains to be done,
except to throw up emollient injections during  the  space of some
days; unless, however, the manipulations made use of should induce
us to apprehend the subsequent development of formidable accidents.
Under such circumstances, the  antiphlogistic treatment with hypno-
tics and  calmants, should the pains  be acute, become  indispensable.
   [Foreign Bodies—Ear.—Mr. Carpenter, of Castelcomer, (Dublin
Medical Press, June 20, 1841,)  has met with remarkable success in
detaching, and then extracting foreign  bodies  wedged  against the
tympanum, in the meatus of the ear. such as garden peas, pebbles,
&cc, by injecting cold water  with force  into the passage, by means
of a syringe containing two ounces or more.  T.]

                          § V.—Polypi.

  A. All the different modes of treatment which have been adopted
for polypi of the nasal fossas, have been  prescribed also for those of
the ear.   Aranzi alleges  that they may be  cured by means of red
precipitate ointment. De Vigo employed by turns for this purpose, the
red hot iron, caustics, and the ligature and forceps.   Paul removed
them with a bistoury made expressly  for this purpose, or by means
of his pterygotome.  G. de Salicet cauterized their root, after having
ligated them with a  horse-hair or silk thread.  The ligature and ex-
tirpation are almost the only two methods employed at  the present
day.
  B. The  ligature,  which F.  de Hilden. Marchettis and Purmann
adjusted by means of a silver  plate  curved in the form of a forceps,
is  rendered more practicable, says C. de Solingen,  by previously
traversing  the  base  of the tumor  by means of a thread, as a sub-
stitute for an erigne.  It is in reality applicable  only in a very small
number of cases, and for those polypi which have a  narrow pedicle
and  in near proximity to the pavilion.  It is executed by means of a
hempen thread and  the  canula  of  Desault, or by the process of F.
de Hilden, as modified by Solingen, or what is still as good, by in-
troducing with the forceps, and causing  it to pass in with a probe, a
running-knot or noose  of the  thread  as far  down as to the root of
the polypus.  After the ligature is placed, by whatever mode it may
be, its two ends are introduced into a knot-tightener, and from this
moment the operation has nothing particular.
  C. Excision is practicable under the same circumstances, and almost
in all cases where the ligature may be made trial of. The polypus hav-
ing been secured with an erigne, we draw it towards us, while revers-
ing it slightly in order to  lay bare its  root and divide it with one cut
of the bistoury.  De Lavauguyon, B. Bell, &c, who prefer this to
the other me.thods, have not found it necessary in order  to perform
it, to make use  of the hook-shaped  knife of  F.  de Hilden; but it is
evident that the  narrow, blunt-pointed scissors, which are slightly
curved flatwise, could be  advantageously substituted for the bistoury. 
EXTERNAL EAR.
435
  D. As  to  arrachement, the  only method in my opinion which
can be advantageously applied to  polypi whose roots are deeply
situated, and which, if necessary, would answer also for the others,
it may be  effected by means of the ordinary hooks, and the eyed
scoops, which are  thin and  garnished with teeth.   The  speculum
auris of G. Fabricius, that of Cleland, as well as all those which have
been proposed before and since  are useless, if not injurious.  Hooks
now take their place.  The surgeon opens them gently, inserts them
between the tumor and the walls of the canal, which he carefully
dilates ; causes  them  in this  manner to glide as  deep within  the
cavity as  possible, and when the polypus is firmly seized  he turns
them upon their axis, and then tears out the whole with a half draw-
ing and half twisting motion.  The  blood  which  escapes at  the
moment conceals the parts to so great a degree, that in most cases
we are obliged to defer till the next day the exploration necessary to
ascertain whether there exists or not, anything more in the auditory
passage.   This  hemorrhage, however, is  never dangerous.   A tent
of lint besmeared with cerate, or a pledget of lint of the same kind,
to prevent the bleeding surfaces from being irritated from  contact
with the air,  form all the dressing that is required, and which more-
over is always made use of after extraction  of polypi from the ear.
  E. However  little there may remain of the  heterogeneous tissue
after the operation, we must endeavor to  destroy it, not with the hot
iron as recommended by G. de Salicet  and F. de Hilden, &c, but
by means of caustics, which, in our time, generally have the  pre-
ference.
  The canula of J. de Vigo, which is to have an opening on the side,
after the advice of Marchettis, Verduc, &c, enables us, it is true, to
apply  the  cautery  exclusively upon the  diseased point; but as we
are sometimes under the necessity of acting  upon large surfaces, or
very near the  membrana  tympani,  the  actual cautery must  here
necessarily be attended with  some  degree of danger.  Nothing, on
the contrary, is  more  simple than to reach the polypus through the
same- canula by means of  a  hair-pencil  besmeared  with butter of
antimony,  nitrate of mercury or any other caustic, even supposing
that the lapis infernalis could not be substituted for  these different
articles.   Instances  of polypi  of the  ear cured by extraction have
been also  related in the Clinique of M.  PI. Portal, (vol. I., p. 265,
366.)
  F. Polypi of the ear are so slowly developed, and produce  so little
disturbance of the functions  in  certain subjects, that many patients
have them for years before asking to be relieved of them.  In Feb-
ruary, 1830,  I  extracted one at the hospital of St.  Antoine in an
adult man, in whom it  had existed for fourteen years.   Their extrac-
tion in such  cases is not unattended with some danger.  The tym-
panum, which has  been shut out for a  considerable length of  time
from the action of its  appropriate stimulants, would be irritated by
their presence if they were removed without caution.  It is the same
as with an eye which  has been operated  on for cataract:  it must  be
first kept  in  darkness and not  afterwards be  exposed to the  light
except by  imperceptible degrees.
  G. Polypi of the ear sometimes acquire a considerable size ; that 
436          NEW  ELEMENTS  OF OPERATIVE SURGERY.

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

                  Article II.—Internal Ear.

          § I.—Perforation of the Membrana Tympani.

  Plemp is the  first, I believe, who has maintained that  the function
of hearing  may continue although the membrane of the tympanum
has been perforated.  The fact  he  relates in support of his  asser-
tion  appeared at  that time so extraordinary, that Verduc  refuses to
place confidence  in it, while Valsalva, who speaks  of experiments
made upon animals, also denies its possibility, in spite of the authority
of Riolan, sustained upon the example of a deaf mute, who having
plunged an ear-picker through it, immediately regained his hearing.
  Cheselden went farther; since, says he, the loss of the membrana
tympani does not produce deafness, we  might perhaps, by perfora-
ting it in some persons re-establish the faculty of hearing.   Unfortu-
nately his  operation  was unattended with success in the criminal
upon whom he first put this suggestion into practice.  Though again
pointed  out  by  Portal, and formally recommended by Busson, as a
means for evacuating  abscesses of the cavity of the tympanum, per-
foration of the  tympanum could not be rescued from oblivion, but
by M. A. Cooper, who first practised  it successfully as  a remedy for
deafness in 1800  and  1802.   Since made trial of with different re-
sults by numerous surgeons, it is  again ranked among the useful and
systematized operations of the healing art.  A small curved trochar
is the only instrument that was used  by M. Cooper, who in order to
avoid touching the malleus and the chorda tympani, properly advises
that we should perforate the membrane at its anterior and inferior fourth.
  Himly, who  pretends to have  publicly described this operation in
1797, states that the opening soon closes up when we use the trochar.
In order to avoid this inconvenience we may perform it with a  punch,
which M. Fabrizi, of Modena, (Journ. des Progres, X. VII., p. 153,)
has ingeniously simplified.  After this remark, the cataract  needle
preferred by Arnemann, the small square-shaped knife as well as Hey's
needle,  with which Buchanan proposes  to divide the fibres of the
membrane transversely, and  thus favor the retraction of the  lips of 
                        INTERNAL EAR.                      437

the wound, together with the triangular sound of Paroisse and the
concealed kystotome of Fusch, ought to be proscribed, as well as the
small stilette  armed with a circular shoulder near its point, invented
by M. Rust, the knitting needle, which according to Michaelis might
equally be adopted, the simple probe of Itard, the needle that Saissy
incloses in a small gum-elastic canula, and the kystotome of La Faye,
which to myself appears to  be more convenient than any other in-
strument.  Finally, it was  also  with a view of having a permanent
opening, that M. Richerand supposed that it would be better to per-
forate the tympanum by cauterizing the  membrane with a  crayon
of nitrate of  silver, and that Zang suggested the idea of leaving a
catgut in the wound.
  To the three successful cases of A.  Cooper, we must now add a
great number  of  others.   Those of Ansiaux, (Clin.  Chir., p. 260,
2nd  edit.,) and of Sanders for example, who has cured a deafness
of three years' standing by means of this operation ; another of Pa-
roisse, in a patient who had been deaf for eight years ;  those of Mi-
chaelis, M. Rust, Itard, Saissy, Maunoir, and Herhold,  which  latter
states that he succeeded in two  cases out of  three;  and those of M.
Fabrizi, who informs  me he has cured in more than ten instances;
but we must not however dissemble that most  of those practition-
ers, as Celliez and Itard among others, and Dubois, in four different
trials, have also  performed  it without deriving the slightest benefit
from it.   Trury and Kauerz have not been, I believe, any more suc-
cessful.   It is  moreover applicable, but in a very small number of
cases.  We  should be wrong therefore to expect any benefit from it
when the cause of the deafness  is found  to  be a lesion of the laby-
rinth, or of the middle  portion of the ear, or of the nerves  or small
bones, or of their muscles; in a word, wherever the  disease does not
consist merely and simply in the obliteration  of the Eustachian tube,
or in a thickening or  any  degenerescence  whatever, of the mem-
brane of the tympanum itself.  Its object in fact, is to admit the air
to enter into the  cavity of  the tympanum  and  the mastoid  cells.
Pus, serosity, mucosities, and other liquid matters, of which it might
also favor the egress, would  not require  this operation unless there
should not exist the more natural route through the pharynx.   More-
over, it is not dangerous, nor does it give rise  to very serious acci-
dents.  Being attended with scarcely any pain, and rarely followed
by a general  reaction, there is no objection to making trial of it when
we have no longer any thing to hope for from other remedies; only
that we must not promise ourselves too favorable results, or build too
sanguine hopes upon it.  The simple puncture moreover is of no ser-
vice.  The aperture often closes upon the following day.   Excision
itself, when a proper instrument has not been  at command, is not free
from this inconvenience.  M. Deleau's punch, which is a kind of con-
cealed spring  which slackens at the  pleasure of the operator, and
which suddenly pushes against each other  two small circles with
sharp cutting edges, in  such manner as to detach a perfect disc from
the tympanum, though one ofthe most perfect instruments, is still far
however from being always attended with success.   There is scarcely
any instrumental apparatus than that of M. Fabrizzi, which will  in
this respect fulfil every indication. 
438           NEW ELEMENTS OF  OPERATIVE SURGERY.

              §  II.—Perforation  of the Mastoid Cells.

  A.  When, in consequence of inflammations that are acute or even
chronic, severe, dull, or tensive pains are found  to exist in the ear,
—when we  have strong reason  for believing that an abscess has
formed in this part,—that injections into the cavity ofthe tympanum
would be advantageous, or  that  there are  some carious  bones or
splinters to be removed, perforation of the mastoid process appears
to be very clearly indicated.   The passage in which Galen says that
where ulcers of the auditory canal have altered  the hard  parts, we
must make an incision  behind the ear and rasp the bones or remove
their splinters, is all that we find in the ancients that appears to have
reference  to  this  subject.   But Valsalva had already made the re-
mark that injections forced  into the  mastoid cells come out by the
mouth.  Riolan and Rolfinck expressly mention  trephining the mas-
toid process.   Heuermann, who saw  an abscess  of the ear make its -
exit in that part, and leave a fistula  there, concluded therefore, like
Duverney in  speaking  of the  surgeon  Deymier, that the best thing to
be done in such cases would  be to apply the crown of a trephine be-
hind the concha, without giving  time  for the  pus to make too pro-
found an alteration in the spongy texture of the process.  A patient
who would not submit  to this operation, recommended by J. L. Petit,
died, while by means of it the same author  cured a certain number
of other patients who  were at least as severely affected.   Observa-
tions of the  same kind have been published by Morand, Leschevin,
J. Frank, Martin, &c.  It is principally upon these that Jasser justi-
fied himself  in operating upon the soldier, in whom he opened the
mastoid process on one side, containing an  abscess with caries, and
that of the other side in consequence  of a simple deafness.   Fiedlitz
has performed this perforation successfully on both sides in  a woman,
who had been rendered deaf by a quartan fever.   The same author,
as quoted  by Richter,  relates two other  cases not less remarkable.
Laefler, who eulogizes  it greatly, recommends that we should  make
use of a perforating trephine, armed  with a border, which prevents
it from penetrating too deep; that we should  incise the soft parts
twenty-four hours before perforating  the bone, in order to have no
blood effused into the mastoid cells ; and that finally, we should make
use daily of injections into the opening, wThich is to be kept  open and
dilated by means of a  leaden sound.   Hagstroem, who however has
had no reason to  be  satisfied with this operation, enters into  many
more  details  upon the mode of performing it than  Laefler, whose
ideas he for  the most  part adopts.  If there already exists a fistula,
he says we should confine ourselves to enlarging it.  Otherwise we
lay bare the  bone while avoiding  the  auricular  artery,  which is
naturally nearer to the concha;  after which we have nothing more
to do than to perforate the  process from  behind forwards,  by means
of a drill, a punch, or a  trochar, rather than with a perforator.   Acrel
considers  trephining the ear useless  when the bones are sound, and
Murray has very properly observed that before the  age of puberty,
as the mastoid cells are scarcely then developed, it could in reality
then be attended with no  advantage.   The case  of Dr. Berger,
who died after  having  been operated  upon by Koelpin, and in 
INTERNAL EAR.                       439
 whom no cells were found, proves that they may be wanting  also
 in some adults.  Similar facts related by Morgagni, however, did
 not deter either Proet or  Arnemann, who assure us that they have
 had  recourse to it with success.   Hydropsy of the cavity of the
 tympanum and simple abscesses do not absolutely require it.  They
 are evacuated full  as well by perforating the membrane of the tym-
 panum, which is infinitely less painful and  less severe.   It is only
 after all in collections of pus, accompanied with necrosis or caries,
 and which have a  tendency to open behind  the ear, that we  are to
 some extent obliged to  have  recourse to it.  In a case  of this  des-
 cription, M. Weber,  who  found  the mastoid  process sound, after
 having trephined it, nevertheless cured his patient.  M. Denonvilliers,
 (These  d'agregat., &c, 1839, p. 72,) in analyzing  fourteen of these
 operations on nine  patients, found nine  cases of cure, two of amelio-
 ration,  three failures, and one death.
   B. Operative Process.—A crucial or T incision lays bare the  whole
 outer surface of the  mastoid  process;  we then  apply to it either a
 perforator, or a small crown of the trephine, a drill or a trochar.   We
 take care to slightly incline the instrument forwards  and  upwards in
 proportion as it penetrates.   As soon  as it  arrives at the auditory
 cells we withdraw it, in order to enlarge the opening, if it  is neces-
 sary, before we stop.  Injections are then forced into it with caution.
 Tents, or rolls of lint, or a leaden sound, should be placed daily  in the
 perforation until the cavity of the tympanum is restored to its natural
 state.   The chisel, gouge  and mallet, which were  used by  J. L.
 Petit, Chopart and  Desault, ought to have the preference, if the bone
 should be extensively necrosed and it were necessary to remove from it
 large sized fragments.  Should nothing beforehand indicate where
 the instrument  ought to  be applied, it  should be inserted at six or
 eight lines above the point of the  process.  The largest cells corres-
 pond to this part.   The auricular  artery, which is found in front,  and
 the submastoid artery, which  is below,  may be easily avoided.

           § III.—Catheterism of the Eustachian Tube.

   A.  The  idea of penetrating into the cavity of  the  tympanum
 through the pharynx, is one that is  already very ancient. Archigenes,
 Valsalva, Munnicks  and  Busson  no doubt had  this in their minds
 when they recommended  to  inhale vapors of water, tobacco,  or
 other  substances, and to forcibly close the nose  as well as  the
 mouth, in order to force them to pass towards the ear during expira-
 tion.   In the year 1724  Guyot, maitre de poste at Versailles,  and
 Cleland  in 1741, each devised an instrument for injecting the Eusta-
 chian tubes, the one by the  mouth, the other through  the nose.   The
 sound of A. Petit, which is slightly curved, rendered the operation still
 more easy.   Douglas and Wathen pronounced in favor of the pro-
 cess of Cleland.   Heuermann and Ten  Haaf adopting that of Guyot,
introduced  through the mouth into the  Eustachian tube  a female
catheter above the velum  palati, and  afterwards  screwed a  small
syringe  to the other extremity of this  instrument.   Again recom-
mended  by Falkenberg, Sims, Chopart and Desault, and by Callisen,
who sometimes performs it through the  nose and sometimes through 
 440          NEW ELEMENTS OF OPERATIVE SURGERY.

 the mouth, and describes its steps very accurately, and by Buchanan,
 Itard,  Boyer, Richerand, &c.;  and proscribed as  inapplicable to
 living  man by B. Bell, and by  Trempel as dangerous;  these injec-
 tions have again been brought  into repute and warmly extolled by
 M. Deleau.  As a mechanical means they enable us to clear out the
 tubes; and as a medical remedy they act with efficacy on inflamma-
 tions and engorgements of every description, and on inspissated matters
 and collections of liquids in the  cavity and guttural duct of the tym-
 panum.   It may be conceived then how important they would  be in
 deafness, which depends upon one of these causes.
   B. There is no doubt that we may penetrate into the tube through
 the mouth by means of a curved sound  above, behind and upon one
 ofthe sides ofthe velum palati, as was done by Heuermann ;  but the
 operation being still more easy and especially more certain through
 the nasal fossa, it is this route which, at  the present day, is generally
 preferred.  Saissy's instrument, Itard's sound in the shape of an Italic
 S, or a catheter,  which differs from a female one in this only, that
 being open at its two extremities, it  has  no apertures upon its sides,
 are with a small  syringe to force in the liquids, all that are required
 for such an operation.  A gum-elastic catheter provided with its stilette
 and  properly curved ; or a blunt-pointed probe in case it were requi-
 site to  overcome the obstructions with a solid instrument, might in a
 case of necessity be substituted for the other catheters.  The surgeon
 being placed on the side and in front of the patient, reverses the head
 with one hand, seizes with the other a catheter besmeared with some
 unctuous  matter, presents  its  beak  at the orifice of the nose and
 causes it to slide  along upon the floor of the nasal fossas at the lower
 part of the meatus, taking care  to keep  the convexity of the instru-
 ment turned towards the side of the  septum and slightly inclined up-
 wards.   Having arrived at the  upper side of the velum, he slightly
 elevates  the extremity of  the instrument without permitting  it to
 leave the external wall of the nostril, which obliges  it gradually to
 reach the upper part of the maxillary meatus ; continues  to push it
in this direction, and inevitably falls into the  pavilion  of the tube,
which  from that  point runs obliquely outwards,  backwards and up-
wards. As soon as the catheter has entered sufficiently far, the syringe
is adapted to its outer extremity, as when we wish to inject in hydro-
 cele, after which any person may comprehend what remains to be
done.  The operation  is repeated once  or twice daily, and nothing
prevents us, as  is perceived, from injecting in  this manner into the
middle part of  the ear whatever medicated liquid  we may think
proper.  Should  the injection  have stopped in the tube and  be pre-
vented by any means from advancing farther, we should in this case
remove the syringe  and introduce a blunt-pointed probe up to the
 point where the difficulty is, in order to perforate or destroy it.  It
must be well understood here that force  must not be used but with a
great deal of caution, and that before having recourse to it we should
make ourselves  certain that it  has  become indispensable and that
better directed manipulations might  not  render it unnecssary.
  C. M. Deleau, perceiving that the point ofthe metallic catheter can-
not escape from immediately butting against the walls of the tube, as
soon as  we desire to advance   it a few  lines,  that its  inflexibility 
INTERNAL EAR.
441
creates pain, and that  aqueous injections do not penetrate in this
manner into the auricular cavity but with considerable difficulty, has
proposed to substitute for it a flexible catheter, and to have recourse to
the douches  of atmospheric air already recommended  a long  time
since by Herhold, (L'Experience, X. I., p. 518.) -By  the processes of
this surgeon the operation becomes practicable at every age.   I have
seen at his residence two young boys, one four years of age, the other
seven, accommodate themselves in the readiest way that could be
desired to  the  manipulations of his  method, without evincing the
slightest indication of pain.   By means of a silver stilette four to six
inches long, having quite a strong  curvature near its extremity, and
a ring on the other extremity, and the diameter of which instrument
varies from half a line to a line and a half he conducts a gum-elastic
catheter into the tube.  The patient being seated upon a chair, holds
his head slightly reversed either  against  the back  of the  chair  or
against a cushion for this purpose, which  supported  upon an upright
may be elevated or depressed at pleasure.  The operator, armed
with the instrument, which  has been previously oiled, presents it at
the nostril  while holding it in his right hand, like a writing pen,  with
the concavity turned downwards and outwards.   Causing it to pene-
trate rapidly while following the floor of this cavity, he soon reaches
the velum  palati, (which is indicated to him by an involuntary move-
ment of deglutition, and the extent of two inches or two inches and
a half, at which he has  entered,) and immediately elevates the beak
outwardly and upward  by a circular or rotatory movement, in order
to enter into the tube.   Seizing with the thumb and  forefinger of the
left hand the free extremity ofthe catheter above, he endeavors, if it has
stopped, to make it advance, while the stilette is kept immovable by
means of his right hand; proceeds in this  manner till he reaches the
obstacle, which he overcomes in  the same manner that wTe would a
contraction of the urethra,  and withdraws  the directing  stilette as
soon as he thinks  he has entered sufficiently far.   A silver pavilion
is  immediately screwed upon the external opening of the canula,
which the surgeon keeps  in its place by means of a metallic  wire
which is passed around it in  the manner of-a forceps, and which em-
braces at the same time the ala of the nose.   Adapting to this pavilion
the beak of a syringe, or bottle, or ball of caoutchouc, he uses this to
force the air beyond the obstruction, not exceeding a degree of pres-
sure which habit alone can enable him to estimate.   By applying our
ear to that  of the  patient, we perceive whether the cavity of the
tympanum  is sound  or altered, empty or full,  and whether the air
which we have forced into it can or cannot come out from it between the
catheter and walls of the tube.   Substituting  for  the  syringe  the
pipe of a reservoir provided  with a manometer, and  in which a pump
does the duty of compressing the air, and then opening the faucet of
this apparatus, we establish in this manner a double atmospheric cur-
rent in the ear, one which enters by the catheter, and the other which
issues out  between it and the guttural duct: the operator, who has
the power  to augment or diminish the force of this douche, intermits
it at the expiration of one or several minutes.
  D.  In order  to penetrate through the other nostril, the instrument
is to be a little more curved, with its beak slightly reversed in the 
442
NEW ELEMENTS OF  OPERATIVE SURGERY.
direction  of its convexity.  Being held in the same hand, with the
concavity turned downwards and inwards, it is made to pass  alon<»
the inferior border ofthe septum.  Having arrived at the velum palati,
the hand is elevated and carried outwards  to incline the extremity of
the instrument behind the vomer, that it may reach the tube.   The
rest of the  process is performed  as  in the preceding one.   In both
cases, if the catheter is not properly  in its place, the patient himself
notices  it  when he has once undergone the operation.
   Its direction and the manner  in which it  is maintained, moreover,
sufficiently point it  out  to  the  surgeon.   He possesses however a
ready  means  of satisfying himself with certainty.  Having  with-
drawn the stilette, we have nothing to do but to force in the air or
liquid by  the canula.  The injection  will fall into the pharynx if the
position is false, and will not penetrate, or, in  the contrary case, will
enter into the cavity of the tympanum.   If after having overcome
the  obstruction, the air  produces in the cavity a pattering sound
(bruit  de  pluie) upon the  membrane  of the  tympanum, or a rough
sound (bruit sec), we conclude  from  this that the middle part of the
ear is not altered ; if it  seems rather to agitate a  liquid, and if the
sound is mucose, (?nuqueux,) we are then authorized in believing in
the existence of pus, blood, serosity or at least an  engorgement  of
the internal membrane of the middle  ear.
   In both cases, if the tube is evidently choked up  or narrowed, and
that the patient perceives sounds better immediately after than before
the catheterism, the deafness is imputable to the condition ofthe tube
and there is every  reason to  believe  that  it may be cured.  When
there results no  change from it, the  disease is very probably else-
where, and we may be almost certain that  this operation will be of
no advantage  afterwards.  If acute pain be produced by the injec-
tion, it indicates an acute phlegmasia  or too great a degree of nerv-
ous irritability, which are to be  treated by means of the  usual reme-
dies.  In simple obstruction or phlegmasias that are purely chronic,
the suffering is almost nothing  either during  or after the operation.
M. Deleau explains the action of the air in a manner which is altoge-
ther mechanical.  It ventilates,  fumigates and washes out gradually
the cavity of the tympanum  and the mastoid cells.  In  returning
between the catheter and the tube, it necessarily makes an effort, and
becomes a dilating  and resolvent  body by the compression which it
exercises  upon the engorged tissues.   Water  and  liquids are much
more liable to  wound and lacerate the membrana tympani, &c, and
do not produce medical effects different from gases.  Any intelligent
person may  understand after  all that every case must require par-
ticular modifications, and that in respect to the operative manual it is
the same with contractions of the Eustachian tube as with the coarc-
tations of  the urethra; and that  on this point, address and trials often
repeated,  joined  to  much prudence, will  be  alone enabled  to give
sufficient degree of dexterity to  the person who would desire to em-
ploy with  advantage catheterism of the guttural duct of the auditory
apparatus.
   E. The sounds, catheters and probes  devised  by  M.  Gairal,
(Journ.  Hebdom., 1836, t. II., pp. 97, 129, 197,) who provides them
with a  leather bottle and faucet (une outre a robinet), and of gum 
THE PAROTID, AND  PAROTID TUMORS.
443
elastic, in order to inject the Eustachian tube, render tne operation
still more easy and perfect.
  F. One doubt remains for me to express: the engorgement, thick-
ening, and inflamed condition of the mucous membrane of the tube be-
ing admitted as a cause of deafness, would it not be allowable to make
use, against these affections, of the treatment which is advantageously
employed for  their radical cure in the urethra, to wit: cauteriza-
tion with nitrate of silver ?  Having made no trial in support of this
suggestion, I merely recur to it, en passant, and am not unaware of
the apprehension that ought naturally to be inspired by the intrdduc-
tion of caustics into the ear through the pharynx.
  I will add that the  attempts made by different  persons since the
first edition of this work, have not yet produced any very satisfactory
result, and that the  excision of the tonsils is likewise a valuable means
in the cure of this  description of deafness.
                 PART  SECOND.

OPERATIONS WHICH  ARE PERFORMED UPON  THE NECK.
                        CHAPTER  I.

             TUMORS OF THE SALIVARY REGIONS.

        Article I.—The  Parotid, and Parotid Tumors.

                 § I.—Examination  of Facts.

  Should we take literally what authors of the last century have
said of it, nothing could be more simple  than the total eradication of
the  parotid gland.   In our times, on the contrary, nothing seems to
be more uncommon, so much so that numerous distinguished surgeons,
Boyer among others, deny even its possibility.
  It is true that most of the cases which have been  related  are far
from being conclusive.  Thus, as Richter had already remarked and
as Burns has  demonstrated, the  assertions of Heister, who says he
had often extirpated the parotid ; those of Scultetus,  Verdier, Palfin,
V. Swieten, Gooch, Berh, Roonhuysen, Gottefried, Errhart, &c, and
of Garengeot, who pretends that this operation scarcely ever causes
any hemorrhage ; of Scharschmidt, who considers that  he has per-
formed it a great number of times with  success, among others, upon
a patient in whom the  tumor weighed three  pounds ; of Acrel, who
was enabled to arrest the hemorrhage by means of simple tampon-
ing ;  of Burgraw and Hezel, and of Alix, who was enabled to extir-
pate a mass of four pounds in weight below the ear,  without produ-
cing  the slightest  effusion of  blood ; of K. Boerhaave, and some
others still, evidently refer to  the  ablation of lymphatic tumors de-
veloped in the depth of the  parotid  space, or to  cysts either salivary, 
444
NEW ELEMENTS OF OPERATIVE SURGERY.
as in the case of M. Krimer, (Bull, de Fee, x. XVI., p. 72,) or pure-
ly serous, as in the patient of M. Henri, (Bull, de I'Acad. Rot/, de
Med., X. I., p. 56,) and not to the parotid itself.  M. Smith, (Gaz. Med.,
1839, p.  43,) who considers that he extirpated the parotid, in remo-
ving  from the parotid  depression a tumor of the size of a nut, and
who divided the facial nerve, took away probably only a degenerate
lymphatic mass.   The tumor  of the  size of an orange, successfully
extirpated by M. Goyrand, (Savournin, Lancette Franc, 1839, t. L,
p. 14,) from the parotid region, was not the gland.   In another case
the same surgeon, (Lancette  Franc, 1839, t.  I., p. 14,) removed a
part of the parotid gland, and the submaxillary gland, together with
degenerated lymphatic ganglions.  The patient got well without any
unpleasant consequences. It would be doubtless difficult to say whe-
ther the  tumor successfully removed from the parotid region by AI.
PI. Portal, (Clin. Chir.,  vol. I., p. 125,) was rather of an encepha-
loid, than lymphatic nature; but certainly it was not the gland itself. In
1781, J.  B. Siebold supposed that he had removed the parotid entire,
because after the  operation it could be readily seen that the digastric
and stylo-hyoid muscles, as well as the parotid artery, were laid bare.
In a  student mentioned  by Heister, it  became necessary to  go so
deep, that the carotid gave rise to a fatal  hemorrhage.  Soucramp,
supposing that he was about  to  remove a lqupe, discovered that he
had extirpated the parotid.   There was much less blood discharged
than the  surgeon  expected, and  the  patient  was perfectly restored.
In 1796,  Ch. G. Siebold,  who removed an enormous tumor from  the
side of the neck in a young girl,  states that the cavity thereby made
was so deep that all the assistants were obliged to  admit that the
parotid had been  extracted from it entire.  In  the  patient operated
upon  by  Klein (Graefe und Walther's Journ., vol. I., p. 106) in 1820,
the facial nerve was divided.   The cure was accomplished at the ex-
piration  of eighteen days.  In the case of M. Idrac, there was no
artery requiring a ligature  ; but the wound presented the same as-
pect as in the patient of Siebold the father.  The case recovered with-
out being followed by paralysis.  The case  of M. Lacoste differs
from  that of M. Idrac  in this only, that there was an abundant he-
morrhage, which was twice renewed, and  placed the life  of the  pa-
tient in jeopardy.  One of the tumors removed by M. Prieger, (Ibid.,
vol. III., p. 455,) weighed  nearly three pounds.  The  carotid was
avoided and the woman  survived.  If we may believe M. Kirby, he
was enabled to satisfy himself, after his operation, that  the interval
between  the pterygoid muscles was void, and  the  auditory passage
laid bare, as well  as the temporo-maxillary articulation, and the whole
length of the styloid process.  Nevertheless, tamponing with sponges
succeeded in arresting the hemorrhage, and notwithstanding an ery-
sipelas which appeared on the face,  the patient recovered.   As to
the fact related by M. Pamard, the author himself  admits that the
parotid was not extirpated in  its totality.   M. Nasgele, on his part,
alleges that we may remove  this gland in  the dead body without
wounding the facial nerve, and maintains  that  he performed it with
success without producing  paralysis.   M.  Moulinie, (Bull. Med. de
Bordeaux, 1833,) having cauterized after having excised  or extirpa-
ted the tumor, lost one of his patients and cured the other.  In a pa- 
THE PAROTID, AND PAROTID TUMORS.
445
 tient whom I have seen and who was first successfully operated on
 by M. L'Herminier of Guadaloupe, the cancer reappeared and caused
 death.   Goodlad furnishes a case which is sufficiently well detailed,
 of extirpation of the parotid;  it is to Beclard, however, that we are
 indebted for the first  demonstration of this fact.   His patient, who
 was operated upon in 1823, had all the muscles upon one side of his
 face paralyzed, and as he died some months subsequently, they were
 enabled to  ascertain that the whole gland had been actually extirpa- '
 ted.  A patient operated upon  in September, 1824, by M. Gensoul,
 and who died in the course of the year 1825, also furnished the proof
 that the parotid  had been thoroughly extirpated.   M. Gensoul,  still
 more fortunate  than in his first case, repeated this  operation in 1826
 with entire success;  but the patient remained paralyzed on one half
 of his face. M. Carmichael had been equally fortunate some time be-
 fore, that is to say in 1818, and mentions the same peculiarity as M.
 Gensoul as the consequence of the operation.
   In 1826, also, M. Lisfranc had occasion to remove the parotid,  and
 ascertained, after death, that scarcely anything of the gland remained
 in the parotid  space.   M. Mott,  (Arch. Gen. de  Med., X. XXX., p.
 419,) who previously tied the carotid, also considers that he extirpated
 the whole gland in a patient,  who  died at the expiration  of seven
 weeks.   M. Roux (Ibid., 2e serie, t. VIL, p. 404,) and M. Chelius
 (Ibid., 2e serie,  t. IX., pp. 230, 265,) in performing the same, opera-
 tion did not find it necessary to tie the carotid  artery.  In the ope-
 ration performed by M. Heyfelder, (Graefe und Walther's Journ.,
 vol. X., p. 575,) in the month of June, 1825, the patient lost but three
 or four ounces  of blood, a small lobe of the gland only was left in
 front, and the paralysis of the face  ultimately  disappeared sponta-
 neously.   In  the patient operated upon  by M. MacLellan in 1826,
 the cure was  complete, says the author, though  the gland had been
 entirely removed.   That of M. Cordes,  (Journ.  de  Walther, &c,
 vol. II., p. 105,) who states that he  did not leave the least particle
 of the gland, also perfectly recovered.  M. Bernt (Bull, de Fer.,
 t. III., p. 287,) also  alleges that he  has performed this extirpation
 with success.   The Archives  (Arch. Gen. de  Med., X. IV., p. 64,)
 contain  another example, in which layer  after layer was removed
 down to the carotid.  In the operation which M. A. Fonthein (Graefe
 und Walther's Journ., vol. XIII., p. 290,)  performed in the  month
 of November, 1828, the carotid was not wounded, no  hemorrhage
 supervened, and the cure was  completed on the thirtieth day.  The
 paralysis itself, which  took  place at first as in the  preceding cases,
 completely  disappeared.   In the month of January,  1829,  M. A.
 Magri  (Bull, de Fer.,  X.  XXII., p. 84, and Journ. des Progres,
 2e ser., t. I., p.  261,)  extirpated on  the side of the neck  a tumor
 which included the  whole of the parotid, and was enabled  to dis-
 pense with  a ligature on the trunk of the carotid.   The patient was
 restored in the space of twenty-six days,  with  the exception, how-
 ever, ofthe facial paralysis which remained.  M. Dugied, who gives
 an extract from most of these  cases, and which are mentioned also
 by MM. Hourman and  Pillet  in  their  dissertation, also states that
MM. A. Cooper and Weinhold have repeatedly extirpated  the  pa-
rotid entire.  But I  have not  been able  to ascertain where these 
446           NEW ELEMENTS OF  OPERATIVE SURGERY.

observations have  been published, with  the  exception  of those of
M. Weinhold, (Bull, de Fer.,X. VI., p. 242,) who has preserved one
of these glands in his museum and shows  it to those who wish to see
it.  To the examples above mentioned  it would be necessary at the
present time to add the following:
   1st. Man, forty-six years of age ; extirpation without previous liga-
ture ; no serious  hemorrhage ; cure;  palsy of the face;  (Hendriks.)
2nd.  Woman, nineteen years of  age;  extirpation without  previous
ligature ;  cure;  palsy of the face ; (Hendriks.)  3d.  Woman, thirty-
eight years of age ;  extirpation  without  previous ligature ; cure;
(Hendriks.)   4th.  Woman, thirty-three  years  of age; extirpation
and cauterization ; cure ; (Hendriks.)—(Baamberg, Dissert, sur YEx-
tirp. de la Parot.)  5th. A woman ; size of a goose egg; extirpation;
cure;  (Eulenberg;) (Journ.  des  Conn. Med-Chir.,  X. III., p. 75.)
6th.  Another ;  enormous;  previous ligature of the  carotid; (Sted-
mann;) (Gaz. Med., 1832, p.  529.) 7th. Another; prolonging itself
upon  the jaw ; ligature of the carotid ;  cure ;  (Awll;) (Western and
Physic Journ., vol. I., p. 423.)   8th. Another: (Eckstrum;) (Bull.
de Fir., X. VIII., p. 204.)  9th. Another;• boy, aged fifteen years;
ligature upon the external carotid  ; apprehension of a return.  10th.
Another;  extirpation  incomplete ; (Ansiaux ;) (Clin. Chir., p. 233,
2d edit.)   11th.  Another; extirpation without previous ligature, and
cure; .(Warren, the father.)   12th. Another; the carotid  wounded
and tied ; fistula and paralysis ; (Warren, the son f) (On Tumors, &c.
p. 280.)   13th. A woman ; thirty-four  years  of age; on  the right
side, and weighed twenty-one ounce? ; performed 26th May ; cured,
14th  July, 1838 ;  (MacGregor ;)  (Lancet,  June,   1838,  p. 498.)
14th.   Another ; the jugular [wounded] and  external carotid tied ;
cured ; (Widmer;) (L'Experience, X.  II., p. 336.)
   II.  Appreciation of the Facts.—The  question whether we may or
may not extirpate the  parotid  gland in its  totality, appears  to me to
have  been incorrectly stated.  The salivary  glands, including with
them the parotid, scarcely ever degenerate.  The tumors that have
been removed under their name almost all belong to other tissues and
to other organs.  Even in the substance of the parotid itself there
are a great number of lymphatic ganglions.  These  ganglions when
they swell  become fungous,  tuberculous, and  cancerous,  and  are
transformed  into bosselated  tumors, which spread  out, flatten, and
disorganize the glandular tissue, and lead to misconceptions of the
real character of the parts which  are extirpated.  I have performed
extirpations of this kind at least twenty times, to such extent as to lay
bare the whole parotid cavity, and to  be afterwards under the neces-
sity of submitting the tumor to a careful dissection, in order to satisfy
myself that the ganglions, rather than the  glands, had  been the source
of the disease.   I have, moreover, encountered in this region meh-
ceromatous, lipomatous, fibrous, melanotic,  encephaloid, and other
tumors.   A new-born infant that  M.  P. Dubois showed  me, in Jan.,
1839, had  in this part an  erectile venous tumor of five  inches in
diameter.  Not wishing to treat in this  place except of tumors which
implicate the parotid, whether they originate or not  from  its tissue,
I  refer to the chapter on tumors in general for those of other descrip-
tions. 
w^
               THE PAROTID, AND  PAROTID TUMORS.            447

                 § III.—Anatomical Remarks.

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

  When the operation is decided upon, the first question which pre-
sents itself, is this :  should we or should we not imitate Goodlad, who
was among the first  that tied, as  a preliminary step, the carotid
artery 1   In the beginning we never can  know whether we  shall be
under the necessity of removing the gland in its totality.  Though
the wounding of the external carotid is almost inevitable, the internal
carotid may in a great many instances be respected.  In making up
our minds  to surround the trunk only with a thread  during the pro-
gress  of the 'operation,  as was done or  appears  to have been done
by Beclard and MM. Carmichael, Gensoul and  Lisfranc, we have,
if it is practicable, the chan.ce  at  least of dispensing with  the liga-
ture, and without exposing ourselves on that account to the  encoun-
ter of more serious difficulties than by any other process.   The sur-
geon finding that the glandular tissue instead of having produced the
disease has  merely become the receptacle of it, endeavors  to  re-
move  the   gland  only  in the manner  of cellular  tissue* which
surrounds or is  in the vicinity of any tumor whatever;  it is to the
lympathic or cancerous tumor, and their branches wherever they may
be, that  he directs his attention, in place of following out the  pro- 
448
NEW ELEMENTS OF  OPERATIVE  SURGERY.
longations of  the parotid gland.  Setting out upon  this principle, I
have never been under the necessity of tying the carotid vessels be-
forehand, though I had penetrated down to the bottom ofthe parotid
cavity.
   A. Extirpation.—The  instruments  that we may  require for ex-
tirpating  parotid tumors,  are  composed of a straight,  convex, and
blunt-pointed  bistoury,  straight and  curved scissors,  a  dissecting
forceps,  a canulated sound without any cul de  sac, a scalpel, the
flattened  handle of which may serve  to  separate the parts, should
occasion  require, needles  armed  with  ligatures,  and whatever  it
would be  requisite to  have at  hand, if we were  obliged  to place a
ligature  upon the carotid  artery.   The rest  of the articles consists
of sponges, small balls and plumasseau  of  lint,  agaric, long  and
square compresses, one or two bandages, and  other articles which
are required in all great operations.
   I.  First stage.—The patient being placed upon  his sound side  and
held by assistants, is to be  fixed in such manner as to be enabled to
breathe and spit freely.  One of the assistants should  hold himself
ready to compress the  trunk of  the primitive carotid in case of acci-
dent.  The size and form of the tumor, and condition of the integu-
ments, determine the kind  of incision which is to  be first made.  If
the skin is sound and free from  adhesion, if the  body to  be removed
does not exceed the dimensions of a  pullet's egg, the crucial or T
incision might  be replaced by the semilunar, to which for myself I
give the  preference.   Otherwise  we  must have recourse  to  the
elliptic incision, in order to remove with the  tumor a flap of cuta-
neous tissue of greater or lesser  extent.   In this last case nothing pre-
vents us from  making afterwards upon each lip of the ellipse another
incision, which transforms it into a legitimate  T, and which after the
operation will  reduce the whole to a  crucial incision.  Unless  the
disease should have extended to a great distance towards the mouth,
there can be no doubt that there  is  less advantage in placing the
great diameter  of the wound transversely, as  Goodlad did, and AI.
Fonthein advises, than  from above downwards.   These are the only
general rules that are  required to  be  laid down on this first point.
It is  upon himself and  upon his personal knowledge and skill that the
operator  will  be obliged to rely, in  order to follow them out, or
to  modify or restrain them.
  II.  Second stage.—The integuments having been dissected, and the
flaps reversed, the surgeon detaches the  altered mass by commencing
at  its superior  part, then going  to its posterior border, in order that
he may not at the beginning fall upon the carotid ; he ties the arteries
in  proportion as they are opened, or if they are of little size confines
himself to their  compression by the finger of an assistant, and takes
care when he  reaches towards the  border of the jaw or near the
pterygoid  muscles, to  hold the  cutting edge of his bistoury rather
turned backwards than forwards, and directed rather against the tis-
sues  to be extirpated, than towards those which are to be preserved.
The  handle of the scalpel ought  to be  preferred so long as  it
appears  to answer.   By  means of this instrument we  detach or
isolate the most of the lobes of the  gland or tumor, disengage them
from among the vessels without incurring the risk of opening the 
THE  PAROTID,  AND PAROTID  TUMORS.
449
arteries, and thereby diminish to the same extent the danger of the
operation.  When, however, we are satisfied that the adhesions to be
destroyed do not include any part which it is important to preserve,
the bistoury should  be  substituted  for the scalpel.  By tearing out
the lobes the dissection  is more safe ; by incision it is less painful,
and more favorable for the subsequent symptoms.
  III. Third stage.—Having  arrived behind the maxillary branch,
the operator should double his precautions.   There  are to be found
the external carotid  and  the  origin of the temporal and internal
maxillary arteries.   Deeper still at the top of the parotid fossa, should
there exist some pedicle or prolongation, which cannot be detached
by the handle of the  instrument, prudence  suggests that we should
apply the ligature to them on the side towards the  sound parts, before
excising them. On the supposition, that during all these manipulations
a large artery, the  external carotid fof  example, has  been opened
into, or that we perceive  that its lesion is inevitable, we ought, before
going any farther, to lay it bare near its  root, in Order  that we may
apply the ligature  to it sufficiently low down not to incur the risk
of wounding it afterwards.  Should not the  muscles of the styloid
process, nor especially the  digastric be  degenerated, we  should do
all in our power to avoid destroying them.   Under opposite circum-
stances we should sacrifice them without any hesitation, as well as the
trunk of the facial nerve, which it is useless to attempt to save  when
the whole parotid  is disorganized.   Finally, it  may  be possible that
the tumor no longer resists except at its summit, and  that in spite of
the tractions made  upon it by the left  hand on  the one part, and
by the handle of the scalpel on the other, this  point adheres firmly
to the bottom  of the wound.   In this case, from the  apprehension
that it may include some large vascular trunk, it is better to embrace
it  with a ligature,  strangulate it  in the  same  way  that we would
a polypus, in conforming to the advice of Hezel, and to restrict our-
selves for the time being, to the excision of that portion ofthe tumor
only, which  remains perfectly free.  M.  Begin, (Elem. de Pathol.,
&c, t. L, 2d edit., p. 204,)  from having  on  one occasion  neglected
to adopt this precaution, found a volume of arterial spouting from the
wound, which gave  him so  much the greater uneasiness, from the re-
tracted end of the vessel having escaped from the  ligatures, and from
the necessity to which he  was compelled of having recourse to  a
methodical, severe and painful compression.
  IV. Fourth stage.—The arteries which may have been  wounded
are, besides the  carotid, the transverse  facial, temporal, auricular,
mastoid, stylo-mastoid, occipital, internal maxillary, the inferior pha-
ryngeal, and even the lingual and facial.   All these  branches there-
fore are to be successively tied, if we have not performed this opera-
tion upon their common trunk at first.  The blood which continues
to flow afterwards can come only from veins, and requires, if it does
not stop of itself, no other means than tamponing.  At the first aspect
the excavation which  has been produced has something frightful in
its appearance; but its depth alone would not prove that we had in
reality extirpated the parotid rather than the lymphatic  ganglions.
If the wound should only be some inches in extent, its flaps could be
approximated and  united either by strips of  adhesive plaster or the
                               29 
450
NEW ELEMENTS OF  OPERATIVE SURGERY.
suture.   But when it is very large, if we attempt immediate and com-
plete union, we incur the risk of purulent collections, and simple or
phlegmonous erysipelas, and all their consequences, as we have seen
in the cases ascribed to Beclard and many others.  After the cica-
trization the patient  may remain feeble, which he should be apprized
of.   The movements  of the pharynx, larynx, tongue, and even the
jaw, sometimes suffer  much from this operation, owing to the muscles
which have been divided.   More frequently still,  the section of the
facial nerve more or less completely paralyzes the eyelids, ala ofthe
nose, the labial angle, or all the corresponding half of the face.
  B.  Ligature.—The  cutting instrument is not the only  remedy that
has been suggested to practitioners for the removal of parotid tumors.
Roonhuysen, who,  deterred  by the  dangers of  hemorrhage, had
already proposed to  substitute the ligature  for it, introduced a double
ligature  deep  down through  the base of the tumor, and afterwards
tied its two extremities separately, the one above, the other below,
in such  manner as  to produce mortification of the diseased tissues.
M. Mayor recommends that we should first lay it bare as in extirpating
it, and that after having isolated all that portion of it which projects
externally, we  should traverse it in the manner of Roonhuysen, or
better still, that we should draw it to the outside as much as possible
by means of an erigne  forceps, and then introduce upon its root a
strong ligature, which he tightens by degrees with his chaplet con-
strictor.  In five or six days, says he, the degenerescence is entirely
cut through or  reduced to putrilage, and no artery has run any risk
of being wounded.  It was  in this  manner that  he cured a young
girl fourteen years of age of a tumor that she had had for three years
in front of the ear; also another patient of eighteen, in whom the gland
extended from the  zygomatic arch to below the angle of the jaw;
finally, a third,  in whom  the morbid mass, eight inches long and four
broad, was situated in  the parotid region.  But whatever the author
may say on the subject, these facts relate much more to  the extirpa-
tion  of  degenerate lymphatic  ganglions than to that of the parotid
gland, properly so called.  I find, moreover, an inconvenience in this
method: it incurs the risk of removing  only a part of the disease
when it extends deep within, while, if it is superficial, the employment
ofthe bistoury  being then less dangerous, the ligature loses much of
its importance.  Nevertheless I would not object to make trial of it
by combining it with dissection in the first of these cases.  Without
giving ourselves the trouble  of tearing out  all the branches of the
gland successively, when they penetrate  too deep into the midst of
the vessels, a  strong  ligature, which would comprehend them en
masse, and which would enable us  to strangulate them by degrees,
appears to  me to offer  a resource which up to the present time, as M.
Mayor justly complains,  has been too much neglected.
  C.  Caustics.—The recommendation of Desault and Chopart, who
proposed, after having excised all the projecting portion of the scir-
rhus, that we should destroy the remainder with a hot iron or caustics,
is assuredly a much more objectionable process, and scarcely deserves
to be taken into consideration.  The actual cautery could only be
useful in this operation for obliterating the  mouths of vessels that had
escaped from the ligatures, and for destroying some morbid vestiges, 
              THE PAROTID, AND PAROTID TUMORS.            451

if there are any, that the instrument has not removed, contrary to the
intention of the operator.   (See on  the  subject of cysts or other
tumors of the parotid region, and the operations required for them
the chapter on  Tumors in general.)

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

  J. B., a native of St. Domingo, aged twenty-one years, came under
my care  in the latter  part of June for a tumor situated  on the face.
He stated that he first observed it in January last, shortly after a se-
vere attack of fever, and that it  gradually increased in size until a
few months ago, when  he became  alarmed at its progress, and
decided upon visiting  this country.
  Upon  inspection I found a very hard tumor, about the  size of an
ordinary fist, involving nearly the whole left side of the face, and evi-
dently formed of the parotid gland, apparently in a  scirrhous state.
(See Fig. 1.)  From its magnitude, and as the  only ehance  left for the
                             (Kg. 1.)
recovery of my patient, I resolved upon attempting its extirpation, and
with his free consent,  after  rendering the  subject perfectly intelli-
gible to him, fixed on the 13th of July for carrying it into effect.
  Accordingly, on that day  the  operation was performed.  It was
commenced  by interrupting the  circulation  through  the external
carotid artery by ligature, and for that purpose an incision was  made
from the posterior angle of the lower jaw downward and inward 
452
NEWr ELEMENTS OF OPERATIVE SURGERY.
 about three inches in  length, so  as to expose to view the inner mar-
 gin of the sterno-cleido  mastoid muscle.   An enlarged  lymphatic
 gland was now exposed, lying directly upon the sheath of the ves-
 sels. Upon turning it to the inside, the external carotid was laid bare,
 and tied  immediately  below the  digastric muscle, and a little above
 the upper border of the thyroid cartilage.   From the tumefaction of
 this part of the  neck  the artery was nearly three inches  from the
 surface.
   An incision was next commenced above the jugum temporale and
 carried  downward in  a semicircular direction, until it terminated
 upon the os occipitis.   The incision in the neck was  now extended
 upward,  to intersect the one over the tumor.
   On detaching the integuments in the form  of a double flap from
 over the diseased mass, its black  appearance  removed the impression
 of its scirrhous character, and fully demonstrated a melanotic condi-
 tion of the gland.  I however determined upon continuing the  dis-
 section,  and proceeded to detach it  from  its various connexions.
 With this intention I commenced by dividing along the inner margin
 of the tumor the adipose and cellular tissue, until the inner edge of
 the  masseter  muscle was exposed to view.   The finger was now
 introduced into the mouth, and cut upon in order to avoid dividing
 its membrane, and  after separating the tumor for some distance from
 the  masseter, to  which it closely adhered,  I detached it  from  the
 jugum, which had  become more or less carious from pressure.   It
 was next dissected from the mastoid and digastric muscles, and from
 the  posterior  angle of the jaw,  but  as the  patient complained of
 excruciating torture when the tumor was raised from below upward,
 I determined  to continue the  dissection from above downward, and
 accordingly separated  it, with a few rapid  strokes of the knife, from
 the capsular ligament of the lower jaw, and removed the bulk of the
 disease, as represented  in Fig. 2, next page.  The portion filling up the
 space  between the styloid and  mastoid processes was cautiously
 detached  with the handle of a scalpel,  and  the  facial nerve or portio
 dura divided by a quick movement of  the knife.   At the instant of
 the division of this nerve, he seemed to evince more pain than at any
 period of the operation.   The muscles of the  left side of the face
 were paralyzed.  All the remaining portions of the disease were, as
 far as practicable, removed.
   Several arteries were tied during the extirpation of the tumor, and
 after its removal.   The trunk of the temporal was cut as it emerged
 from the disease, and yielded a profuse retrograde hemorrhage.
   The operation lasted about an  hour, and the patient lost perhaps a
 pint of blood. In the operation I was assisted by Drs. Vache,
 Wilkes, Hosack, and Dykers, and it was performed in the presence
 of Drs. Barrow, A. Smith, Graham, and Seaman, and about twenty
 pupils.
   After waiting a  proper time, to see  if any bleeding would occur,
 and  refreshing our patient, although he did not  seem exhausted, the
 wound was closed by several sutures  and  adhesive straps, and lint,
 compress, and double-headed roller, completed the dressings.
  Evening.—Has had  a little  sleep and feels  as well as he expected.
No hemorrhage;  reaction has come on; took claret and water, with 
THE  PAROTID, AND PAROTID TUMORS.
453
                            (Fig. 2.)

toast, which  he sat up and  ate  with a  relish,  shortly after the
operation.
  Ulh, morning.—Left two  pupils with him during the night, who
report that he had slept well, and did not take the morphine that was
directed, if he should be restless and in much pain.  Pulse 94—skin
natural.  As  he was averse to taking tea or barley-water, from the
impression that it would occasion vomiting, he  was  allowed his
favorite drink of weak  claret  and water.
  Evening.  Has had  no evacuation from his bowels;  directed the
nurse to administer  a  common enema; pulse  104;  skin pleasant;
complains of considerable pain in swallowing.
  15th, morning.—Enema operated favorably.   Did not rest well
during the night, but  in the morning got some refreshing sleep.   Skin
a little heated ;  pulse 122.
  Evening.  Says he is more comfortable every way.  Skin moist;
pulse 108 ; recommended an  enema.
  16th, morning.—Has had a very undisturbed sleep, and feels  better
than at any time since the operation.   Skin soft; pulse 96.   Takes
only sugar and water as a drink.
  Evening.  More comfortable than in the morning ; has slept con-
siderably during the day.  Face more swelled;  pulse 100; skin cool
and soft; ordered an enema previous to bed-time.
  11 th, morning.—Passed a pretty good night;  had a free perspira-
tion.  Pulse 98 ; skin natural. 
454
NEW ELEMENTS OF OPERATIVE SURGERY.
  Evening.  Feels in all respects better; pulse more frequent than
in the morning;  skin the same.
  18^.  Swelling of the face rather diminished ; does not complain
of any pain in the wound, or in his head; pulse 95.
  19th. , Some discharge from the lower part ofthe wound.  Dressed
it; looks very well. Pulse 88.  Ordered chicken water and an enema
in the evening.
  20th.  Says he  passed an excellent night, and feels  much better.
Pulse 96 ; skin natural; swelling of the face subsiding.
  21st. Dressed the wound ; discharge very good ;  pulse 88.
  22c? and 23d. Dressed the wound ; seems improving in all respects.
  24th.  Removed all the plasters and dressed  the entire wound;
took away several of the sutures; very much healed  by adhesion.'
Pulse and skin natural; bowels have been moved naturally. Directed
more nourishment.
  21th. Upon cleansing  the wound, ligature from the carotid came
away.  Removed  remaining  ligatures  and  sutures; wound mostly
healed; at a small unhealed point, opposite the lobe of the ear, the
integuments appear to be taking on the melanotic aspect and a bloody
fluid is discharged.
  30th. Wound  entirely healed, excepting at the point opposite the
ear, which has every appearance of a reproduction of the disease.
Complains of pain in the left knee, of which he has had several pre-
vious attacks.  Directed leeches and warm fomentations.
  August 5th.—Leeches have been  repeated, followed by blisters.
Pain in the knee less, but tumefaction increased; reunited portion of
the wound taking  on a melanoid fungous character; a small tumor
making its appearance  over the right eyebrow.  Ordered syrup of
sarsaparilla, with a small quantity of muf. hydr. in solution.
  12th. Several tumors have made their appearance upon the scalp;
fungous ofthe wound rather increased; a dark spot showing itself in
the integuments  of the diseased side of the face ;  tumefaction of the
knee increased ;  complains of  pain in the right side.  Skin assuming
a yellow color.
  20^. Tumors all increased in size ; hepatic affection very decided;
confirmed hectic,  and  is evidently sinking.   Every thing done to
make him comfortable.
  31 st.  In all  respects worse.   Permitted every thing he desires.
  Sept. 5th.—Died this morning.
  After deatb every exertion was made in order to obtain an exami-
nation of the body, but such were the feelings of the friends of the
deceased, that even the desire of passing a lancet into one of the tu-
mors on the scalp, with a view of ascertaining their positive charac-
ter, although I had no doubt ofthe case being constitutional melanosis,
was  obstinately refused, and compelled to  be abandoned.
  On dividing the tumor longitudinally, not  a vestige of the original
organization of the gland could be observed.  The inner surfaces had
the appearance of firm tar, and imparted a black color  to the fingers
when touched.  V. Mott.]
  [Extirpation  of the Parotid.—M. Larrey, in  the case of a girl
aged nineteen, in whom the  chain of lymphatic glands on the left side
of the neck  became so  hypertrophied as to constitute an enormous 
SUBMAXILLARY GLAND.
455
tumor in that region, implicating the parotid, (L'Examinateur Medi-
cale, Aug.  15, 1841,) first effected a resolution of the  ganglia by the
actual cautery,  moxas, mercurial  frictions, &c, which treatment
occupied two years,  and then removed the parotid, when a perfect
cure resulted.   T.]

              Article  II.—Submaxillary Gland.

                             §1.
  There is no conclusive proof to show that the sub-maxillary gland
has ever passed into the state of scirrhus or cancer.  The examples
which have been brought forward for this relate to the conglobate
glands which  are in its neighborhood,  and which are found between
them and the border of the jaw and platysma-myoides muscle.   Its
induration, in consequence of chronic  inflammation, in grenouillette,
for example, is far from being as unfrequent.
  Abscesses that become developed in the cellular tissue of its neigh-
borhood, and which remain fistulous after being opened, also produce
this result.  But however obstinate it may be, this malady ordinarily
yields to other means than extirpation, which never seems to be abso-
lutely required.   Of the observations which have been published in
France, the one which I  have made known, and which belongs to M.
J. Cloquet, is a pure and perfect example of extirpation  of the supra-
hyoid ganglions ; that of M. Amussat comes  probably under the same
description, and moreover it is far from being demonstrated that in
his patient the operation  was absolutely necessary.   I would  say the
same of the case related by M.  Warren, (on Tumors,  &c, p. 129.)
It moreover appears to me evident that the tumor of the size of an
egg extirpated by M. Sicherer, (Gaz. Med., 1838, p. 810,) under the
title of a maxillary  gland, was nothing more than a lymphatic tumor.
Was not this the case also with the sub-maxillary cyst removed by M.
Malcolmson, and which I have spoken of elsewhere ? (see Salivary
Cysts.)  The cases of extirpation of the sub-maxillary and sub-lingual
gland mentioned by M. Diday, (These de Concours, 1839,p. 59,) being
unaccompanied  with any detail, are still less conclusive.  The tumor
of the size of an egg developed under the angle of the jaw in an epi-
leptic, and extirpated by M. Petrunti with much difficulty, the opera-
tion causing frightful convulsions for the space of four days, (Gaz. Med.,
1839,  p. 122), was, as  I  conceive,  only a  lymphatic  mass, and  not
cancerous, as the author supposes.  In this case  the disease  did not
repullulate and the epilepsy  disappeared.  In conclusion, whether
the disease be seated in the gland or in the ganglions which surround
it, the  operation when we have once decided on removing it is nearly
the same.  The sub-maxillary gland, embraced as it were inferiorly
by the concavity of the digastric  muscle and separated from the in-
teguments by  the  facial  vein  and platysma-myoides muscle, rests
superiorly  against the inner surface of the jaw, inwardly against the
hyoglossus muscle and the mylo-hyoid, upon the external surface of
which one of its  prolongations extends.  The facial artery runs along
its upper and inner side.   The lingual nerve  and the artery of the
same name pass below it.  Far above, it receives the  plexus of the
myloid nerve. 
456
NEW ELEMENTS OF OPERATIVE SURGERY.
                    § II.—Operative Process.

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

              TUMORS OF THE SUB-HYOID REGION.

                Article I.—The Thyroid Body.

  Goitre, or bronchocele, is a tumor which has attracted much at-
tention in the present state  of medical science, and which should not
be attacked by surgical means  until after having unavailingly made
use of iodine, the powder  of  Sency, and other pharmaceutical re-
sources which have been much extolled in these latter times ; also it
is requisite that the tumor  should have  sufficiently  incommoded the
patient to jeopardize his life. Serous, sanguineous and purulent cvsts. 
THE THYROID BODY.                    457
and vascular, erectile, fungous, aneurismal, tuberculous, calcareous,
fibrous, schirrous,  colloid, encephaloid, and viscous (gommeuses) tu-
mors, have been confounded with the hypertrophy of the thyroid tis-
sue under the  common  title of goitre.  The surgeon therefore will
not be enabled to undertake their cure with advantage until he shall
have ascertained their species, or until having consulted  the memoir
of M. Sacchi (Arch. Gen. de Med., ser. 11, t. II., p. 246,)  on this sub-
ject.   Caustics, employed at the time of Celsus, and since by a small
number of practitioners to destroy goitre, are no longer in use at the
present day.   The steatoma which extended from the superior part
of the larynx down to the sternum, and which was cauterized and
cured  by Pietsch, (Gaz. Salut., No. 34, p. 3, 1771,) was  it in reality
a goitre 1
                             § I.

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

bad  character.   In  severe cases  it has been proposed  to apply the
ligature upon the  bronchocele, to extirpate it or to ligate the princi-
pal arteries which enter into it.

                         § II.—Ligature.

   It is to Moreau, surgeon of the Hotel Dieu, that Valentin ascribes
the suggestion  of attacking  goitre  by the ligature.   One of the pa-
tients  thus  treated in  1779 was  not cured, but the other recovered
perfectly.   The tumor in the  first was a  cancer, that of the se-
cond was of a  fatty nature.  The surgeon inserted a double ligature
through its base, as if for the purpose of dividing it into two equal
parts, which he afterwards strangulated separately.   Some years
subsequently, viz., in 1791, Desault also had recourse  to it, but it  was
for the purpose of terminating an extirpation, the last stage of which
was attended with too much danger. Brunninghausen used it with en-
tire success in 1805, to destroy an enlargement of the size of an egg,
which was situated at the fore part of the neck, between the larynx
and sternum, in a young man 25 years of age.
   A child 12 years of age, operated upon by M. Mayor in 1S21, for
a goitre of the  size of an orange, was  discharged from his hospital
perfectly cured at the expiration of  a month.  In a  young man 21
years of age, the tumor occupied the front part and both sides of the
neck, and extended  from the angles of the  jaw and  the parotid re-
gion,  as far down  as to the sternum  and  clavicles.   Of the three
lobes of which  it was composed, one, or that of the middle, equalled
in volume the head of a 7 or 8 months' foetus.   The  entire mass be-
low the jaw was nine inches in height and 26 in breadth.  The gen-
eral  condition  of the patient was  bad, but M. Mayor nevertheless
effected a radical cure in less than two months !  Nor was he  less
successful in a lady of Sackendorf, who had in vain consulted the most
distinguished medical men of all countries for the removal of a tumor,
which she had had for the space of about thirty years.   This tumor,
which continued to increase, occupied the entire left side of the neck,
had pushed the larynx to the right, and appeared seriously to compro-
mise the life of the patient.  His process consists in laying bare  the
anterior surface of the bronchocele  in  afterwards isolating it from
the subjacent parts by means of the  fingers  or the handle  of the
scalpel, and then applying a strong ligature upon the  root of each of
its lobes, or traversing its base with a double ligature, which admits
of its being strangulated above and below.   In place of one or  two
ligatures he sometimes employs as  many as four, each one of which
is then made to include a fourth or third of the gland, and as may be
supposed, the chaplet constrictor is the one to  which  he accords the
preference.  From these details, nevertheless, it is evident that the liga-
ture here is but an auxiliary means, or a resource against hemorrhage,
when we are fearful of  wounding some vessels of importance;  and
that if we were sure of avoiding all the large  arteries with the  bis-
toury, extirpation  would be  still far preferable.  It is  an operation,
moreover, which is not unattended with danger; and two of the pa-
tients operated upon by  M. Mayor himself, perished.   It causes  suf-
focation, extreme anguish and difficulty of respiration, and frequently 
THE THYROID BODY.
459
some of the symptoms of typhoid fever.  The soldier of M. Malle,
(These de Concours,  Strasbourg, 1836, p. 27,) created  the  greatest
degree of alarm in the mind of the operator.  Consequently I should
not recommend it, except the tumor is first detached by means of
the cutting instrument or fingers to as  great an extent as is possible,
in order that there may be a pedicle only instead of a large base  to
be strangulated, and upon the condition also  that the goitre should
be promptly excised,  external to the ligature, and not left to putrefy
in the wound.

               § III.—Obliteration of the Arteries.

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

                        § IV.—Injections.

  If there should be a cyst, whether serous or sanguineous,  irritating
injections, as recommended by Rullier and others, might have some
chance of  success.  I would not recommend  them to be made with
chlorine, as has been suggested by M. Deconde, (Encyclog. des Sc. 
460          NEW ELEMENTS OF OPERATIVE SURGERY.

Mel., 1836, p. 6,) but  I would willingly make use of the solution of
the tincture of iodine, in the same way as for any other cyst.

                         § V.—Incisions.

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

                      § VI.—Extirpation.

  By means of extirpation we remove the totality of the disease, and
the  patient  is promptly relieved of it;  but it is attended with so many
and such formidable  dangers,  that the great majority of authors, at
the  present time, agree in proscribing it.
  A.  That, at  the time of Albucasis, a patient who was submitted to
this operation should have died of hemorrhage, has nothing in it very
surprising ;  that  the young lady  mentioned by Palfin succumbed
during the  operation from the same cause, we may  also readily con-
ceive ; though one of the patients cited by Gooch perished, exhausted
at the end of eight days, and  that in order  to save the other  it be-
came necessary that the  assistants should relieve each other during
the  space of a week, in order to compress without intermission, by
means of their  fingers, all the arterial branches  which  had  been 
THE  THYROID BODY.
461
opened;  though an  officer, whose  history is given by  Percy, also
perished from  hemorrhage, and  that the patient operated upon by
Dupuytren survived the ablation of the tumor but thirty-five hours;
though the instances of extirpation of goitre adduced  by Freytag,
Theden, Desault, Giraudi, Fodere, and the barber who, according to
Paradi, performed  it successfully upon his wife, may not all of them
be very satisfactory; and though the  young girl treated  by Klein,
(Graefe und Walther's  Journ., vol. I., p. 120,) was seized with an
apoplectic fit  and  perjshed  from  it,—we  should nevertheless be
wrong in censuring, in  absolute terms, the  essays  made to  render
us more familiar with this operation.   Peckel and  Ravaton  (Petre-
quin, Bull, de Ther., X. XL, p. 344,)  have performed it several times
with success, and Vogel (Bibl. Chir. duNord., p. 391.)  has been no
less fortunate.  M. Graefe, (Gaz. Med., 1835, p. 169,—Rufz, Arch.
Gen.  de  Med., 2e  ser., t. X., pp. 25, 41,—Graefe und Walther's
Journ., 1820,)  who lost  one of his  patients, has  cured  two  others.
M. Green (Lancet, 1829, vol. II., p. 351,) succeeded  in  extirpating
one of the lobes  of the gland, and M. Warren, (On Tumors, &c,
p. 305,) who  tied  the carotid, also  saved his patient.  That of M.
RouX (Rufz, Arch. Gen. de Med.,2e ser.,t. X., pp. 25, 41,) died  after
the eXpiiation of a  few days ; but that of M. Voisin (Gaz. Med., 1836,
p. 372,) lecovered  perfectly.'
   The enormous tumor extirpated by M. G.  Bell, (Arch. Gen. de
Med., X. IX, p. 283,) soon repullulated.   But the cyst removed by M.
Gubian (Ibid.,  X. XII., p. 315,) did not reappear.   By combining ex-
tirpation  with  the  ligature, as has been done by  M. Mayor and M.
Hedenus, (Graefe und Walther's Journ., vol. II., p. 240,) there  can
be no doubt that in future some successes might be obtained from it.
The most complicated cases could not intimidate this last mentioned
surgeon, who in 1822 could already enumerate six successful results
obtained  by him.   His process differs from that of M.  Mayor in this,
that he carefully dissects the bronchocele down to its  deep-seated
surface, and ties the arteries in proportion as they are divided by the
instrument; and in this  also, that with him  the  ligature, which he
applies in other respects after the manner of  the  practitioner  of
Lausanne, but which he knots in the same manner as for obliterating
a large vessel, has  no other object than to strangulate what he  dare
not venture to divide, and to enable  him to excise the entire morbid
mass immediately,  with security.  For myself, however, I should not
decide upon extirpation of an actual goitre, until after having satis-
fied myself that there was not  any co-existing lesion of the heart or
tendency to apoplexy, and that the surrounding lymphatic  glands
were sound ; and until after having  made trial of either the seton in
the manner of M.  Quadri, the simple incision indicated by Fodere,
and employed successfully by Delpech, or the  numerous incisions
which I have recommended, or as Rullier advises, an irritating injec-
tion into  the cyst,  if any exists, or  the previous ligature  upon the
thyroid arteries; and not until  after the pressing entreaties of the
patient, and only in cases where the bronchocele  instead of constitu-
ting only a simple deformity,  forms a disease whose progress  and
character threaten  the life of the individual.
  B. Operative Process.—We will suppose that there exists a goitre 
462
NEW ELEMENTS OF OPERATIVE SURGERY.
 which involves every portion of the  gland.   The  preparations are
 very nearly the same as for the removal ofthe parotid.  The patient
 is placed upon his back, with the head gently reversed, and support-
 ed by  assistants.  The operator being  situated  on the right  side,
 makes upon the median line a first incision, which commences above,
 and is to finish a little below the tumor;  transforms this wound into
 a crucial incision ;  detaches  the flaps, and dissects them  down  to
 their base ; divides transversely the  fleshy fibres which he  cannot
 push aside, reverses them towards their attachment if they are sound,
 or comprises them in the  subsequent excisions if  they are diseased;
 ties  such vessels as interfere with him ; reaches by  degrees the bor-
 ders of the tumor, which he draws towards him while tearing rather
 than cutting it out, and  finds deep down, at  their superior and inferior
 part, the four principal  arteries of the organ, each of which he iso-
 lates and surrounds  with a ligature.  Avoiding with care the trunk
 of the carotids, the  internal jugular, the descending  branch of the
 great hypoglossal nerve, the pneumo-gastric, and the great sympa-
 thetic and the cardiac  nerves, which  are seen a  little farther to the
 outside, crossed by quite a considerable number of  secondary veins,
 the surgeon then detaches the tumor at its upper part, from  the sides
 and anterior face of the larynx, from which it is  separated only by
 the  thyro-hyoid  muscles, cellular lamellae, and some small  arteries
 which must be tied,  and which come from  the lingual or maxillary
 branches.  Returning towards its borders, which he raises and sepa-
 rates from the oesophagus or trachea, near which  run the laryngeal
 nerves, he recognizes when the tumor holds no longer, except by its
 lower border, whether the venus plexus which issues from it, and the
 thyroid artery of Neubauer,  which very  frequently enters into it,
 would make  its  complete separation dangerous.  If so he includes
 all these objects with  a  ligature, or traverses their pedicle with a
 double  ligature, and  strangulates them as  powerfully, and  as near
 to their  root  as possible, after which  he may excise without  any
 fear the totality  ofthe goitre.   So  laborious and delicate a  dis-
 section  cannot  be rapid.   The  patient requires  to be  allowed to
 repose from time to time, in order to breathe.  All  kind of pressure
 upon the trachea or larynx should be carefully avoided, and  the  sur-
geon should vigilantly bear in mind that  if the inspirations are not
 free, the blood  will be instantly seen to accumulate  in the veins, and
to rush out in large quantities  from the slightest cut of the bistoury.
   Before proceeding to the dressing, it  is  important that even the
 smallest arteries should be tied or twisted.   As to the veins, they
 will  cease  bleeding  as soon as the patient shall be free from oppres-
 sion and be  enabled to  dilate his chest freely  and without fear.
 Should  it be otherwise, the  ligature must be  applied to them.   The
convulsive movements and even death which have sometimes super-
vened,  during  the extirpation of  tumors  connected with  a great
development  of the vascular system,  might  be  attributed in  this
region to the  introduction of air into the veins, (see  Volume I.;) M.
Boullay, (Gaz. Med., 1839, p. 79,)  who  saw a horse perish a  few
minutes after bleeding the jugular for an attack of pneumonia, ascer-
tained that the air had been introduced in large quantity into the
heart and vessels; but as I have already said, it remains for the fact 
            TUMORS FOREIGN  TO THE THYROID BODY.          463

to  be demonstrated in all the  cases of this kind which have been
related.  The surfaces  being thoroughly sponged and the ligatures
brought to the angles of the solution of continuity, nothing more re-
mains to be done than to approximate the  flaps of the wound and to
close it up more or less perfectly.  As in front of the neck the centre
of the division  is more  elevated than the sides, it cannot but be at-
tended with advantage  in undertaking immediate reunion, either by
means of adhesive plasters or even a few  points of suture, provided
however that with the exception of a few ligatures we are not forced
to leave any foreign body under the skin.   The different portions of
dressing moreover should be light and gently applied.  All compres-
sion in such a region would be dangerous,  and too great a number of
pieces of dressing would cause an  injurious  accumulation of heat.
Should the tumor  involve only  one side  of the  thyroid,  or if
independent of this  gland this tumor should  be on another  point of
the anterior half of  the neck, the modifications which would require
to be made in the process which I have described are too unimpor-
tant and too easily anticipated to  make it necessary to  point them
out in detail.

     Article IV.—Tumors  Foreign  to  the  Thyroid  Body.

   Synovial cysts, loupes and lymphatic tumors, &c, may develop
themselves in the neck as well  as in any other region;  but  having
treated of these  in another chapter, it  is not my intention to notice
them again in this place.  I  have successfully removed an athero-
matous cyst of the size of a large nut, which was  situated in  the
supra-sternal fossa of a young  American, between the layers of the
fascia cervicalis ; I have seen lymphatic masses and aneurismal tumors
of the aorta elevate themselves from behind the sternum as high up
as to the neighborhood of the larynx ; but it has not fallen to my lot
to effect the extirpation of a degenerate thymus, an operation men-
tioned by M. Haugster,  (Arch. Gen. de Med., 2nd ser.,t. III., pp. 109,
263.)  There is still another sort of tumor of the neck, viz: the  em-
physematous, upon which 1 have only one word to say.  This tumor,
in the case of M. Ollivier, (Ibid., X. I., p. 421,) which followed a sud-
den crepitation, was situated on the supra-sternal region ;  in the cases
of the English  physician, (Med. and Phys. Journ., June, 1833,) when
irritated by exertions it extended itself rather towards the face,  and
in the case of M. Malle, (These de  Concours, Strasbourg, 1836,) or
M. Begin, (Elem. de Chirurg., &c., 2nd edit., t. II., p. 24,) it was occa-
sioned by the extirpation of a thyroid  tumor.   It is a description of
tumor which is imputable to some laceration in the air passages,  and
which must be treated like  any other emphysematous  tumor 
464
new elements of operative  surgery.
                        CHAPTER  III.

                         AIR PASSAGES.

                   Article I.—Bronchotomy.

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

               § I.—Indications and Appreciation.

  A.  P. d'Abano, who calls it subscannation, and  nfter him Gherli
of Modena, G. Martine, &c, consider bronchotomy indicated in all
cases  of tonsillary or laryngeal angina, which threaten the suffocation
ofthe patient; but, though advocated by Mead and Louis, their opi-
nion, which goes back  moreover as far  as  to the time of Avicenna,
and which has been zealously opposed by Cheyne, is at  the present
day scarcely sanctioned except  by Baillie and Fare.  Anginas that
are purely inflammatory, however intense they may be, rarely make
it necessary  to have recourse to a remedy of this kind.   It would be
difficult to comprehend why an acute engorgement of the tonsils, for
which Flajani ventured to have recourse to it, should ever require it,
unless it were impossible to  open into  the  mouth  and to penetrate
down to the pharynx.  The same  may be  said with greater reason
of their chronic enlargement, which is relieved by excision with much
less danger.   When the tongue  becomes swollen suddenly, in  such
manner as to fill up the mouth and close the arches of the palate,
Richter and  B. Bell, who recommend bronchotomy, had without
doubt forgotten that in such cases two  or three deep incisions  upon
the dorsum of the diseased organ will effect its diminution, and very
probably were unaware of the observations of  De La Malle on this
subject.  It would be difficult also for  me  to believe  that it  might 
BRONCHOTOMY.                      465
not have been possible to dispense with  it in the case where M.
Burgess performed it, since in that case there was nothing but an in-
flammatory intumescence, produced by a burn at the bottom of the
buccal cavity.  On the other  hand it is almost universally admitted
since the time of. Desault, that it is not applicable to cases of submer-
sion,  and that Detharding, in prescribing it as a remedy in asphyxia
from  drowning, entirely misconceived the manner  in  which death
takes place under such circumstances.  Nevertheless, M. S. Cooper,
who considers it more  prompt and  easy than the introduction  of a
gum-elastic catheter through the nose or mouth, justly argues, as it
appears to me, that it should not then be proscribed without restric-
tions.  Should the mouth be firmly closed, and it became impossible
for the catheter to be inserted into the entrance of the larynx, bron-
chotomy would be better than nothing when it was important to act
speedily and to force the air to pass into the lungs. When we reflect
upon the difficulty of shutting up the glottis completely, by means of
the tube which we insert into it, and of preventing the air, which is
blown in, from escaping into the digestive  passages, in all those cases
in which the surgeon deems it proper to attempt artificial respiration,
we cannot but be induced to accord to it a preference over simple
catheterism.
  B. GEdematous  Angina, that  is to say,  a serous engorgement  of
the lips of the glottis, is still another disease for which bronchotomy
appears to constitute the remedy par excellence.  In sustaining the
respiration, it gives the physician time to attack the disease by  suit-
able  remedies, and to the organism the means of subduing it, or at
least of making farther  resistance to it.  The antagonists of Bayle,
who  was the first  who mentioned it  for such cases, reject it under a
pretext which does not appear to me valid.   Their permanent canula
by the natural passages could  not certainly remain without danger in
the trachea  during  the space of from eight to fifteen days; while a
canula which has been once inserted through the artificial opening into
the respiratory tube, occasions very little inconvenience to the patient.
I am of opinion, therefore, with M. Lawrence, that in this description
of disease, which  moreover is  almost constantly fatal, it deserves
some attention, and that  it would offer  infinitely better chances of
success than scarifications  of the infiltrated  parts, as  proposed by
some practitioners.
  The patient whom M. Roulois, of Mayenne, mentions in his thesis,
and who was operated upon at  the Hospital of St. Antoine in 1828,
by M.  Kapeler, died it  is true  at the expiration of thirty-six hours,
but after having been restored as  it were by a miracle from death to
life, and dying very probably because the air could not be made to pass
in sufficiently large quantity and uninterruptedly into the lungs.  The
case  mentioned in the Journal Complimentaire  was less unfortunate,
inasmuch as he survived.  A woman operated upon  by M. Purdon,
(Arch. Gen. de Med., 2e ser., t.  II.,  p. 102,) also recovered.  M. C.
Broussais, (Coqueret, These, No. 185, Paris, 1834,) was no  less  for-
tunate.  Operating  for a thickening of the mucous  membrane of
the larynx, M. Regnoli, (Revue  Med., 1829, t. II., p.  520,) succeeded
in two  instances, and M. Senn once.   M. Fournet has published two
other successful cases.   M. A. Robert has also communicated to me
                                30 
466
NEW ELEMENTS OF  OPERATIVE SURGERY.
two others which belong to him.  I have performed tracheotomy but
twice as  a remedy in cedematous  angina, and  both patients were
cured.  We should be wrong then not to  have recourse to it under
such circumstances.
  C.  Tumors and engorgements in the vicinity.—A  polypus, or any
tumor whatever in the nasal fossas or  pharynx, the thyroid body, or
certain lymphatic  ganglions, any  of which have become swollen or
so hard  and voluminous as to prevent the air from passing into  the
trachea, do not render the  operation indispensable, only so far as there
may be imminent peril of suffocation, or if it shall have been found im-
possible or attended with  too much danger to attempt the ablation of
these morbid masses.  It was, chiefly, for these cases only that Sharp
reserved  it; for it did not  appear to him to be absolutely required
in the extraction of foreign bodies.   It might, moreover, be  advan-
tageously performed if, in  consequence of a wound or otherwise,
the larynx had become completely obliterated, as in  the young man
whose history has been  given by  M.  Reynaud, (Journ. Hebdom.
Univers., X.  III., p. 201.)   M. Porter, (Gaz. Med., 1838, p. 392.) em-
ployed it with success in  a  case  of gangrene of the epiglottis and
hyoid region caused by suicide.  M. Warren, who undertook to per-
form it in a  patient in order to  remedy the entrance  of  air into  the
veins; and M. Sampson, (Ibid., 1837,  p. 667,) who found nothing so
advantageous  to restore a drunken man, might both,  however, in my
opinion, have dispensed with it.
  D.  Foreign Bodies.—It is for the purpose of reaching heterogene-
ous substances which sometimes become introduced  into the larynx
or trachea, that the operation  of  bronchotomy, since the time of F.
Monavius, has been most  frequently performed.  It  has been made
use of and might be employed in this manner, in order to extract clots
of blood that have come from  the moutn, or even from a wound in
the  larynx,  lumbrici worms, a  leech (Lacretelle),  flies,  portions  of
food,  (Thierry, Bibl. Med., 1829, t. II., p. 450,) such as small fish
bones, (Willaume,  Bull, de  Fer., X. XXIV., p. 167,)  fowl, pieces of
mushrooms, apples, chesnuts,  acorns,  of polypus  in  the pharynx, a
cherry pit, a prune, apricot, harrico bean, raisin-seed,  melon-seed,
(Jameson, Bull, de Fer., X. I.,) a pill, a  filbert, a coin of gold, piece of
silver, locks of wool or tow, a ball, a marble of the diameter of 8 lines,
(Arch. Gen. de Med., 2e ser., t. II., p.  125,) a button mould, a  pebble,
pin, needle,  (Blandin, Bibl. Med., 1829, t. II., p.  450.) fibrous tumors,
probably syphilitic (Arch. Gen. de 3led., X.  V., p. 564,) polypi (Swin-
ger, Morgagni, Lieutaud,  Herbiniaux, Desault, Voigtel,  Windt, Otto,
Prinz, Albers, R. Gerardin, &c.)  and  hydatids (Aubertin, Delonnes,
and Harless;) encysted tumors  (Albert,)  fungous  or  sarcomatous
tumors  (Tortual,)   lymphatic  and  warty  tumors (Wurtzer,) schir-
rhous and cartilaginous tumors  (Macllvaine in Urner, 1833, Obs.
Mid., 1835, p. 116), developed in the interior of the  larynx ;  a piece
of cartilage, tendon, wood, iron, or  membranous concretion; in  a
word, for the extraction  of  all  bodies  whatever, that  may  be-
come lodged in the glottis or trachea.   As soon  as the presence of
one of these objects in the respiratory passages is clearly established,
we are justified, unless we can reach it better through the mouth by
means ofthe fingers or forceps, in calling to our aid the resources of 
BRONCHOTOMY.
467
bronchotomy.   The sound of a small stone moving up  and down,
and which M.  MacNamara mentions, (Dub. Hosp. Reports, vol. V.,
p. 592,) after  having performed  bronchotomy successfully in such
cases in two instances, is a very good sign.  In the case published by
M. D'Arcy, the bean, though the accident had happened only a few
hours  before, had  become  swollen to treble its  size.   Though the
first symptoms which these substances have produced may partially
subside, it nevertheless will continue to  be  clearly indicated.  In
fact the  monk who  is  mentioned in  the  Eph. des  Cur. de la Nat.,
and who was afraid at first to complain, died of phthisis, but not until
after the expiration of two years.
  One of the  patients mentioned by  Louis appeared so well that he
was considered almost as cured, when he died near the expiration of
the third week.  Another, who lived several years with a Louis d'or
in the bronchi, nevertheless ultimately died.  Tulpius. V. D. Wiel,
Bartholin, Pelletan and Dupuytren have  also seen in certain cases
the foreign body admit the respiration to reacquire, in some sort, its
natural function, and not cause death until after one or more months,
or even years.  There are cases also in which, after the lapse of this
space of time, the bodies have been  expelled spontaneously ; as for
example,  the  chicken-bone mentioned by Sue.   A lead  pencil, an
inch and a half long, was thus ejected after the lapse of six years,
(Gridley, Journ. des  Prog., X. XIII., p. 269.)  M. Guastamahia (Gaz.
Med., 1838, p. 797,)  mentions  the case of a cherry-nut which was
thrown out in a paroxysm of coughing, after  having remained two
months and a half in the trachea.  Monteggia mentions  a similar
case  of a tooth swallowed by a young lady.  But these  fortunate
efforts of the system so rarely take place,  that it would be imprudent
to count upon them, or ever to dispense with bronchotomy under
such idle pretexts.
   E.  Foreign bodies lodged in the oesophagus, and the inflammatory
engorgement  which  wounds and injuries of the neck sometimes pro-
duce, have also induced some physicians to resort to bronchotomy in
order to prevent suffocation and give time to attack the principal dis
ease.   Habicot  performed it upon the spot upon a boy who, return-
ing from the  fair, found no better means of escaping  from robbers
than  to swallow,  inclosed in a packet, the pieces of gold which he
had in his possession.   He performed it in the same manner success-
fully in a  patient who  being  severely wounded, was upon the point
of perishing from inability to respire.  This is the way in which we
undoubtedly ought to act, should life be  seriously menaced by the
presence of foreign  bodies in the oesophagus, or by an  intumescence
in the lips of a wound in the larynx,  provided it should be impracti-
cable to  remove  by any other mode and instantaneously the cause
ofthe suffocation.   A student of medicine, from suffering pain in the
pharynx, supposed that he had swallowed a bone while eating soup.
According to his account, this bone consisted only of a very small
fragment.   The exploration of the throat led to no discovery.  The
accidents which were  at first quite serious,  subsided  by degrees;
but about the twentieth day this young man was seized with suffoca-
tion, and vomited and threw up a corroded bone of the size of a nut.
Bronchotomy, which nevertheless became necessary, was performed 
468          NEW  ELEMENTS  OF OPERATIVE SURGERY.

by M. Sanson,  and the general health of M. F. was gradually re-
established.
  F.  Croup, or laryngeal and tracheal diphtheritis, that formidable
malady, the nature of which has been no less clearly elucidated than
its treatment by the admirable researches of M. Bretonneau, is one
of those  affections  in which  it would at first sight appear that bron-
chotomy might be resorted to with the greatest degree of advantage.
Nevertheless, in spite ofthe assertions of M. A. Severin and Bartho-
lin, and of some other practitioners ofthe seventeenth and eighteenth
centuries, who  assert that they had in many instances had recourse
to it  with successful results, the physicians of our epochs still doubted
in 1825, if in a  disease of this description it can be of any great value,
or that there existed in science a single  conclusive or well authenti-
cated  example of cure which could in reality be attributed to it.
Those which are cited by M. S. Cooper, whether in his own name or
in that of M. Lawrence, or of M. Chevallier, do not prove in fact that
the cases treated  by these  physicians was legitimate croup.  The
case  related in  the name of Andree by Bursieri, Locatelli, Michaelis
and White,  is the only one which is accompanied with details suffi-
ciently circumstantial to afford any satisfaction upon this point.  The
light in which  bronchotomy has hitherto been considered would not
enable us to derive any very great advantage from it  in croup.  We
cannot, in fact, understand how it could  remedy the inflammation or
spasm of the larynx, which,  according to Royer-Collard, &c, ulti-
mately cause death in this disease ;  or the pulmonary engorgement,
any more than it  can the reproduction of  the morbid product.  In
this point of view M. Caron has certainly exaggerated its importance,
while MM. Desruelles, Bland, &c,  have very properly contested its
utility.  But it is not in this way that it should be considered.  Pa-
tients  attacked with croup die from want of the ability to respire.
This asphyxia,  which is caused by a false membrane or the engorge-
ment of  the laryngeal  membrane,  does not depend  on spasmodic
lesions, which  are rendered  impossible or insignificant in the larger
bronchi,  the trachea and the larynx,  by their cartilaginous texture.
It is  less with  a view of  extracting the membraniform  concretions
that  we have recourse to bronchotomy in this disease, than for gain-
ing time  and placing  the  patient in  a  condition to breathe while we
are devising the means for his cure.
  M. Bretonneau has shown  that when the trachea is once opened,
we may  introduce into it advantageously a solution of calomel, or
even one of nitrate of silver, and follow up the false membrane as far
as into the bronchi.   Under this point of view, bronchotomy is a pre-
cious resource,  which should be made use  of wherever the disease,
having reached into the larynx or below it, can no longer be attacked
through the mouth by means of topical applications,  and where, not-
withstanding it has not yet passed beyond the first bronchial divisions.
Unhoped for successes have come  to the  support of this doctrine.
In the month of July, 1825, M. Bretonneau, being called  to see Aille.
de Puysegur, four years  of age, whose three brothers had already
perished from croup, and  who herself was laboring under it to a vio-
lent  degree, freely laid open the trachea;  placed a canula in the
wound; saw the false membranes escaping  from it in great quantity 
BRONCHOTOMY.
469
during the space of several days ; blew in calomel in powder, which
was badly supported,  subsequently the same  substance diluted in
water, and thus succeeded in saving this afflicted  child.  In a boy 7
to 8 years of age, and whom I had an opportunity of examining at
Tours, in 1827, a monfh after his cure,  and who in the most advan-
ced stage ofthe disease had been abandoned  as upon the point of ex-
piring by his parents, M. Bretonneau laid  open  the trachea as in the
preceding case; saw life returning  at  the expiration of a few  min-
utes: effected the  extraction  of  numerous  membraniform  concre-
tions ; and found himself under the necessity a short time after of in-
troducing through the  canula which  he  kept  permanently  in the
wound, a solution of nitrate of silver as far down as into the bronchi,
when, after various obstacles which were  destroyed  as soon as  they
made their appearance, the child was entirely restored.  In October,
1831, the same practitioner was no  less fortunate in  a third patient.
The child, which was 11 years of age, was considered as dead, when
M. Bretonneau was sent for to him.  He instantly opened the trachea,
and after various accidents which were overcome  by the most  judi-
cious treatment, this  young patient  was finally  completely.restored.
Similar successes have been since obtained by M. Scoutetten (Coque-
ret, These, No. 185, Paris, 1834,) M. Gendron (Journ. de Conn. Med.
Chir., X. I. et. II.,) of Chateau  du Loir, and  by  M. Gendron (Acad.
Roy. de Med.. 1838,  t.  III., p.  391,) of  Vendome, M. Gerdy, (Chres-
tien, Arch. Gen. de Med., 2nd  ser., t. V., p. 517,)  M. Crozat (Precis
Med. d'Indre et Loire, 1833, p. 5,)  and especially by M. Trousseau,
(Journ. des Conn. Med. Chir., X. I. II., and  III.)  Out of 18 or 20
operations, M. Bretonneau at the present day counts five or six cures.
Out of 60 cases and  over, M. Trousseau points out more than 20 suc-
cessful results.  I  must however remark, that  I  lost the  four  chil-
dren upon whom I performed it, and that  up to the  present time, it
has been unavailingly made trial of in  a great number of patients at
the Hospital des Enfans.  It has  been decided upon too late, as has
been remarked by M. Maingault,  (Arch. Gen. de Med., X. XXX., p.
419; 2nd  ser., t. L, p. 129,) and the consecutive treatment requires
too many  precautions  to allow of its  succeeding with every one as
well as it did with MM. Bretonneau and Trousseau.
  G. There  are also other diseases  which  it  would appear to me
might be  advantageously treated  by bronchotomy.   Laryngeal
phthisis, for example, and chronic phlegmasias, which ultimately re-
sult in producing a degree of contraction in the  glottis, as in the  case
cited by M. Gintrac, (Revue Med., 1830, t. I., p. 106.)  The air find-
ing a free passage below the disease, would  leave the larynx in re-
pose, and would no longer interfere with  the salutary efforts of the
system.  Moreover, we should thus be enabled to place through the
new opening, should it become necessary,  topical applications imme-
diately in contact with the diseased part.  Trials of this kind have  been
made  since being recommended by me;  a  pregnant woman affect-
ed with a syphylitic  ulcer in the larynx, and upon the point of suffo-
cating, was cured in  this manner by M. Purdon, (Arch. Gen. de Med.,
2nd ser., t. II., p. 102.)   A man who had ulcers ofthe same charac-
ter, accompanied with engorgement ofthe cordas vocales, and whom
I operated upon at the Hospital of La Charite,  in the month of No- 
470
NEW ELEMENTS OF  OPERATIVE SURGERY.
vember, 1838, was also restored.  M. Trousseau  and M. Amussat,
by operating in this manner in cases of tubercular phthisis, have
prolonged at least the lives of some of their patients.
   H. Horses affected with cornage also have the glottis contracted,
and present to  the observer experiments, all of which are at  hand,
ip favor of  what I have just advanced.   Two of these animals em-
ployed in a manufactory of minium at Tours, recovered their ordi-
nary condition  of health after having had a  large canula fastened
into their trachea.  M. Barthelemy (Bull, de la Fac. de Med., t. VII.,
p. 27,) and  other veterinary practitioners, have  cited cases  that are
nearly similar.  Applied to man, these facts have  not deceived the
expectation  of  practitioners.  M. Clouet, of  Arerdun, (Journ.  de
Prog., t. XVIL, p. 226,) caused a similar canula to be worn for the
space of twelve years, by a woman  whom  a fistula  in the larynx,
and other wounds, had exposed to  the risk of suffocation.   Price im-
puted ten years of flourishing health to a remedy of this description.
M. Bulliard, in  1824, restored to  health a  young  soldier  whom  a
chronic  laryngitis, and not  croup as he supposes, had  brought to the
verge of death  after  many paroxysms of suffocation, by placing in
his larynx a canula, which the patient wore during fifteen  months.
M. Godeve was no less fortunate,  in  1825, in another patient, affect-
ed, he says, with an ulcer in  the  larynx, but rather, as I think, with
an engorgement of the cordas vocales, and who was enabled to re-
move his canula without any inconvenience at the  expiration of six
months.  The patient  of M. White  carried it for  the space of two
years, and  that of M. Senn eleven  months.  The same occurred
nearly in the two patients operated upon by M. Regnoli.
   I.  Recapitulation.—In  conclusion,  bronchotomy is an  operation
to  be made trial of in all  cases, or nearly in  all cases, where a me-
chanical obstruction  from whatever source it may arise, has a ten-
dency to produce asphyxia. M. Gendron, (Journ. Ilebdom., 1836,1.1.,
p. 380,) who has seen two cases, proposes even that  should a fistula
exist between the  trachea and  oesophagus, bronchotomy should be
had recourse to in order to cauterize the fistula  through his bivalve
canula.   The operation, in reality, has but little danger  connected
with it.   If up  to the present time it has not  been more frequently
performed, it is from its effects, except in cases of foreign bodies, not
having  been accurately understood ;  from its having been supposed,
that in order to re-establish respiration it was sufficient to open any
passage whatever for  the  air; and  from not having reflected that
if the artificial  opening is perceptibly less in extent than the natural
 passages, the lungs remain incapable of completely performing their
 functions, and that, in such cases, the design of the operation is to  a
 great extent defeated.   This is a truth which, placed beyond all dis-
 pute by M. Bretonneau,  I consider that I have established, and the
 practical consequences of which  ought to be of the  most  beneficial
 character.   In  one of the horses just mentioned the  tracheal canula
 was only six  lines  in diameter.  As soon as the  animal became
 fatigued, he was seen gasping and out of breath.  A  large canula an
■ inch in diameter was substituted  for the  first, and the horse imme-
 diately breathed freely and could undergo the most violent exercise.
 In the little patients who were cured by the practitioner of Tours by 
fpp—
                         BRONCHOTOMY.                      471

 means of bronchotomy, was not the canula naturally too small, or
 made so by the concretions and  mucosities which contracted its di-
 ameter?  Though the symptoms  of asphyxia momentarily disap-
 peared, they were found  speedily to return.  But on the contrary,
 it was no sooner  cleared out, or a larger canula made use of, than
 the child seemed to revive.   The same effects were  observed in the
 cases of MM. Bulliard, Senn  and Trousseau, and I was  enabled to
 demonstrate, on my part, to a great number of persons, the correctness
 of this  observation in regard to the patients whom I operated upon
 at the Hospital of La Charite in 1837 and 1838.  W. Cullen, (Journ.
 de Prog., X. VIL, p. 144,) who neglects to give credit for this sugges-
 tion to M. Bretonneau, collected, in 1827, other facts not less conclu-
 sive, in order to sustain it and  to  give currency to  it in England.
 After all, every  one  may, on  this  point,  experiment on himself.
 Should we, for  example, diminish  the volume  of the column of at-
 mospheric air which  is naturally inspired into the lungs, or diminish
 the openings of the nostrils one-half or two-thirds of their dimen-
 sions, by  closing  them upon a  portion of quill  or  gum-elastic ca-
 theter, and  keeping the mouth shut; the respiration  will  not be ar-
 rested, but it will soon become painful, and  so  much the  more so in
 proportion as the passage for the air shall be more contracted  It is
 important then, when  we venture to have recourse to bronchotomy,
 with the view of sustaining an artificial respiration beyond the space
 of a few minutes, that we  should  open largely into the respiratory
 tube, and that we should leave  in the wound a canula also of very
 large diameter.

              § II.—Examination of the  Methods.

   This leads us to examine which  ought  to have  the preference,
 tracheotomy, laryngotomy,  or  laryngo-tracheotomy.   The ancients
 had no occasion to discuss this question, as they attempted only the
 opening of  the trachea.   The opening into the crico-thyroid mem-
 brane, has only been  employed in practice since the time of Vicq-
 d'Azyr, who proposed it  before  the close of the last century.  De-
 sault is the  first person who  suggested the division moreover of the
 thyroid cartilage  upon the median line, and it is to Boyer to whom
 we are indebted for the idea of incising at the same time from above
 downwards, the cricoid cartilage and the first rings of the trachea.
  A. Laryngotomy, after the manner  of Vicq-d'Azyr, and adopted
 by a great number of surgeons, possesses the advantage of being the
 most easy method, of  acting upon a membrane which is but slightly
 organized  and  superficially  situated, of not incurring the  risk  of
 wounding  any  vessel or any important organ, and  of leaving the
 glottis intact; but on the  one hand, it does not procure an opening
 sufficiently  large  to  admit of the introduction  of  instruments re-
 quired  for  the  extraction of  foreign  bodies,  while on  the other
 hand, the canula which it would allow us to employ would be rarely
 large enough to  admit of a sufficient quantity of air.  In imitating
 Desault on the  contrary, as  has  been done  in America and in Eng-
 land, and as is  also practised by M. Whithley and AI. Blandin, we
open into the larynx  as  freely as possible, and no vein or artery of 
 472          NEW ELEMENTS OF  OPERATIVE SURGERY.

 any size runs any risk of being divided.   It is the only means in
 some sort of laying bare  the foreign bodies, which in most cases be-
 come imbedded  or arrested between the lips  of the glottis, or the
 polypi or other vegetations, which also are rarely seen except in the
 vicinity of this part.   Nevertheless, though the lesion of the cordas
 vocales, which has been so much  dreaded by those who have op-
 posed Desault, may be  easily avoided, and is moreover  a matter of
 little consequence, and though the voice in patients treated by this me-
 thod-may not have suffered more injury than by any other, it does not
 however merit the preference, except  in the cases which have just
 been pointed out; moreover, the patient  should not have reached
 that time of life, when the thyroid cartilage has become  charged to
 too great a degree with phosphate  of lime.  Should the dread of
 wounding the cordas vocales deter him, the surgeon would have to
 do nothing more  than to adopt  the advice  of M. Fouilhoux, and in
 order to avoid  them, divide the  thyroid cartilage upon its side, and
 then lay open the soft parts  of  the  glottis transversely.   When the
 foreign body is situated  below the larynx, or that it becomes advisa-
 ble to insert a tube into the wound, it is  evident that this process
 can no longer be applicable.  Perhaps rigorously speaking, it might
 even be possible  to replace it  always by another operation which
 has been proposed by M. Vidal (de Cassis) with  the view of opening
 abscesses of the  glottis, and also  by M. Malgaigne ; an operation,
 the first suggestion of which no doubt was derived from the experi-
 ments of Bichat upon the  voice, and  which consists in  penetrating
 into  the larynx through the thyroid membrane.   Nevertheless an
 operation of this kind has something in it repugnant,  at least at first
 view, which admonishes me to dwell no longer  upon  it, notwith-
 standing it succeeded very well in the  trials which I have made with
 it upon the dead body.
  B.  Laryngo-tracheotomy, which  ordinarily  leaves  the thyroid
gland entire, and which incurs  the risk of  wounding only the crico-
thyroid  artery, does not enable us, like the  method of Desault, to ex-
amine into the bottom  of the larynx  ; being too  remote from the
bronchi for  foreign bodies, possessing but little mobility, to  reach
with facility the opening which has been  made, the division at the
 same time is in too near proximity to the glottis, not. to render the
 employment of a  permanent canula dangerous ; so that in spite of its
inconveniences, tracheotomy still appears to combine the most advan-
tages under all circumstances where  the  method of Desault is not
 absolutely required.
  C. Tracheotomy.—The trachea, which is a sort of cylindrical canal
which descends to a line with the  second or third dorsal vertebra,
 and composed of about twenty cartilaginous rings and resting against
the oesophagus rather more on the right side  than on the left, is
 covered: 1st, by  the common integuments  ; 2d,  by the cervical apo-
neurosis ; and 3d, by the uniting bridle of the thyroid lobes close to
the cricoid cartilage ; lower down by the supra-sternal venous plexus,
and the  middle thyroid artery when that exists ;  4th, slightly upon its
side by the sterno-hyoid and sterno-thyroid muscles.  Accompanied
posteriorly by the inferior laryngeal nerve,  and at a considerable dis-
tance from it by the primitive carotids, it is  sometimes crossed by one 
BRONCHOTOMY.
473
of the thyroid arteries, which in that case goes from one side of the
neck to the other.  In infants especially, the trunk of the innominata
almost always conceals its anterior surface,even as high up as above
the thorax; so that the right carotid also does not leave it until at a
point very high  up, where it takes a situation completely on one side
of it.  I have also seen the left carotid originate upon the right side
and pass in front of the trachea, in order to reach its usual destina-
tion, and that of the right side do the same.  Other vascular anomalies
also have been met with in this region, and deserve no less  attention
than the preceding.   From all  these relations it results  that  the
trachea, which  is sufficiently  superficial above, where  the thyroid
gland, which protects moreover its lateral portions, alone almost sepa-
rates it from the integuments, becomes deeper and deeper in propor-
tion as it descends or inclines towards  the chest in order to follow the
thoracic concavity of the spine,  and that at the lower  part  of  the
neck we are obliged to seek for it more than an inch  deep under the
integuments.  Finally, from the great  mobility it possesses we might
very readily, when  seeking to lay it  open,  if we were not on  our
guard, push it so much aside that the  instrument might fall  upon the
primitive carotid, as happened in a case mentioned  by Desault, and
where it is seen that a  pupil of medicine, who was in a state  of
asphyxia, was killed in  this manner by one of his companions who
was endeavoring to save his life.
  I. The ancient authors, who recommended bronchotomy, restricted
themselves probably like Antylus,  to dividing transversely  at  the
middle of the neck the integuments and space between the third and
fourth rings of the trachea. J. Fabricius is the first person who pro-
posed to perform the operation in two stages : first, to incise the  soft
parts from above downwards upon the median line, and then to open
into the respiratory duct  in the manner performed by the  ancients.
He recommends moreover that we should  leave in the wound a
small straight canula furnished with wings ; a canula which Casserius
caused to be slightly curved, which, according to C. Solingen, should
be  flattened, the external opening of which  Moreau  covered with a
small p6rtion  of lint,  and Garengeot with, a piece of muslin, in
order to  intercept foreign bodies.   In order to prevent  its obstruc-
tion and not to be compelled to withdraw it when we wish to clean
it, G. Martine found an advantage in inserting two, one within the
other.   Ficker, who adopts the  idea  of Martine, requires that the
outer one should be made of silver and the inner of gum-elastic, and
that both should possess a certain degree of curvature ;  finally, some
moderns have  maintained with Ferrein that it could  be  advanta-
geously replaced by a portion of quill.  The manner  of inserting and
fastening  this canula has varied no less than its form.   Sanctorius
adjusted it by means of a trochar, and Dekkers inserted it into  the
trachea by dividing also the skin with  the same instrument.   Moreau
made a passage for it between two rings by means of a simple lancet,
and Dionis  suggested that it should  be conducted into the tracheal
tube upon a probe.   That of Bauchot is very short  and  flat, and its
inventor, who moreover made use of a kind of crescent mounted upon
a handle \n order to steady the larynx, had, like Dekkers and  Sanc-
torius, a stilette of the same form, with a cutting edge at its extrem- 
474           NEW  ELEMENTS OF OPERATIVE SURGERY.

ity. that it might traverse the skin and penetrate, by the same move-
ment, into the trachea.   Richter (Biblioth. Chir. du  Xord, p. 231)
incurvates the instrument of  Bauchot into an arc, with the view of
rendering it more supportable, and maintains, as M. Collineau (Arch.
Gen. de Med., 2d ser., t. L, p. 589) has done  since, that by means of
the puncture from the wound  of tbe trachea being immediately filled
up by the canula, the hemorrhage becomes  infinitely more difficult
than by incision of the tissues.   But  this is  an error, and whatever
Bergier and B. Bell  may have said of it, all these modes of arriving
by a single operation into the canal, are at  the present day generally
and properly proscribed.   The fear of wounding the cartilages also,
again revived  by Purmann,  no  longer  attracts the notice  of any
one.   Heister has clearly demonstrated that we may divide them
without the slightest risk.  Vigili of Cadiz  who was obliged to divide
them as far down as to the sixth ring  in a soldier, in order to prevent
the danger of suffocation which the ordinary incision had  produced
by causing an effusion of blood into  the trachea, and who, in place
of a  canula, kept in the wound a piece of sheet lead curved upon  its
borders and perforated with holes,  found no reason to  regret  it.
Wendt, with the view of extracting the half of an acorn, ventured to
incise three of these cartilages, and Percy on this subject advises that
we should use the scissors instead of  the bistoury, which latter how-
ever is much more convenient, and preferred with good  reason by
almost every practitioner.
  II. It is doubtless already anticipated what are my views upon the
importance  of these  numerous  modifications of  processes.   In the
first place, I would recommend the rejection of every kind of trans-
verse incision.  If the obstruction to be removed is a foreign body,
the division of one of the intercartilaginous spaces will  not  prove
sufficient, and if the object of the operation is to enable the patient to
breathe, a wound  of this description  will never be found sufficiently
large.  If any other proof were found wanting, it would be found in a
case operated upon in my presence in  one of the large hospitals. The
opening of the trachea had been well made and the canula properly
adjusted, but it was a portion of gum-elastic catheter, and the patient
compelled to breathe through so small a tube found himself partially
relieved only of the  suffocation, which it had been attempted to re-
move by  means of the bronchotomy.  In the first case the canulas
and  perforated plates are useless.  As soon  as  the trachea is free
we must reunite the wound or let it  close up.  If the foreign body
is movable, the air  of the lungs may  expel it outwards.  If it does
not present itself  spontaneously at the wound, we must proceed  to
search for it in the direction  of the bronchi, by means of a pair  of
curved and delicate forceps  or  some other  appropriate instrument.
When  it becomes impossible to reach it or  meet with it, it must  be
abandoned, and the wound left open and  the patient dressed.  On
the following day or  the day after, it  is generally found on the deep-
seated surface of the dressing. Desault, Pelletan and Dupuytren have
in this manner noticed the expulsion of a bean, kernel of  fruit, piece
of money, &c, and the needle that M. Blandin was unable to seize, after
having divided the thyroid cartilage, also made its exit in the same way.
In the second case the canula is  indispensable, but as no author had 
BRONCHOTOMY.
475
pointed out the importance of a large and permanent opening in the
trachea, none of the tubes that have been proposed answer the pur-
pose.  That of M. Bulliard is cylindrical, long and strongly curved.
M. Bretonneau has caused several successively to be constructed of
various kinds.  The canula which he used in Mile. Puysegur is dou-
ble like that of Martine,  and flattened,  slightly concave on  its  in-
ferior border,  and four lines in breadth in  its  greatest diameter.
That which he used in the patient whom I  saw, is formed  of two
halves, one superior and  the other inferior, which are  placed sepa-
rately in the wound,  and which when once reunited, present  no
other than an instrument analogous to the preceding.  M. Scoutetten,
(Coqueret, These, No. 185, Paris, 1834,) M. Lawrence, (Ibid., p. 21,)
M. Trousseau, M. Coqueret, (These, No. 185, Paris, 1834,) M. Mo-
reau, (Gaz. Med. de Paris, 1838,) Boyer, (Coqueret, These citee, p. 24,)
M. Sanson, &c, have since contrived others; so that at the present day
we possess those that are  simple, double, flattened, cylindrical, eyed,
cribbled, and bent into an angle or curved into an arc.   Inordinary
cases that of M. Bulliard is most convenient; under other circumstan-
ces we should have recourse to M.  Gendron's, (see the Atlas ;) the
important  point is, that it should be sufficiently large and frequently
cleansed.
  III. Whether we do or do not wish to make use of a  canula, some
persons  have  proposed that we should not  restrict ourselves to a
simple section of the  cartilages of the trachea, but remove and ex-
cise  a flap of the anterior wall of this  canal.   It appears that ve-
terinary surgeons very frequently proceed in  this manner.  Andree
also  appears  to  have followed  this process,  which is  formally re-
commended  by M. Lawrence, M. Porter, (Dublin  Hosp. Rep., vol.
V.,  p.  560,) &c.  But it is  a precaution which  is at the same time
wholly useless as well as dangerous:  useless, because the pure  and
simple incision always enables us to introduce  the artificial tube;
dangerous, because  if it should become afterwards advisable to  let
the wound close up, there would necessarily result from  it an incura-
ble contraction of the respiratory passage.  Consequently the process
of M. Collineau,  (These,  No. 676, Paris, 1829,)  to accomplish  this
loss  of substance, and  at the same time to  render every  kind  of
hemorrhage  impossible; a process which consists in perforating the
trachea by means of a cutting-plate, making  a projection upon the
circumference of  a flattened disc of copper heated to a white heat,
and which is mounted upon a long handle, in my  opinion appears to
possess no utility, and  ought  to be abandoned, as well as the advice
of MM. Carmichael and White, which has the same object in view.

                  §  III.—Operative  Process.

  A. The instruments  for bronchotomy are composed  of a straight
or convex bistoury ; a  blunt-pointed bistoury ;  several canulas armed
with  threads, and everything which may be required to  attach them ;
very delicate ring and polypus forceps ; several simple ligatures and
some needles ; erignes or sounds curved  in the form of hooks, and
various articles of dressing.   The patient being placed upon his back,
should have the head  only slightly reversed. Verduc has shown 
476
NEW ELEMENTS OF  OPERATIVE  SURGERY.
that by inclining it  too much backwards the respiration is rendered
more difficult,  a remark which  is applicable,  moreover, to all  the
modifications of bronchotomy.   The  surgeon  being placed on  the
right, in order to incise from above downwards, and not from below
upwards, as some persons recommend, grasps and steadies the larynx
with  his left hand, while with a convex  or straight bistoury in his
right hand he divides the tissues.
  I.  Tracheotomy.—In  order that tracheotomy may  be  well per-
formed, it is necessary that  the wound of the soft parts  should  ex-
tend from  the  neighborhood of  the cricoid cartilage  as  far down
nearly as the sternum.   After the integuments and aponeurosis  we
come to the vessels which are to be tied  in  proportion as they  are
divided; the veins  of the thyroid plexus,  which should also be tied
when it appears impossible to avoid them; then the middle  thyroid
artery, when it exists, and which it would be dangerous to wound.
When arrived upon the front ofthe trachea, should the  blood flow in
abundance and no  necessity exist for  haste, we may rest for some
minutes in order that the respiration may arrest the hemorrhage; but
if it is necessary to be rapid we  hasten to pass threads around the
vascular branches  which bleed;  or, what is  still better, we imme-
diately proceed to lay open the respiratory tube itself.   Though  the
straight bistoury, held as a pen, is sufficient for effecting this opening,
which ought to  comprise at least the fourth, fifth, and sixth, if not
the third and seventh cartilaginous rings, there are, however, practi-
tioners who prefer  the blunt-pointed bistoury to extend the  incision
after the puncture.   I see neither any inconvenience or  advantage in
this :  though even the point of the instrument should touch the poste-
rior wall of the respiratory tube, which seems to be so much dreaded,
there would probably result from it no very serious danger.  This part
of the operation being terminated, we  proceed differently, according
as we have to extract a foreign body  or to  relieve the suffocation.
tn the first case, should the  body which is  to  be removed not be ex-
pelled instantly, then if it presents itself at  the wound, whose lips  the
operator is to cautiously separate apart by means of the ring forceps
or hooks, we endeavor to reach it with a suitable  instrument, and to
draw it out.  When it remains immovable in the direction towards
the bronchi, which, as Favier has shown, is quite rare, we insert, with
every precaution possible, in this direction a  suitable  forceps or a
small scoop, in order to detach or seize it.  Should such researches
prove unavailing, they should not be too often repeated.  Should  the
surgeon have no other object in  view  than to establish artificial  res-
piration, he  immediately proceeds to adjust the canula.   Having
seized it, he places  it  in  the trachea, while with the ring forceps he
separates the lips of the wound wide apart.   By conducting it upon
a probe or canulated sound, which serves as an axis to it, I ordina-
rily succeed in introducing  it into the wound without any difficulty.
If during the operation the  venous hemorrhage should  be too abun-
dant, and resist the ordinary means, we should  not get alarmed and,
in our fright, abandon the  patient, as Ferand did in a similar case.
If the patient is at the age of reason, we should soothe him and in-
duce him to respire as freely as  possible, when the blood  soon stops
of itself.   Should any of it escape into the trachea and give rise to 
BRONCHOTOMY.
477
accidents, it would be an additional inducement to imitate Vigili, and
immediately lay open the respiratory tube largely, as I did in one in-
stance successfully in 1838.   We might also, after the manner of M.
Roux, (Lancette Franc., X. I., p. 182,) should the danger be pressing,
apply our mouth on  a tube or the end of a  gum-elastic catheter, in-
troduced into the wound in the trachea, in order to suck out  the ex-
travasated fluids which  lead to the apprehension of suffocation.
  II. Cricoidean Laryngotomy.—When we wish  to  lay  open the
lower part of the larynx the incision is  to commence at the project-
ing angle of the thyroid cartilage, and descend a little below the
cricoid, without the  necessity however of  making  it as long as for
tracheotomy.   The  surgeon divides in succession, or with one cut,
the skin, subcutaneous layer, and aponeurosis ; separates the thyroid
muscles;  places  the pulp of  his forefinger upon the crico-thyroid
membrane ; endeavors  to feel  the artery of the same  name; raises
it up or depresses it  with his nail, according as he wishes to incise  it
above or below ; plunges his  straight  bistoury, guided upon the nail
of one  of his fingers, perpendicularly into the membrane;  turns the
cutting edge of his instrument upwards or downwards, according as
he has  succeeded in  pushing the  arterial arcade to one side or the
other, and makes in  this place an opening of the proper dimensions.
   III. Laryngo-tracheotomy.—In order to  transform the preceding
operation into laryngo-tracheotomy, as M. Duchateau (These, Stras-
bourg,  1823,) has in  one instance successfully done, we have nothing
more to do than to insert a  blunt-pointed in place ofthe straight bis-
toury, and to enlarge the wound  from above downwards by dividing
the cricoid cartilage and first rings of the trachea upon the  me-
dian line.
   IV.  Thyroidean  Laryngotomy.—The  same  instrument directed
from below upwards accurately upon the median line, would serve
full as well to separate the two halves of the thyroid cartilage, after
the manner of  Desault.   Upon the supposition that  in spite of every
precaution possible,  the crico-thyroid  artery has been  divided, and
that it may give  rise, which is difficult to comprehend, to an alarm-
ing hemorrhage, it could be  easily surrounded with a ligature upon its
right and left, and it surprises me that a vessel of so little importance
has attracted  so much  attention.  The little finger  inserted into the
wound is first  made to  proceed  in search of the foreign body, and
then serves as  a director to the forceps or  other instruments which
it may  be deemed advisable to employ.  As soon as the body is re-
moved, the wound is to be reunited by first intention,  and the cure
is  generally effected in a  very  short  time.   When,  however, we
have not been  enabled to find it, the wound is to be  left open and we
proceed afterwards  in the same manner as in tracheotomy.  In my
opinion, moreover,  the suture recommended by some authors and
used by Herhold, ought never to be made trial of, whatever Delpech
and M. Serre  say of it.  The patient mentioned by Wilmer, and in
whom it was made  use of, died suddenly on the fifth  day after the
operation.  It  can only have a tendency, in such cases, to  favor the
extravasation of sanguineous  or  other fluids, either between the air
passage and the tissues which surround it, or into the interior of this 
478
NEW ELEMENTS OF OPERATIVE SURGERY.
 canal itself, while  the other containing means are always sufficient
 for reunion in  a wound of this  description.
   V.  Thyro-hyoidean  Laryngotomy.—After having laid bare the
 thyro-hyoidean membrane upon the median line, by means of an in-
 cision about two inches long, it will be found less difficult than might
 be supposed,  to reach  the superior cordas  vocales, provided wo
 divide it transversely above the cartilage which gives attachment to
 them.   A bistoury  plunged in  at this point from above  downwards
 and from before backwards, traverses the root of the epiglottis, falls
 immediately into the  larynx, thus making for  the finger or forceps a
 passage, which can be enlarged at pleasure, and which enables us
 to pass  round the whole of the glottis without wounding  in any way
 whatever either the cordas vocales or the cartilages.  No artery of
 any size nor any important nerve can be wounded.   The laryngeal
 branch  of the superior thyroid artery and the corresponding nerve
 are  sufficiently distant from the median line, to enable  us to avoid
 them with ease, and no venous  plexus is encountered at this point.
 The wound made by this operation might have, I should  think, some
 tendency to remain gaping open,  but it is probable that in living
 man the inflammation would speedily approximate its borders, and
 that cicatrization would be effected  without difficulty.
   B. If our intention is to restore the respiration of the patient, and
 not to extract any foreign body from the  aerial passages,  the surgeon
 having satisfactorily removed the suffocation, has still to attend to two
 things, to wit, the disease of the larynx and the canula which he has
 left in the wound.  Under the first point of view therefore he will have
 recourse to antiphlogistics, general or local, to resolvents, detergents
 and even caustics, either by the mouth, or on the skin or  wound, and
to blisters, antisyphilitics, &c, according  as the disease may be laryn-
 gitis, croup, ulcers or a venereal  affection of the larynx.  As to the
 canula,  it is important to  have at least  two of them, and that they
should be changed or  cleansed as often as the respiration appears to
 be incommoded.  They are to be kept in place by means of two rib-
 bons of some breadth,  which are  to be crossed on the nape and
 brought  forward to be  attached by a bow-knot in front of the
neck at the supra-sternal fossa.   Patients should wear this canula as
 long as  the air  does not pass freely through the glottis.  There are
some, moreover, who dispense with them-without danger at the end
of the  first  or  second month, while  there  are others who have to
wear them for one or  several years, and  even during all  their lives.

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

  There will doubtless be sufficient time to make improvements in the
 method and instruments to be employed in laryngotomy, and in tra-
 cheotomy, for croup, &c, after  the operation itself shall have ever
 received the sanction of the profession, under  any circumstances ex-
cept for the  removal of foreign bodies.  Though  the pathological
condition of the system, which results in the production  of the false
membrane in croup, even throughout  every ramification of the bron-
 chial tubes, has no parallel with the  perfectly sound state of the air
 passages, when foreign  bodies  have  become  lodged  there, still the 
BRONCHOTOMY.
479
restless impatience of innovation  is such, that some surgeons have
already, before the propriety of the operation in  croup, at all, is yet
decided upon, begun, like Dr. Af orand among others, (Recueil des Tra-
vaux de la Soc Med. d'Indre et Loire, in Gaz. Med. de Paris, 1846,
XVI. annee, 3e ser., t. I., p. 210.) to refine r.pon the  character ofthe
wound and the nature of the instruments required to perfect the pro-
cess in question.   Thus, to prevent asphyxia, and  the desiccation of
the mucus of the passages, and the better to reach and draw out the
glove-like prolongations, he proposes to open into the trachea largely,
also to dispense with the canula, and  to dilate the wound by instru-
ments for  that purpose, and then  to  place  over it  a thin gauze, in
order  that it may become  moistened  by the air expired.   The dila-
tation of the wound must expose to greater hemorrhage, and there-
fore to greater danger of blood passing  into the trachea, and stran-
gulating the patient.   As to the hope  of thinking to  extract the false
membrane after it is once formed, it  appears, in our judgment, alto-
gether chimerical.
  Air.  Lawrence thinks laryngotomy by a  small  aperture, with the
two-edged bistoury, into the crico-thyroid membrane, quite sufficient,
and preferable to tracheotomy in all cases where  we desire to obtain
artificial respiration.   The former is  unattended with danger, while
in the latter we  may have serious  hemorrhage *from  the  thyroid
veins, (London Med. Gaz., June 20, 1845.)  But  the serious charac-
ter of the  hemorrhage, as we  have explained m our  notes, arises
from the danger of some particles of blood  getting  into the trachea,
and  causing immediate convulsive  strangulation,  suffocation,  and
death.  This is most  to be apprehended in children, wherever the
opening may be  made, as  the  vessels, especially the veins, become
enormously distended, and enlarged, and engorged, by their cries
and struggles, as in  the case (vide infra,) of the  removal of a large
dressing or shawl pin by Dr. Mott.   Mr. Coote, in examining the
false  tubular membrane in a  case Mr.  Lawrence operated upon,
found  it to be a yellowish soft coating, extending throughout the
minutest ramifications of the bronchi of the  left  lung.   This adult
had been laboring under bronchitis, (lb., loc. cit.)   Mr. Coote ascer-
tained that the membrane constantly  preserved its tubular character,
that it was ofthe thickness ofthe mucous membrane, and that it con-
sisted  of pure fibrine.  Mr. W. Chapman,  on the other hand, in  a
case of acute laryngitis, (Lond. Lancet, June 7,  1845,) made his in-
cision  longitudinal, and half an inch long,  and just one  inch above
the sternum, and  then introduced the tracheotomy trochar and can-
ula.   He  insists  that this  is the best place in  such affections, and
especially because we thereby save  the patient  from  the irritation
caused by air passing over the inflamed  surface of the larynx.   He
properly insists that it should be performed  early, and before the last
suffocating stages have arrived.  This, we perceive, by what takes
place in respect to the deposition of the false membrane above,  is
correct reasoning.  Mr. Chapman saved and cured his patient.  Mr.
Liston also prefers tracheotomy in all  diseases of the larynx and
glottis, and in a majority of the  cases  of foreign bodies in the air pas-
sages, especially if they are in the trachea, (London  Lancet, Nov. 23,
1844.)  His object is to have a large opening, and also in laryngitis 
480
NEW ELEMENTS OF OPERATIVE SURGERY.
to get  below the disease.   AVhere the canula has to be left in, Mr.
Liston says the patient can generally clean the tube  of mucus by
putting the finger  partially over the outer end of the tube, so as to
narrow it, and  excite resistance to the expiration, and  thus promote
a  slight cough, (Ib.)   A  double canula allows you to  clean one
while the other is left in.
   AI. Vogelvanger (Annates de la  Societe de  Med. d'Anvers, Gaz.
jSI'd. de Paris, and also the Provincial and Med.-Surg. Journ., Abiy
27, 1843, p. 217,) succeeded, in 1840, in extracting a large slice of a
carrot, nearly an inch and a half in length,  which had become im-
pacted or wedged  into the upper part of the larynx, in a girl between
five and six years of age.   As the incision into the trachea afforded
relief to the  respiration, as a return of suffocating  symptoms took
place when the  wound was closed, and as the body could not be
seen, the surgeon naturally thought this latter was above the wound
made.   Introducing, therefore, a dressing forceps upwards, the por-
tion of carrot was immediately extracted, and  the patient's life thus
saved.
   A remarkable and instructive case in which tracheotomy was per-
formed, is one which  occurred  in the practice  of Air. J. Elkington,
at Birmingham, England, (Provincial Med. and Surg. Journ., April
22, 1846, pp.  184, 185.)  The patient, a woman aged twenty-six, in
the ninth month of her pregnancy, was  seized, January 6, 1846, with
a  croupy cough, bloody expectoration, and loss of voice, which in-
creased, together with suffocating paroxysms to such  degree, that
the trachea was opened at the usual place, January 17, which  gave
much relief.   The same evening labor came on, and on the next day,
January 18, she was delivered of a dead child without any difficulty.
On the morning of the 19th she slept two  hours.   The breathing
being then worse, the  canula was removed, and at half past  three,
P. M., an attempt  made to enlarge the opening, by which  means a
vein was divided and some blood got into the passage.  At four a
dreadful convulsion came  on, and  she  expired.  The  appearances
after death presented a false membrane of coagulum lymph on the
entire mucous lining of the air passages, larynx, trachea, and bron-
chial tubes, down to their smallest ramifications.  Here is  an une-
quivocal and  aggravated case of croup, in which leeching and other
depleting and antiphlogistic measures  do not appear to have been
carried sufficiently far.  This case also calls up again the subject of
the extreme  danger of the entrance of the blood into the trachea in
tracheotomy,  (vide  infra,) and the question, how far the attempt to
enlarge the wound may have led to  the immediate fatal result.
   A foreign body will play up and down in the trachea like a pea in
a quill, for weeks, without other inconvenience  than occasional fits
of coughing.   Finally it will become  permanently lodged, probably
in the rima glottidis, and may there suddenly cause death by suffo-
cation during an access of coughing, as in the case of a  pebble swal-
lowed by a little girl, between two and three  years of age, as related
by Mr. Pitcher, (Lond. Lancet, 1844,) and also in the case of an infant,
mentioned by the  same surgeon, and in whom a piece of cabbage
stalk was found, after death,  to have  got  imbedded  between the
cordas  vocales.  Laryngotomy  would  have saved both,  perhaps. 
BRONCHOTCMY.
481
 The same surgeon, (Ib.) called to a child who had swallowed a tama-
 rind stone, at once proceeded to open the trachea, but found  no evi-
 dence with the forceps of any foreign body.  Bronchitis ensued, and
 under the supposition that the operation might have caused this, the
 wound was closed up.  Death followed, and a tamarind  stone  was
 found imbedded  in the upper  part of the right lung, having passed
 through the right bronchus.  The lung  was one mass of disease, and
 in quite a pulpy condition.
   A girl aged  16, at  the  city of Dublin Hospital, is stated by Dr.
 Houston, (Dublin Med. Journ., 1844, vol.  XXV.,  p.  532, &c.,) to
 have swallowed, about a month before Feb. 1841, a fragment of wood,
 while laughing with it in her mouth.   She suffered especially at night
 from fits of coughing, and  had a constant mucous rale, with stridu-
 lous croupy breathing.   The coughing  however,  was always reliev-
 ed by a  sup of any  liquid.  Tracheotomy was  performed  by Dr.
 Houston, May 19, which brought on a violent paroxysm of coughing,
 probably from inattention to accurate  sponging  of  the wound, and
 previous careful ligature or torsion to all the vessels, so  as  to  pre-
 vent the slightest introduction of blood into the tube.  [See what
 we have elsewhere said  of the  opinion  of Dr. Alott, on this  point.]
 During a violent  paroxysm, and not until the month  of August, was
 the fragment thrown  up, which proved to be a wooden peg of a boy's
fiddle, after which she recovered rapidly, though  in fact her general
 health had never been impaired.   It  is remarked  in this and all other
 cases, that the upper  parts of the air tube  about  the glottis may be
 freely explored without causing any irritation, whereas it  is  the re-
 verse in the direction towards the bronchi.   In a child aged six years,
 a small brass nail, such as is used by upholsterers for covering chairs,
 got impacted with its point  upwards into the  sinus of the ventricle
 of the larynx, and with its  head downwards below  the glottis,  and
 soon terminated in death, notwithstanding the operation of tracheot-
 omy by the surgeon, Mr. Richeley (Dublin Med.  Journ., vol.  XXV.,
 1844, p. 516,) asphyxia  unfortunately having taken place before  sur-
 gical relief was sought for.   No mention is made of exploration of
 the larynx.
   In confirmation  of the above case, in which a fiddle peg remained for
 so long a time in the trachea, and also in proof of the necessity of our
 being on our guard against any  hasty inference that no foreign bodies
 have been introduced, or that they have been discharged, merely be-
 cause the suffocating paroxysms are immediately arrested by the swal-
 lowing of any  liquid,  we may remark that.a similar, but much less ag-
 gravated case occurred to Dr. L. Pagen, (see M. Capuron, in Arch.
 Gen. de Med.,  3d  ser., t.  VII., 1840, p.  369,) of France.  A young
 child while playing with some beans, got one into the larynx, which
 caused symptoms of suffocation,  but which were immediately calmed
 as if by enchantment, by giving it a tea-spoonful of olive  oil.  This
 remedy succeeded in  the same  manner, as often as the paroxysms
 supervened, until finally, at the expiration offorty days, the bean was
 expelled in fragments, by the efforts of  the child  itself. Where pa-
 tients or parents will not submit to an operation, and where the dan-
 ger is not imminent, we are thus at least furnished with a  temporary
                            31 
 482          NEW ELEMENTS  OF OPERATIVE  SURGERY.

 resource of great value, and which may in fact aid in accomplishing
 the ultimate spontaneous removal of the difficulty.
   M. Petel, who has been (see Arch.  Gen. de Med., 3e ser., t. XIII.,
 1842, p. 361,  362) one of the earliest advocates for tracheotomy as
 an extreme remedy in  croup, and who cites three cures which he
 effected by this process, prefers  for the operation the bivalve canula
 of M. Gendron, as modified by him.   (Journ. des Conn. Bled.  Chir.,
 October, 1841.)
   Of late years many efforts have been made to introduce or revive
 tracheotomy for croup by MM.  Bretonneau,  Trousseau,  and others,
 (see Valleix in Arch. Gen., Oct. 1844, p. 256, et seq.)   The operation
 will not be sanctioned  in our opinion, for the following reasons:
 1. As it cannot properly be substituted in the first stage, for a  vigor-
 ous plan of antiphlogistic, emetic, and revulsive treatment, (viz., ve-
 nesection,  large blistering, leeching and  emetics,) it will be had re-
 course  to only in the last  stage, merely to prevent immediate suffo-
 cation,  and thus prolong life for  a few hours.  2. Because it is  an
 operation  which is  generally contra-indicated, and  properly pro-
 scribed under any circumstances, or  in any disease whatever at the
 period  of  infancy, or that when croup mostly occurs.   This is be-
 cause of the danger of either laryngotomy or tracheotomy, in them,
 as the smallest drop  of  blood passing from the incision into the tra-
 chea has been known to produce immediate strangulation and death.
 This accident is the more  to  be  dreaded from the great  vascularity
 of the parts, and the extreme  distension of the veins, and therefore
 more abundant hemorrhage caused by the cries and struggles of the
 child during the operation; showing how incorrect it is in a surgeon
 of Paris to recommend, as has been done  recently, with the utmos'.
 nonchalance  possible,  such an  innovation  even of  tracheotomy
 as that of  direct puncture through  the crico-thyroid membrane by
 means  of  a trochar, with  a cutting spring forceps inclosed, this too
 with the patient on his back.   3. Because in no sense could tracheo-
 tomy be justifiable as a remedial measure for croup, because in the
 first stage  it would necessarily aggravate the symptoms, and again
 in the second stage, after the formation of the finger of glove-like tubu-
 lar membranous prolongations  into  the bronchi and their ramifica-
 tions, death could not possibly be  averted by it.   In illustration ofthe
 above remarks, we refer to the remarkable case of the successful ex-
 traction of a shawl-pin from the  trachea by Dr. Mott.  (See Infra.)
   M.  P.  Jousset had  already (Arch. Gen.. 4e ser., t. V., August,
 1844, p. 402—416,) done full justice to the subject of tracheotomy in
 croup.   As interne  at that time  in the Hospital des Enfans, at Paris,
-he had admirable opportunities  of demonstrating the  true character
 and structural ravages of croup  and the inefficacy of surgical means.
 M. Jousset shows ihat the operation under the name of bronchotomy
 was performed at the  remotest  period of  time, and for croup under
 the name of angina gangrenosa.  Hence the mistake of the moderns,
 in thinking  the disease and  the operation  both new, whereas At,
 Jousset clearly shows, that our  own  countryman, Dr.  Samuel Bard,
 (lb., p. 401,) of New York, had many years since satisfactorily de-
 monstrated that as respects the disease, the angina gangrenosa of
 the older authors was identical with croup.  Out of 219 cases of the 
BRONCHOTOMY.
483
operation, from 1782 to 1844, as collected by M. Jousset, it is ascer-
tained that 40 only terminated  in cures ;  while he has verified from
the time of Galen to the present epoch 35 cases of croup or angina,
which recovered by medical  treatment  exclusively, and that even
after the expectoration  of false membranes,  of which 35, ten were
cases in which false tubular membranes themselves were discharged.
The practice of Van Swieten therefore, in favor of early tracheotomy
in croup, undoubtedly the most rational period, and that of Louis, who
after him considered it  the only cure at any  stage of the disease, as
well as the modern advocacy of the operation, are wholly and vehe-
mently proscribed by M. Jousset, except as an extreme and last resort
to prevent immediate suffocation.  In two such cases even it was in
his hands followed by a cure.
  Tracheotomy in Spasmodic  Dyspnea from  Bronchocele.—Dr.
Handyside, of Edinburgh, (Cormack's  Monthly Journ., &c, Jan..
1845, p. 30, &c,) in the case of a young man, aged 18, with hyper-
trophied  condition of the thyroid body  (bronchocele,) to great ex-
tent, causing distressing attacks of dyspnea and bronchitis, obtained
immediate relief by cutting down through the right portion of the
diseased gland to the trachea, which  was displaced by it, and insert-
ing a tube in the opening made into  the windpipe.  The profuse ve-
nous hemorrhage however, which followed, and which it was found
difficult to restrain, had no doubt much to do in this ease in allaying
the pulmonary disease, and in  promoting free muco-purulent expec-
toration, and ultimately, in about two weeks a cicatrization of the
wound and  almost total absorption of the enlarged thyroid body.
The case however is one of much interest surgically, and the opera-
tion was the true cause of its successful termination.
  Spontaneous Expulsion of Foreign Bodies  from the Air Passages.
—In addition to the well-attested cases of the length of time during
which such bodies may be retained in the trachea or  bronchi, caus-
ing there chronic inflammation, and purulent or bloody expectoration
for two or three years, and then be finally expelled by efforts of cough-
ing,  we may mention  that of a man aged  42,  mentioned by  Dr.
Duncan and  Dr.  Spence, (Northern  Journal of Medicine, Aug.,
1845.)   This person letting slip two pieces of bone into his trachea
while at dinner, in February, 1841,  became affected with the symp-
toms as above described, wThich continued till  March 2nd, 1845, when
during a violent paroxysm of coughing  he expelled  the foreign bo-
dies, one of which was rhomboidal  and  an inch long, and the other
a slender fragment of nearly the  same length.  By June of the same
year he  had perfectly recovered.   In  another case, a boy aged 5^
years, while chewing an ear of grass in a field, got the same into his*
trachea in 1840, when he was  attacked with the  usual inflammation
and expectoration of pus and blood, which finally threatened hectic
fever, until during a violent fit of coughing 22 months afterwards, the
foreign body was  expelled.   It was an entire  ear  of the crested
dogstail grass.   The boy recovered  perfectly, (lb., loc. cit.)
  M. Ehrmann, of Strasbourg,  (Arch.  Gen.,  Mai, 1844,)  had  re-
course, with success, to an incision into the trachea hi a woman, for
the purpose  of  extracting a fihro-cellular polypus, the upper part of
which had extended up  between the lips  of  the glottis.  The whole 
484          NEW  ELEMENTS OF OPERATIVE SURGERY.

length of the lower left ligament of the glottis was closely grazed off
by the bistoury.
  Foreign bodies in the Pharynx.—Mr. R. Jackson, (Edin. Med.
and  Surg.  Journ.,  July,  1843,) describes a  case  of suicide  in a
woman, aged 42, who designedly swallowed a key, which lodged be-
hind the glottis, with its ring part downwards.   The severe inflam-
mations in the air passages, with  the abundant expectoration which
ensued, but without deglutition being much interrupted by the foreign
body, caused death in a few weeks.   A very similar case  occurred
in a man named Gilbert. Dr. Handyside, also, has given cases (lb.) of
foreign bodies lodged in the pharanx ; in one the  body was rejected
during a  paroxysm of vomiting.   (See  notes under the  head of
Oesophagus.)
  Pharyngeal Fistula.—Professor Albers, of Bonn, had the rare oppor-
tunity of examining (see Graefe's und Walther's Journal, Bd. XXX.,
Heft 3;  also Arch. Gen. de' Med.. 3e  ser.,  t.  XIII., pp. 489,  490,
491,)  in the year 1841, a case of pharyngeal fistula, immediately,
above the os hyoides, near the angle of the jaw, two  inches  in height
and one in breadth, in a German soldier, aged 41.   It was caused by
a sabre wound, in the campaign of the  French against Constantine,
and, except  for  the  first  few weeks, during which  its edges were
cicatrizing, had not prevented him from following the active life of a
soldier and engaging in other battles, in some of which he  has been
again wounded.   He wears a leather strap over the fistula, and with-
out this  can neither swallow, articulate, or cough.  When it is re-
moved, he breathes through this large aperture only, and  a  good op-
portunity  is then afforded  of observing the position and play of im-
portant  parts in  life and robust health, as that  of the velum  and
arches of  the palate, the epiglottis, glottis, larynx, &c. No attempt
appears to have been made to cure the deformity.
  Bronchial Calculus.—Dr. S. C. G. Tice describes, (Me.dico-Chi-
rurgical Trans., vol. XXVL, London, 1843,8vo.) an interesting case
of bronchial calculus, the symptoms of which were pain in  the right
side, increased by pressure over the liver, dyspnoea : finally, suffoca-
ting paroxysms of cough on lying down, great fetor of breath, end-
ing, after  a continuance of six weeks, in laryngitis and sudden death.
There was nothing before this event to indicate  the true nature of
the disease.  On examining the body, an abscess, of the size of a pullet's
egg, was found in a mass of enlarged bronchial  glands at the bifurca-
tion  of  the trachea.   It  opened  into  both bronchi, and  into the
oesophagus, and  contained a quantity of calcareous matter, some of
which was hard and some  of soft consistence.   A  hard triangular
portion was firmly wedged  in the aperture, communicating with the
right bronchus.  This was found to consist of phosphate of lime.   (See
also  British and Foreign  Med. Rev.,  vol. XVIII., July—October,
1844, p. 365.)   T.]

           Article II.—Catheterism of the Larynx.

  Catheterism of the larynx, whether in new-born infant's  or at any
other epoch of life, is  too simple an  operation to require  to be de-
scribed more in  detail.  While with one hand the instrument is con- 
               catheterism of the oesophagus.              485

ducted through the nose, or what is better, through the mouth, some
of the fingers of the other hand, directed upon the lower part of the
throat, secure its  extremity, bring it  into the glottis and prevent its
passing into the pssophagus.
                       CHAPTER IV.

                   ALIMENTARY PASSAGES.

         Article I.—Catheterism  of  the CEsophagus.

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

                   § I.— Through  the Nose.

  The first method, or that which consists  in entering through, the
nasal fossas, and which was adopted for a long time as the preferable
one, is  at  the  present day almost entirely abandoned.  Being fre-
quently difficult, and always fatiguing  to  the patient,  it should be
reserved only as an exceptional method.   If the  catheter is inflexible
(fixe) its curvature will scarcely allow it to go beyond the apex of the
pharyngeal cavity, and consequently to penetrate into the oesophagus.
If it is flexible and straight, it buts against the vertebral wall of the
posterior fauces, in such manner as to make it sometimes difficult to
disengage it.  This route however is better than none, should the other
not be practicable.  The sound, held in the right hand as a  writing
pen, is introduced through the nares in the same manner and with the
same precautions as for catheterism ofthe Eustachian tube, except that
the concavity of its beak, in place of being turned outwards or inwards,
is rather to be directed  downwards.   By means of the forefinger or
a blunt hook glided  into the mouth, the operator endeavors to reach
its extremity as soon as it arrives in the upper part of the pharynx;
depresses it a little with the left hand, while with the right  he con-
tinues to push it forward; in this manner directs its point into the
axis of the oesophagus, while avoiding with care the entrance of the
larynx or  making too  much friction on the parts; penetrates and
advances by degrees;  stops upon encountering the slightest diffi-
culty ; changes a little the direction of the force  applied; withdraws 
486
NEW ELEMENTS OF  OPERATIVE SURGERY.
the instrument slightly in order to push it in again in another direc-
tion, if he meets with any resistance, and descends to a greater or
less depth according to the indication he  proposes  to fulfill.  Upon
the supposition that a straight elastic catheter should  have occasioned
some embarrassment, nothing would  be more easy  than to remedy
this  inconvenience;  it should  be passed  down to  a line with the
glottis by means  of a curved stilette, which  should then be with-
drawn, leaving the catheter in and proceeding in such manner for the
rest of the operation as above described.

                       § II.—By the Mouth.

  Whatever may be the mode  adopted, the patient  being seated on
a chair, is to be  supported  as in all other operations which are per-
formed upon the face.   AVhen  he  enters  by the mouth the surgeon
gently depresses the tongue with the left  forefinger, which he intro-
duces, if possible, as far down as to the epiglottis, in  order to protect
him  against the deviations of the instrument  in  the direction of the
respiratory passages, then causes the sound or catheter to glide along
the radial border of this finger while  following the dorsal surface of
the tongue ; enters without difficulty into the oesophagus if it presents
the slightest curvature;  secures its extremity with  the finger in the
contrary case in order to compel it to follow the axis of this canal,
and finally forces it to take such course as he judges most suitable.
  When circumstances require that it should  be kept in its place
after the operation, it is to be  inclined  to one side in  the interval
left between some of the  teeth, should any have been extracted,  in
order that we may adjust it at one  of the labial commissures, by
means of a ribbon whichis to be fastened moreover around the head.
Though it has  been introduced by the mouth, should its presence
cause too much  fatigue to this  cavity, nothing would prevent us, as
has  been  remarked by Boyer, from bringing its  outer extremity
through the nose and thus changing the organ.  All that would be
required for this purpose, when it is once  placed, would be to secure
it by means of Bellocq's sound or  any  flexible bougie whatever,
introduced through the nose, and to make traction upon it by means
of a thread previously fastened to  its extremity, in the same manner
as would be done in tamponing the  nasal fossas.   Unless the osso-
phagus should be deviated, contracted or abnormal, its catheterism is
in general very  simple.  We should  incur no risk  of wounding its
walls, making a  false passage or blundering, in a word, or perforating
it, as happened  to the surgeon mentioned by Chas.  Bell, unless we
should proceed  with extreme  imprudence or use a  degree of force
that no  instructed  surgeon would attempt to employ.   The  finger
being charged to guide the catheter as far down as to beyond the epi-
glottis, there can be no difficulty in  ascertaining whether it has not
accidentally descended into the larynx, as appears to have happened
in the case  mentioned  by AVorbe.   Presenting a light  at the orifice
of the instrument, or the impossibility almost of its penetrating lower
down than on a  line with the bronchi, or better still, the  injection of
a few drops of liquid, which in that event would not fail to bring on
cough, &c,  would moreover soon assure us of the fact. 
CONTRACTION OF THE  OESOPHAGUS.
487
                             §  III.

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

         Article II.—Contraction  of  the Oesophagus.

  Since Mauchart has demonstrated  the analogy which exists be-
tween the  coarctations of the urethra and those of almost all the  mu-
cous canals, surgeons have endeavored at different times to apply to
the contractions of the oesophagus, most of those remedies which
have been found useful against those of the  excretory duct of the
urine.  Mechanical dilatation was one of the first which was ventured
upon.   Recommended by  Richerand and Dupuytren;  made trial of
on one occasion by MM. Carrier and Jallon, in a merchant of Orleans,
who got along very well with it for more than a month, but ulti-
mately perished from a destructive ulcer in the oesophagus ; employed
by  Boyer, in the year 1797, in a  woman who experienced  but slight
advantages from it,  and by M. Sanson on a patient who, after having
obtained much benefit from it, was desirous  of leaving  the  Hotel
Dieu, and  considered it no longer necessary to continue under treat-
ment ; it appears to have been attended with a completely success-
ful result in a case of Migliavacca, cited by Paletta ; in another of E.
Home ;  a  third of M. Earle ; a  fourth of M. Mcllvaine, and  a fifth
of M. Denis, (Journ. Hebdom., 1835, t. II., p.  5.)  Catheterism is the
process  used.   The  bougies, whether emplastic, elastic  or conical
rather than cylindrical, or better still, hollow sounds  denominated
ozsophagean, used in such manner that their size may be gradually
augmented, should be manipulated, in these cases with the same cau-
tion and prudence as when used in  the urethra.  But the canal being
larger or being intended to receive greater dimensions, the size  that
we  are soon obliged to give to these instruments has placed us under
the  necessity of substituting other contrivances for  them. 
488
new elements of  operative surgery.
  A contraction  produced by an abscess which  had left an o'sopha-
geo-tracheal fistula, was cured by M. Gendron, (Ibid.,  1836, t.. I. p.
378,) by means of a dilating sound sprinkled with alum.  The author
upon the strength of this fact  and another, which was communicated
to him by M. H.  Berard, (Journ. des  Conn. Med-Chir., Nov.  is:i7f
p. 175,  187,) proceeds to lay it down  that contractions of the  oeso-
phagus  ought to be treated, and may be cured by catheterism.   The
instrument of M.  Fletcher is curved and slender, and of metal, and
consists of three branches, which a central rod provided with a head
enables us to approximate Or separate at pleasure.  After having in-
troduced it like an ordinary Catheter, beyond the point of coarctation,
it suffices to cause  its  movable axis to ascend, to enable the surgeon
to separate its branches gradually to the extent that  he may judge de-
sirable.   However ingenious this instrument may appear, it ought to
be rejected.  It is by means of a uniform  pressure, and not at three
points only of the contracted  periphery, that dilatation can offer any
prospect of success.  It is necessary before all other things, that this
indication should be perfectly fulfilled, but M. Fletcher appears to have
entirely overlooked it.   The air dilatator of M. Arnott, or the flexible
and  sheathed meche-holder contrived  by M. Costallat, in order to
reach deep-seated coarctations of the  rectum, and  especially of the
urethra, would have a decided preference over  it.   Many surgeons
also  have  turned their  attention towards cauterization.   Though
among us this mode of treatment has been rarely made trial of,  and
that  Boyer has thought proper formally to proscribe it, it is not how-
ever the same in other countries.   M. Mondiere, (Arch. Gen. de Med.,
2nd ser., t. I., p. 465, t. II., p. 504, t. III., p. 28,) in fact shows that in
Italy, England, and America, it has been several times had recourse to.
A flexible rod, wrapped in linen saturated with liquid caustic was in-
troduced by Paletta as far  down as to the stricture,  and the patient
who died some weeks  after found himself at first relieved by it.   E.
Home properly rejecting every substance  of a fluid  character, pre-
ferred nitrate of  silver, and used it in seven instances.  Four of his
patients were cured, and the three others died from the natural pro-
gress of their disease.  Out of three cases published by M. Andrews,
one only succeeded.  In the two others the  treatment  could not be
continued.    Finally, MAI. C. Bell and Macllvaine also declared
themselves its partisans as Darwin had previously  done, and appear
to have made  use only of nitrate of  silver.   A difficulty which
first  causes us to  hesitate, is  that of ascertaining  the-nature of the
contraction which is to be overcome.  Those only which arise  from
chronic phlegmasia, or an induration or  lardaceous transformation
ofthe mucous tunic or suprajacent  membrane, admit of the employ-
ment of cauterization ; but how are these to be distinguished from le-
sions which may  be produced by tumors, cancerous or fungous de-
generescences,  ulcers  of all  kinds, aneurisms,  polypi, &c. ?  The
urethra being, so  to speak, liable only to the first, incurs the risk of
no embarrassment of this kind.   Its small diameter, superficial situa-
tion, and the arrangement of its walls moreover, renders its mechani-
cal dilatation an easy matter,  and unattended almost with any dan-
ger.   The oesophagus being surrounded with pliant tissues, and being
itself exceedingly dilatable, is  far from possessing the same  advanta- 
                contraction  of the  oesophagus.             489

geous conditions under this point of view.   By widening the contrac
ted part, bougies scarcely do  any more  than  to  push outwardly
the projection which was tending inwardly, and the disease returns
almost as soon as the use of the  instrument is suspended, making it
therefore only a palliative treatment.  As to the nitrate of silver,  I
would use it much less in  its  character as a  caustic, than  with the
view of  modifying the morbid condition of the parts ; in this respect,
the exactitude with which  it is applied to this  or that point in prefer-
ence to another, is of less importance than is supposed.   This, more-
over, is a question which will be treated of under the head of diseases
of the urethra.
   [Organic Stricture or Contraction of the Oesophagus.—This dis-
tressing  disease, which usually ends in a slow death by inanition or
starvation,  has naturally  engaged  much  attention.  M.  Gendron
furnishes one of the  most  interesting cases of cure of this disease,
obtained by perseverance  under  every obstacle of the processes of
alternate dilatation and cauterizations with alum and nitrate of silver:
the dilatations being effected  by the ordinary whalebone  probang,
made very flexible, with spherical sponges on their extremity of 6
to 7 centimeters in  diameter, and the cauterization  by the  gum
elastic canula with  the wax border, to protect other parts  than the
structure itself from the action  of this substance.  The patient, a
gentleman 33 years of age, had been for near two  years the victim
to distressing suffocating  spasms in the throat and gullet, accompanied
with still more  annoying  and prolonged attacks of eructation  after
taking his food. Finally,  he  could swallow  nothing but soft-boiled
meat, and scarcely a drop of liquid.  The necessity of abstaining
from nourishment soon wasted him away, and the-thirst tormented
him  with agony.  M. Gendron, (see Arch. Gen. de Med., 3e  ser.,
t.  XV.,  1842, pp. 448, 457, also cases  by the same author  in the
Journ.  des  Connaiss. Medico-chirurgicales  de  Paris,  Nov.  1837,)
by the probang, and especially  by aiding this instrument  with his
fingers in the pharynx,  whenever the sponge was stopped and the
whalebone bent on encountering the impediment, succeeded in locali-
zing the seat of this latter  behind  the first ring of the  trachea.
Meanwhile great relief  was  obtained  by introducing any kinds of
liquid food through the canulas used.   The proof that  duplicatures,
as well  as a firm  bridle  existed at the  point, was shown by the
greater  difficulty of swallowing  liquids, as these are caught by such
folds in  the lining membrane.   The caustic brought away the debris
of the abnormal obstruction, and the patient was after a  long and
resolute  course of treatment by the instruments in question, restored
to excellent health, enbompoint and cheerfulness, but still was under
the necessity of persevering  in  the  catheterism with  the probang
twice a  week, to keep up the calibre of the  passage to  its normal
dimensions.   The flatulence, spasms, &o. were wholly  removed.  It
is  a singular feature  of these circumscribed strictures, that they are
unaccompanied with any defined  pain in the part or vicinity.  Though
with most surgeons  catheterism and cauterization of the oesophagus
have been considered of  late, to be more hazardous and injurious than
useful, there can be  no  doubt, judging by the details  given  by. M.
Gendron, that much of the disrepute into which they have fallen has 
490
NEW ELEMENTS OF OPERATIVE SURGERY.
arisen from the imperfect manner in which they have been perform-
ed ; and that if practised as perseveringly and with as  much appa-
rent judgment, caution and tact as they were in the  remarkable case
in question by that  surgeon, they will claim a yet higher reputation
than they have hitherto reached, in a disease, which without some
such surgical resource  must necessarily  end in a frightful death.
  The oesophagus sometimes becomes preternaturally dilated, as in the
case related by Dr. Lindau of Thorn, (Casper's Wochenscrifft, 1840,
No. 22,) in the form of a pouch occupying all its middle and poste-
rior portion, and no less than four inches in diameter at its largest
expansion, the whole of this sacculated diseased mass being adherent
to the surrounding parts.   Whether such  pouches be the result, in
the first place, of cancer, and then  a  constriction  interrupting the
food, and thence giving rise secondarily to dilatation from the efforts
in deglutition ; or whatever the cause may be, it will be found that
one diagnostic mark will present itself after the dilatation is com-
plete, which is the reverse of what we have seen in the  case above.
Thus, in dilatations it  will  be the most liquid kinds of food which
will make their way most readily into  the stomach, while the solid
portions from the absence of propulsive power in the tube will con-
tinue to accumulate in  the pouch.  T.]

        Article III.—Foreign  Bodies in the OEsophagus.

  A crust of bread, a piece of tripe,  large mouthfuls of hard and
tough meat or skin, a slice of fruit, a sugar-plum, a piece of mutton,
cake, a  slice of ham, an entire egg, a chesnut, pear, fig, and all other
substances that may possess some solidity, and which belong to arti-
cles  of  food, or that are sometimes introduced into the  mouth, may
be arrested in the oesophagus and give rise to serious accidents.  As
these different bodies, however, are more or less soluble in the excre-
tions of the digestive  passages,  it rarely  happens that  they do not
ultimately descend into the stomach.   Pebbles, pieces of glass, a fish
or other small bone, a  piece of money, a blade of a knife, a fork, and
a thousand different modifications of foreign bodies, so many instances
of which are  contained in the memoirs of Hevin and Sue, are infi-
nitely more dangerous, though the organism  has in more than one
instance got the better of them without any assistance.  They lace-
rate or  contuse  the parts, produce inflammations, abscesses  and
frightful pains, which frequently end only  in death.   To the numer-
ous facts which are already contained in authors, we could, without
the slightest difficulty,  add a multitude of  others.   MAI. Gilbert and
Corby,  (Arch. Gen. de Med., X. XVII., p. 139,) Murat, Bard, &c,
have also added many to the list, and practitioners daily encounter
new instances.   The aorta was in this manner perforated in the cases
mentioned by AIAI. Laurencin and Leger or Alartin, by a piece of
six  livres.  It was  the pulmonary artery  in the patient of AI. Ber-
nest, and the trachea in the case  of Dupuytren,  (Begin, Journ.
Hebd., t. II., pp. 93—124.)  Routier, (Bull, de la Fac, X. IV., p. 499,)
speaks  of a five franc  piece which having become  implanted in this
manner, caused death  at the expiration of a month.  Dumortier has
in this manner seen the presence of a piece of money arrested in the 
FOREIGN BODIES IN THE OESOPHAGUS.
491
oesophagus cause a perforation of the primitive carotid artery. When
it is evident that  the presence of these foreign bodies may produce
injury, and that the organism alone is incapable of relieving itself of
them, three classes of resources may be had recourse to before pro-
ceeding  to  the section of the oesophagus.   They are to be pushed
down into the stomach, or obliged to return by the natural passages,
or we restrict ourselves to preventing, or combatting even with active
means, the accidents they may give rise to should they already exist.

                       § I.—Propulsion.

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

                       § II.—Extraction.

  When we cannot reach the foreign bodies lodged in the pharynx
or oesophagus  by means  of the fingers, we must have recourse to a
long forceps slightly curved,  or for example  to the urethral forceps
of Ravaton, erroneously denominated Hunter's forceps.  The species
of tenaculum or hook of iron wire of Riviere, (Bonet,  Corps  de Med.,
t. IV., p. 150,) or Perrotin, incurs  the risk of lacerating  the tissues
when it is withdrawn, as occurred to Petit of Nevers.  Stedman, by
terminating it with a button, has evidently improved  this instrument,
and Dupuytren, who  replaces it by a long silver stem terminated in
a ball at one end and a ring at the other, and who makes it an explo-
ring instrument or species of catheter in straightening it, and a hook
in curving it, has rendered it still more easy of management.
  A.  F. de  Hilden's hook, in  the form of a scraper, would be much
more dangerous.   That which Petit contrived, with a double flexible
silver wire,  turned into a spiral form, and curved towards its noose, 
492          NEW ELEMENTS OF  OPERATIVE SURGERY.

in the  manner  of Pellier's palpebral elevator, has no objection  to it
but its want of strength.   The probe or whalebone having upon it a
collection of small  movable rings, which was extolled by the same
practitioner, and  which De la  Faye  modified by restricting  himself
to the use of strands of flax attached to the small ring of the com-
mon stilette of the catheter, is also not to be neglected, when the
body to be extracted is irregular and of small size.
   B.  A  noose  of packthread  or  whipcord, which  Alauchart found
reason to be  satisfied  with;—1st, a sponge strongly  bound with
a thread, and introduced below the foreign body by means of a large
leaden canula, at  the end of which it is held, and drawing on the  two
extremities of the thread, which  are brought, one through the canal
and the other along the outer side ofthe instrument, as was done by
Brouilliard; 2d, the same substance  attached to the extremity of a
whalebone, as Willis recommends, or of an ordinary catheter, or that
leaden, or copper, or cribbled  canula, borrowed from  Arculanus or
Ryff, and modified by Hilden, who, in  order to render it stronger,
added  to it a leaden  stylet;  3d, the  sponge in  addition,  which
Hevin recommends, should be surmounted by a purse of cannepin
or silk, in order to prevent it from swelling before it had descended
sufficiently low  down, which Bonfils,  (Arch. Gen.  de Med.,  t.
XXIII., p. 530,) as well as  Petit, attaches to the extremity of a whale-
bone,, inclosed as  far up as to its handle in a flexible  tube, made of
silver wire, rolled  in a spiral manner, and which Quesnay covered with
sheep-gut, and Ollenroth hung to  the extremity of  a  chain chaplet,
composed of 61 balls of pewter,  might  also be applicable in certain
cases ; 4th, the same remark applies to the species of broom, whip, or
brush,  or excutia ventriculi, which had already been mentioned by
Wedel, Teichmeyer, and Heister, and which the English, who call it
provendor, form  by attaching  small  portions of scraped linen, or  a
bunch of hog's bristles, at the extremity  of a whalebone, or brass
lateen  Or wire.
   C. The manner of using these different instruments, whether for
the purpose of forcing the bodies  in  question into the stomach or for
extracting them,  is moreover too easily comprehended to make  it
necessary to dwell any longer upon  it.   The same remark  may be
made of their relative value  in the different  cases where many of
them may be advantageous.   It is for the skillful surgeon to select
which of them is best, the most simple, certain and least injurious
among those which he  has at command.   The species of forceps  with
several branches, which is opened and closed by a particular mechan-
ism, before and after having seized the foreign body, and which AI.
Missoux in his thesis in 1825 has  described under the name  gerano-
rhinque, is, though ingenious, too  complicated to  be adopted.   The
crane-beak,  designed  for seizing the foreign  body  while  another
curved forceps widens the walls of the canal, employed by M. Gen-
soul (Journ. des  Hop. de  Lyon, X. L, p. 233)  to extract a piece of
of cutlet, would be preferable.   That which Al. Blondeau (These, No.
44, Paris, 1830) proposes, and which is  founded on the principle of
litholabes and enclosed in a flexible sheath, would be equally prefer-
able if it was not already in itself too complex.  The  same must be
said of the ingenious apparatus devised  by M. Parant (Trans. Med.. 
GESOPHAGOTOMY.
493
t. VI., p. 72.)   The small dilating blade of AI. Doussault, (These, No.
41, Paris, 1831,) and  all those instruments which, after being intro-
duced shut up, open  themselves in the oesophagus in the manner of
an umbrella, are too  dangerous not to be replaced by the bladder
that Al. Oury (These, No. 290, Paris, 1833)  attaches  to the. end of a
sound, and does not dilate until after it has  been made to advance
below the foreign body, should that have presented sufficient resist-
ance to require it.
                             § III.

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

                 Article IAr.—QEsophagotomy.

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

                              §  L

  The incision of the oesophagus, performed for the first  time by
Goursault in 1738, and then by Roland, (Acad, de Chir., X. III., p.
10, in 8vo,  1819,) is  an operation which  is  applicable only  to  two
descriptions  of particular cases:  1st, when we  wish to extract a
foreign body which, by its presence in  the oesophagus, compromises
to a greater or lesser degree the life of  the patient; 2d, to introduce
artificially nutritive substances  into the digestive passages, and to
prolong to a greater or less length of time the life of those persons
who are prevented from swallowing by means of a coarctation of the
lower part of the  pharynx.   In  the first case, before proceeding to
cesophagotomy, we must make trial of every  means in order to com-
pel the foreign body  to be ejected by the natural passages, unless it
is of such a nature as to render it improper to force it towards the
stomach without  some danger.   Since  cesophagotomy has taken 
494
NEW ELEMENTS OF OPERATIVE SURGERY.
rank among the systematized operations of surgery, it has received,
like almost all the others, various degrees of improvement.  Guattani,
who was not unaware that the oesophagus is situated a little more to
the left than  to the right of the trachea, advises that we should take
up  a  transverse fold of  the skin and incise it from a line with the
cricoid cartilage as far down as to the sternum and upon the left side
of the neck ; separate  the lips of the wound by means of hooks; and
arrive gradually to the oesophagus, and  divide it in a direction paral-
lel  with its fibres.   According to  B. Bell there  can  be no settled
place for the incision, as it should always be performed upon the pro-
jection which is made  by the foreign body.  He knew moreover that
with certain precautions the recurrent nerve could easily be avoided.
   To be more certain  of dividing no vessel of any size, Richter re-
commends that the muscles  should be separated by means of an
ivory knife.  The method of Eckholdt, extolled for what reason I do
not know, by Sprengel, and  which consists  in making the external
incision fall upon the triangular space which separates the two roots
of the sterno-mastoid muscle, appears to me to deserve the oblivion
into which it has  sunk.   I would make the same remark of that of V.
Gescher, (Rus f s Handbuch der Chir.,X. XII., p. 281,) who recommends
that we should traverse the trachea to reach the oesophagus from
before backwards.   M. Chas. Bell'says, that if we place the thumb
on the track of the internal jugular vein, in order to cause it to dis-
tend while we are incising the skin, the platysma-myoides and ner-
vous  branches of the  cervical plexus, and that if we separate the
muscles apart by means of the handle  of a scalpel, the oesophagus
will soon  present itself, so to speak, of its own accord, and  that in
this manner, cesophagotomy is not dangerous; but this author is evi-
dently mistaken in regard to  the importance of a precaution of this
kind.   M. Richerand, who only  admits of cesophagotomy in cases
where the size of the foreign  body is so considerable  as to make a
protrusion  beyond the  surrounding  parts, and who justly  main-
tains that  it is almost always at  the entrance of  the canal of deglu-
tition  that these bodies become arrested, adopts, in every particular,
the process of  Guattani  or B. Bell.   In this hypothesis, in fact, the
external projection is  a  guide which directs with certainty to the
oesophagus, and which favors  the pushing aside  of all those organs
which it is important should be avoided.   An instrument which was
devised by Vacca  enables us to effect  the same object in all cases.
It  is a long metallic stem, terminated in a button, and cleft in the
form of forceps at one of its extremities.   This stem slides in a canula,
which has a large opening upon one of its sides at some inches beyond
its extremity.  The complete instrument is introduced, shut up, until it
reaches to below the foreign body.   The surgeon then draws gently
towards him the forceps, one of the  branches of which, acted upon
by its own elasticity, does not fail to get caught in the lateral  hole of
the canula, which served it as a sheath,  and thus raises upon the side
of the neck the different layers  which  are  to be divided.   But the
dart-shaped sound is infinitely more convenient still than the instru-
ment  of Vacca, if it be that we require a director when  we perform
cesophagotomy.  In raising  up all the  soft parts  to the left, and  in
front,  by  means of the  beak  of a sound, previously introduced 
03S0PHAG0T0MY.
495
nearly down to  the body to be extracted, as proposed by M. Roux,
the carotid artery, jugular vein, and pneumo-gastric nerve are neces-
sarily left posteriorly.   The thyroid vessels themselves, and the tra-
chea, are also sufficiently distant to prevent any danger in pushing
his dart-shaped  instrument from within outwards, and from making
use of it afterwards in the manner of a canulated sound, as in litho-
tomy.  Nevertheless  it  is unnecessary  to  proceed in this manner
blindfolded.  Nothing  prevents our dividing at first, layer by layer,
the different  tissues which  separate the oesophagus from the integu-
ments, and not  making  use of the sound except in the last stage
of the operation.  By this process cesophagotomy has no longer any
thing alarming  in it, or difficult, and may  be performed by every
surgeon.  If it were necessary, in fact, there would  be no objection
in substituting an ordinary sound for that of F. Come.

                   § II.—Operative Process.
                                   •
  The patient is placed  in the same way as for tracheotomy, except
that we  incline  his face a  little towards the right.   The surgeon,
standing  up, and to the  left, divides with a  straight  bistoury the in-
teguments and  platysma-myoides, to the extent of two or three
inches, upon the anterior border  of the sterno-mastoid  muscle, be-
tween the sternum and the larynx, and as much  as possible immedi-
ately opposite to the foreign body, the position of which he has  pre-
viously ascertained, by means of the blunt-pointed sound of Dupuy-
tren, the dart sound, or any other instrument.   Afterwards pushing
this muscle  towards the outside,  he  lays bare the omo-hyoid  and
sterno-hyoideus; pushes them  aside in their turn;  tears, by  means
of the beak of a canulated sound, or cautiously divides with the bis-
toury the fibro-cellular layers, in the same way as if he were  apply-
ing a ligature to the primitive carotid artery: then raises up  and
pushes inwards  and forwards the thyroid body.   Adopting the same
precautions until he comes down to the groove, which is  situated
laterally between the oesophagus  and trachea, he there encounters
the inferior laryngeal nerve.
  Having introduced his dart sound through the mouth, he causes its
point to pass through the oesophagus, as far down as to the bottom of
the wound ; secures it with the thumb and left forefinger; requests an
assistant to push forward its arrow;  directs  the point of.his  bistoury
upon the grooved concavity of this stem, and immediately makes an
incision into  the oesophagus, proportionate to the size of the body to be
extracted.  When we do not employ a director, we  must first open
into the canal on its side by a small puncture, which enables us im-
mediately to introduce a canulated sound into its interior, and after-
wards to  enlarge its wound by means of a bistoury or blunt-pointed
scissors.   If the substance to be removed does not present itself at
the opening which has just been made, we must proceed to search for
it by means of forceps  or  any other  appropriate instrument.   The
wound may be united  by first  intention.  If an  arterial branch of
some size has been wounded, a ligature is to  be applied to it.  A gum-
elastic catheter  must be introduced through  the nares or mouth, as
far down as into the stomach, and not be withdrawn from  it before 
496           NEW ELEMENTS OF OPERATIVE Sl'RRERY.

the third or fourth day, in  order that  the  aliments  and drinks may
not in any manner interfere with the agglutination of the wound of
the oesophagus, or escape  into the tissues  of  the  infra-hyoid re-
gion.   If cesophogotoiny, performed  on  the  thirtieth  dav by AI,
Arnott, (Gaz. Med., 1834* p. 45—Med. Chir. Rev., July, 1S33*. p. L>lO,j
to extract a portion of the  vertebra of a sheep, caused the death of
the patient at  the expiration of three  days,  two patients that were
operated upon after these precepts at the Val-de-Grace by AI. Begin,
(Journ. Hebd., X. XL, pp. 94, 111, 124,) one on the eleventh day,and
the other on the sixth, in order to extract a piece of bone, were per-
fectly restored.

                             § III.

   The anomaly pointed out by AIAI. Steadman, Kirby, Hart, Gode-
man, and Robert, as well as by myself, of a carotid or subclavian pass-
ing around the oesophagus in the manner of a spiral, or gliding under
its vertebral surface in order to reach the side of the neck, would not
expose to any dangers unless the operation  should be performed very
low down.
   [An iron-cellar key four inches long and one  in breadth at either
extremity, got lodged in the upper part of  the oesophagus, and  there
remained for the space of 58 days, giving rise to the supposition only
of a  protracted  tracheo-bronchitis, wasting away the strength, and
not materially  interfering with the swallowing  even of hard solid
food.   This occurred in the case of a woman  aged 42. described
by Dr. Ji. Jackson of Leith, (Edinb. Med. and Surg. Journ., July,
1843,)  the woman having designedly swallowed the  key to destroy
herself, yet  persisting in denying it to her death.  The block of the
key was  found resting close to the  epiglottis and on the hyoid bone,
the shank of the key and ring lying downwards in the oesophagus,
the ring  having  caught in  a  fold  of  the  lining membrane of this
tube, and which fold  constituted a  sac for it.   Some thickening of
the tube  was  apparent,  and a few slight  ulcerations.  Death was
here caused by irritation of the air-passages, not by dysphagia.
   Dr. Antony of Philadelphia, (Philadelphia Med. Examiner, April.
1845,)  ingeniously  removed  a fish-hook lodged in  the gullet, (and
which  a  boy had mischievously dropped with its line into the throat
of an  old lady while she was  asleep,)  by saving a  portion of the
line, and  passing  down by this means upon the  hook a bullet drilled
through the middle.   Then passing down  upon  this bullet by means
of the same string a hollow reed, the hook and bullet were withdrawn
through the reed without any injury to the parts.
   Foreign Bodies in the Integuments, Eye,  Spc—Dr. Bachelder of
this city, (see  Collins's New  York Medical and Surgical Reporter.
June  27, 1846, p. 303, &c.,) in cases of  needles, Sec in the palms
of the  hands and soles of the feet, operates with great success in the
following manner:
   " The  operation to  which I allude, and which,  as I have said before
and now repeat with emphasis, I have practised with uniform suc-
cess, is to  make  two  incisions, which  commence in a point a little
distance, say a quarter  of an inch,  from the  place where the needle 
w^
                        CESOPHAGOTOMY.                      497

entered, and  diverging on either  side  of the  place  of entry,  and
dissect up the triangular flap, whose base and sides should be about
five-eighths of an inch long.  It is  best  that  the point whence they
diverge  should be longitudinally in a line with the place of entry,
and on the proximal or distal side  of it, according to the supposed
direction in which the needle entered or lies.  These incisions, which
should of course correspond as nearly as circumstances will admit,
with the longitudinal direction of the member, may be carried down
to the  palmar or  plantar aponeurosis, and indeed  through either if
necessary, with safety ; for the  blood-vessels and nerves lie beneath
those membranes: and the dread of wounding the  fibrous tissues of
these parts  has long since ceased to haunt  the imagination of the
surgeon.  As  the resistance of those aponeuroses causes the fracture
of the needle  in most instances, to happen just exterior to them, you
will generally need only to dissect and turn back the  triangular flap
of integument, and  then if requisite, remove  with the dissecting
forceps and scissors the cellular  substance which intervenes between
it and  the aponeurosis, in order  to feel and extract  the foreign body
with the fingers or forceps.   If you do not succeed, the aponeurosis
itself may  be treated  in  the  same  manner as  the  tegumentary
covering.
  " As needles and pins have remained many years in the system—
have travelled in all directions, and been found in almost every part
except the  brain,  without having caused much harm  or serious in-
convenience, the question might be  asked whether  it is best to  inter-
fere at all, or  let them remain and  take their own course ;  to this
interrogatory  I would reply, that I  have also known  many cases in
which they were productive of very serious mischief, by undermining
the general  health, and nearly, if not quite depriving the patient of
the use of  the limb ; therefore always remove them  in the first in-
stance if practicable."
  M. Castelnau (Arch. Gen.,3e  ser., t. XV., p. 210, &c.,) relates the
extraordinary case of a man, who for three years and a half retained
a sharp, triangular fragment of  iron,  13  millimetres in length, in the
globe  of the eye,  without producing any other effects  than severe
pains in  the organ, but not  until two years after the injury occurred.
It then made  its way, but without  any suppuration, to the cornea,
where  it occasioned intense conjunctivitis.   It  was  readily  ex-
tracted, when the accidents immediately ceased.  The absence of the
suppurative process noticed by  M.  Velpeau in the  text, as the usual
consequence of metallic fragments  in the globe, is, when taken into
connection with the  unprecedented  size of the foreign body, and its
comparative innocuousness for so long a period, a remarkable feature
in this case. T.]
                              32 
498           NEW  ELEMENTS  OF OPERATIVE  SURGERY.
PART  THIRD.

    THE  CHEST.
                         CHAPTER I.

                            TUMORS.

     Article I.—Tumors and  Extirpation  of the Breast.

                        § I.—Indications.

  A. Compression, employed from  1809 to 1816 by Yonge, rejected
as dangerous in 1817 by the physicians of Middlesex, upon the report
of Chas. Bell, and proposed at a subsequent period by Pearson, has
since afforded to M. Recamier results which this practitioner considers
worthy of attracting attention in treatment of tumors of the breast.
Nevertheless this is not a reason for rejecting the operation properly
so called, or for not recurring to it but as an extreme measure as some
people seem to think. Many women cannot support compression, how-
ever well it may be made.  A great number of cases obstinately re-
sist its application, and nothing proves that it  has  ever cured a true
cancer.   Under the most fortunate circumstances, the assiduous cares
that it exacts are so fatiguing  in themselves, as to have given rise
to the question, if extirpation be not preferable  to it.  It is not, in
fact, as  an operation, that extirpation of the breast is dangerous, but
because  it is frequently followed by a return.  The amount of pain
that it produces is assuredly  less  than that  which results from  a
course of treatment whose duration cannot be  less than from two to
three months.  In an instant  the patient is  relieved of her disease,
and fifteen days or a  month ordinarily suffice to effect a complete
cure.   On the other hand there  is no reason for maintaining that the
return would be less frequent after the employment ofthe compress-
ing bandage, than  after the ablation of the scirrhus.  Experience has
already shown that when it becomes necessary to suspend the  com-
pression, before having entirely dispersed the  morbid  mass, the pro-
gress of  the cancer soon goes on with an increased rapidity, in such
manner that its development, though momentarily arrested, soon as-
sumes a more frightful  character than ever.
  B. As to the question  whether  extirpation is a remedy  which
sound practice ought to allow us to  make trial  of, I do not hesitate to
answer  in  the affirmative.   To Celsus, (Sprengel,  t.  VIII.,  trad.
Franc,  p. 422 ; Celsus, liv. V., chap, xviii., sect. 2,) who forbids the
cancer from being meddled with,  because it always returns ;  to
Albucasis, (Chir., lib. IL, s. 53 ;  Sprengel, VIII.,487,) who has never
seen the  operation followed by entire success; to Alonro, (Sprengel,
VIIL, 457,)  who says that out of more than sixty women whom he
had met  with, after this operation, four only had not had a return at
the expiration of two years ; to Boyer, also, (Mai. Chir., X. VII., p. 
           TUMORS AND  EXTIRPATION OF  THE BREAST.         499

237,) who, out of more than one hundred cases, could cite only a very
small number of radical cures ; to Rouzet, (Rech. et Obs. sur le Cancer,
1829,) who asserts  that he  has found in the annals of science but
verv equivocal evidence of permanent success; and to M. McFarlane,
who, out of one hundred cases, has not seen one effectual cure ; we
may oppose the evidence of Hill, (Cases in Surgery, Edinburgh,
1772,) who, put of eighty-eight extirpations, most of which were ulce-
rated, has met with  but twelve failures ; that of Schmucker, (Bibliot.
Chir. du Nord, p. 296,) who operated at the beginning of the disease;
that of B. Bell, who confirms the accuracy of Dr. Hill; and that of
Dr. North, quoted by Dorsey, (Elements of Surg., &c, vol. IL, p. 4,)
and who, out  of one hundred  examples, noticed but  a very  small
proportion of a  return of the disease.  MM. Richerand, Roux and
Dupuytren,  and before them Sabatier, on their part, had  evidence
that cancer  is far from repullulating always,  when  the extirpation
has been  made in time.  My experience  also  shows  that many pa-
tients operated upon at Tours by M. Gouraud, at the hospital of St.
Louis by M. J. Cloquet, and at the hospital  of the School of Medicine
by AIM. Bougon and Roux or myself, since the last  12, 8, 6,4 and 2
years, continue to enjoy good health.
  C. Cancer ofthe breast is not the external sign ofa general disease,
as Delpech  maintains, at least in  most cases, except  at quite an ad-
vanced period of its development.  In the majority of cases, it  is at
first only a local affection, but one which tends constantly to pervert
the fluids and solids to such  extent  as to be soon reproduced on one
region or another, although it may have been entirely destroyed at
the part where it appeared to be  situated.
  Consequently nothing can be more dangerous than to shrink from
its ablation  under idle pretexts ; and compression, which is necessa-
rily less efficacious, would not be proper to be had recourse to, except
in timid persons, or such as from  any cause whatever were not wib
ling to submit to the action of the bistoury.   If general and local treat-
ment possess any value, the operation, which is in no respect incom-
patible  with their employment, cannot but  favor their success.   We
should be wrong even to allow ourselves to be deceived by the  pres-
ence of certain glands at the hollow of the axilla or in the supra-clavi-
cular region.  These glands may have preceded the scirrhus, or been
produced by it without participating in its character.  Bartholin, Bor-
rich, Assalini and Desault, (Sprengel, Hist, de la Med., X. VIII., pp.
439, 440,) have seen them disappear spontaneously after extirpation
ofthe cancerous breast.  The same fact has been frequently noticed
in these latter  times.  This result took  place  in 1825, in  a woman
operated upon by M. Roux, at the Hospital  of Perfectionnement, and
who had a chaplet of indurated glands extending from the side of the
neck down into the hollow of the axilla.   Nor does a slight yellowish
tint, or  the commencement of what is called the  cancerous diathesis,
always form an absolute counter-indication.  Morgagni,  having to
treat a patient in this condition, ventured to extirpate in spite of the
formal advice  of Valsalva.  The cancer returned at the end of five
years;  Morgagni  again operated  and the disease  was not repro-
duced.   The adhesions of the tumor to the ribs  considerably dimin-
ish the chances of success, but do not render it absolutely impossi- 
500           NEW ELEMENTS OF  OPERATIVE SURGERY.

ble.   The operation therefore should be performed in all cases where
the last roots of the'disease may be extirpated without occasioning
too great a loss of substance, and where there is no evidence to show
that it exists in the other organs.

                    §  II.—Operative Processes.

   It is to the barbarous processes used at different epochs by various
surgeons, that we must look for an explanation, if the removal ofthe
breast still  occasions so much alarm to people in general.
   A.  Cauterization of the wound with the iron heated to a moderate
red heat, already mentioned in the writings of Galen ; the precept
of Leonidas,  (Aetius, tetr. 4, serm. 4, cap. 43; Sprengel, 8, 42'A.) to
bum after each cut of the bistoury the bottom ofthe wound in order
to prevent  hemorrhage  ; or excision with the knife heated to a white
heat, or when the cancer is adherent, by means of a blade of horn
which has  been dipped in  aqua fortis, as prescribed by J. Fabricius,
(Op. Chir., p. 1, cap. 49; Op., 19fJ;  Sprengel, 8, 436,) must necessa-
rily have been attended with excruciating pain. The process of Scul-
tetus, (Armam., p. I., p. 22,  tab. 24, 36 ; Sprengel, 8, 441,) which con-
sisted in introducing two threads crosswise through the tumor, in order
to raise it  up and excise it with a single cut of a large concave bis-
toury,  and then to cauterize the entire bleeding surface with a plate
of red  hot iron ;  that of Purmann, (Chir. &c, t. IL, chap. 6, p. 144;
Sprengel, 8, 444,) who  added  to these  threads a ligature strongly
tightened upon the root of the  disease with the view of benumbing
the parts;  those of Nuck, (Obs.  et Exper. Chir., p.  101;  Spren-
gel, 8,  445,) who used a double hook and a falciform knife ; of Dio-
nis, (Oper.  de Chir., demonst. XL, fig. 28,) who commenced by
plunging into the cancerous mass those famous Helvetian forceps of
which so much was said at the commencement of the last century;
of Hartmann, (Barbeu,  These de Haller, X. I.,)  and Arylhorne, (])■•
Cancro. Mam., &c. ; Haller,  2, 449 ; Sprengel, 8,  453.) who after
having strangulated the schirrus at its base, secured  it still farther by
means of a  sort of veterinary pincers, (moraille,) and then with the
bident of Helvetius, while  its excision was effected  by a mechanical
instrument of their invention ;  and of Schmucker, (Chir., &c, lib.
IL, p. 51 ;  Sprengel, 8, 471,)  who after having laid open the skin
pressed the tumor in order  to make it protrude, introduced into it a
species of  awl slightly curved, and then  separated  it from the sur-
rounding parts ;  were  also well  calculated  to create  such appre-
hensions.
  B. Those who caused the separation of the tumor by surrounding
it with a ligature saturated with aqua fortis, or who having entirely
or partially excised it in one way or another, made use of the re-
peated applications of arsenic, orpiment, potash, butter of antimony,
&c. ;  and those who cautiously  dissected all the surrounding vessels,
in order to place a double ligature on each of them, and to  divide
them without danger in the interspace of the two threads before re-
moving the cancer, or  who  after the  incision of  the  integuments
made use only of their fingers, and terminated the operation by tear- 
           TUMORS AND  EXTIRPATION OF  THE BREAST.         501

ing out the tumor, presented no arguments for changing public opin-
ion upon this subject.
  C.  At the present day, when extirpation of the breast is reduced
to its greatest simplicity,  there is  nothing  in it which is alarming or
in reality severe.
  I. When the skin is in no  respect diseased, nor the tumor of a
large size or adherent, the surgeon confines  himself to dividing  the
common integuments, taking care  to  give  to the incision  all the  ex-
tent required,  and to cause its lips to be separated apart,  while with
an erigne, or even with the ends of his fingers, he draws the scirrhus
to the  exterior,  and with the  other hand armed with a bistoury,
destroys all its cellular or vascular attachments.   When  the patient
possesses a certain degree of embonpoint, or that the breasts are  na-
turally greatly developed, though  the carcinoma may be clearly cir-
cumscribed ■ and preserve  all its mobility, there is  some advantage in
not being so sparing of the skin, and in excising even an ellipse from
it of greater or lesser  extent.   The operation is thus rendered more
easy and more prompt.   Its success  also then becomes more proba-
ble, for the lips of the wound, which are then moreover cut almost in
a uniform manner, are placed under more favorable conditions  for
exact coaptation, than if all the integuments had been preserved.
  II. If the skin itself is comprised in the  disorganization, or red,
or too  attenuated eyer to acquire its "primitive  characters;  or if it
adheres by its deep-seated surface to the  morbid mass, we  are still
compelled to adopt the same  precept, and to include the entire dis-
eased portion  between two incisions,  which should always embrace
a certain extent  of sound parts, that is, between two semilunar in-
cisions, as recommended by Zeller and Kern, (Rust. Handb.de Chir.,
vol. VI.) In conclusion, it is much better  to remove more than less,
provided we leave enough to allow of reunion of the wound by first
intention.  The   circular  incision  adopted by the ancients, and also
by Dionis, is essentially  objectionable.   It makes a wound which is
difficult of cicatrization, and the loss  of substance which it produces
is much more considerable than by any other mode.   It  can be  ap-
plicable only to globular tumors, which are as it were confounded with
the skin upon their anterior surface.,  It would be under such circum-
stances, that we might, after the  example of M. Fardeau,  (Journ.
Hebd., 1835, t. IV., p.  110.) by means of a knife introduced through
the tissues between them  and the chest, detach the tumor  first abov^e
and then below7.   The elliptical incision which was already used by
Paul of Egina, (Sprengel, t. VIII., p. 425,)  and afterwards by Chesel-
den, (Observ., &c, 1749 ;  Sprengel, t. VIII.,. p. 452,) &c, is the most
convenient of  all.  The  crucial incision preferred by Palfin  (Spren-
gel, t. VIIL, p. 450,) and Heister, (Institut. Chir., Sprengel, t. VIIL,
p. 451 ;) and the T  incision  employed by  Acrel, and even  by Cho-
part,  (Sprengel, t. VIIL, p. 475,)  evidently possesses fewer advan-
tages, and would be applicable only in certain particular cases.
  D. Some with Gahrliep and  M. C. Bell,  place the great diameter
of this incision from above downwards; others prefer that it should
be transverse; while the  precept of Pimpernelle, recommended  ac-
cording to Sprengel by Verduc, and which consists in placing it  ob-
liquely from above downwards, and  from without inwards;  that is 
502           NEW ELEMENTS OF OPERATIVE SURGERY.

to say, in the direction of the fibres of the pectoralis major, is gene-
rally adopted  by the modems.  The  advantage of being enabled to
apply the uniting means with more facility in the first  case, is more
than counterbalanced by the risk of dividing the muscular fibres per-
pendicularly, and of not being enabled to bring to the outside the ster-
nal portion of the integuments but with much difficulty.   The second
process  would incur  the risk of the same inconveniences, without
which enables us to employ the adhesive straps, as well as any other
presenting the same advantages.  Consequently the  oblique incision,
process,  and which leaves intact the fibres of the pectoralis major,
deserves the preference which is now accorded to it.
   E.  In  a case of necessity, all cutting instruments are  applicable to
this operation.   We could, if so disposed, succeed with a razor or
amputating knife.   The bistoury, with a  broad and square-shaped
point, devised  by A. Dubois with a  view of avoiding the chest with
greater certainty, is neither better nor worse than any other.   The
ordinary straight bistoury, or better still the convex, is the one which
is  usually employed.   In order  that  the  blood of the  first incision
may not  interfere with the execution of the second, we begin in con-
formity with the indication laid down by Palfin, and afterwards by
Desault,  by the lowest.   Nevertheless, when the  section of the in-
teguments has been once effected, there  is some advantage in dis-
secting the tumor from above downwards.  In the opposite direction
the lower or outer border of the pectoralis major would  be  much
more  exposed to the action of the bistoury.  No one  moreover at
the present day recommends with Home, (Sprengel, Hist,  de la
Med., X. VIIL, p. 440,) Lapeyronie. (Ibid.,  463.) and Le Dran, (Ope-
rations, p. 375,) that we should commence by a semilunar incision,
and not complete the ellipse which  is to represent the  wound until
after having detached the cancer always  in the same direction, or,
terminate by dividing the skin  from  the deep-seated parts towards
the exterior, as recommended by M. Galenzowski.   This manner of
proceeding however has no other defect than that of giving less reg-
ularity to the termination of the  operation,  and of incurring the risk
of destroying too great or too small an extent of the cutaneous tissue.
   F.  When the loss of  substance is considerable, and to so great an
extent as to render the coaptation of  the borders of the division im-
possible,  or at least very difficult,  it has  been proposed to isolate
each lip of the wound from the subjacent parts, to  the  distance of
one or several inches, hoping by that means to remove all the ob-
stacles which  are opposed to their approximation.  This is  a modi-
fication,  the value  of which,  in  my  opinion, has not hitherto been
fully appreciated.   By means of this process we should always have
a sufficiency of skin to unite the wound by first intention ; the integu-
ments are then borrowed from  the surrounding parts,  and the pro-
cess must always  be a precious resource in  cases where we have
been compelled to  destroy a large portion ofthe cutaneous envelope.
Under the chapter on anaplasty, I have stated what value ought to
be placed under such circumstances upon the different  descriptions
of autoplasty, and especially of the process  that M. Alartinet (Gaz.
Med., 1834, p. 657) appears to have employed.
   G.  The small arteries  that are divided  belong  to  the external 
           TUMORS AND  EXTIRPATION OF THE BREAST.          503

mammary, the superior thoracic, the internal mammary  or the inter-
costal arteries.  Those that we meet of the largest  size, and which
we must first attend to, are always towards the outside.  In placing
a ligature upon  them in proportion as we divide  them, there is no
danger that they will retract and escape into the midst of the tis-
sues, nor that the action of the  air will  prevent  our finding them
a^ain subsequently ;  but the operation in this way  becomes more la-
borious and protracted.  Unless they should be too  numerous or very
large, I prefer making use of the fingers of an assistant to close their
orifices at the moment that they are divided  by the bistoury.  Should
there be any which cannot be found after having cleansed the wound,
they are generally too small to occasion the  slightest inquietude.   In
the contrary case, it would be so easy to  establish upon them a point
for  indirect or direct compression, that  in  this respect we  have in
reality but little to apprehend. Even when we unite by first  inten-
tion, ligatures are far from being always indispensable.  Theden did
not make  use of them;  and Petit ordinarily dispensed with  them.
D'Arce  and Aranhorne, who  also omitted them, tore out the tumor
with the fingers, and only used the  bistoury for dividing the integu-
ments.  I  have frequently dispensed writh  them,  and among other
cases, in that of a young woman in whom I had removed a scirrhous
mass as large as the fist.   Prudence, however,  requires that we
should tie or twist all those which may be  recognized; and that if
there be any that escape the researches of the surgeon, the dressing
should be carefully watched during the space of a day or two.
  H. The precaution of not definitively dressing the  wound until
after the expiration of some hours, in order  to give time for the cen-
trifugal  action of the vascular system to become established, and to
make manifest the arterial mouths which are to be  closed, would pos-
sess the serious inconvenience of worrying and  tormenting- many
patients, and of being at the least unnecessary.  At  the present day
it would be absurd  and barbarous  to dissect, as has been recom-
mended, and  afterwards to excise all the veins that go to the breast,
or only to compress or agglomerate (masser) them by means of the
fingers, in order to extract or expel  from them that .black or atrabil-
iary humor which the ancients had so much dread of.
  I. Immediate  union, which was indicated by Paul and Gahrliep,
and lauded by Nannoni, who confined himself to  approximating the
lips  of the wound,  and also by Cheselden and Garengeot, who  em-
ploy the suture, and which has been adopted by almost all the mod-
erns, nevertheless finds  some opponents.   The objection made  to it
is that it interferes with the issue of any matters that  may form at
the  bottom  of  the  wound,  and  of being  frequently  followed  by
phlegmonous  erysipelas, and consequently that it may jeopardize the
success of the operation.   These  formidable accidents, especially in
fat  or cachectic women, will be in most  cases  avoided, if no void is
left at the  bottom of the wound, if the coaptation is more exact near
the muscles than towards the skin, and if the containing means act
principally upon the deep-seated  parts, and not exclusively upon the
cutaneous tissue; if in a word we take  care to reserve an opening
at a depending part for the escape of the fluids.  Moreover,  as  it is
almost next to impossible to obtain perfect primitive  reunion, perhaps 
504
NEW ELEMENTS OF OPERATIVE  SURGERY.
it would be more prudent to treat the wound by secondary imme-
diate union.  As  to the suture, though again warmly recommended
by M.  Serre, I should not venture to recommend its employment in
these cases, until  after having seen results from it more fortunate or
more conclusive  than those which it has given me up to the present
time.   It evidently renders  the operation more painful.   Except in
certain cases, where the skin is so attenuated that  after being dis-
sected  it has  a tendency to roll up upon itself, adhesive plasters, or
the simple bandage, may be  perfectly well substituted for it.   AI.
Chaumet, (Journ. des  Conn.  Med.-Chir., t.  V.,  p. 117,) who gives
three  examples of it and eulogizes it, says that the cure in his  first
patient was effected in 52 days, in 15 days in .the  second, and in one
month  in, the third; but since without  its employment we may, in
reality, accomplish the cure in the  space of ten  to  twenty days, I
cannot see what advantages it would possess.

                   § III.—Operative Process.

  Though we may, as many practitioners do, support the patient on
a chair while we  are operating upon her, there are nevertheless in-
disputable advantages in placing her in a recumbent posture, either
upon the  bed or  upon an operating table.  The  syncopes are then
much less to  be apprehended, and the surgeon is in fact much more
at his  ease.   The head and chest are to be sufficiently elevated, to
make the breast project as much as possible.   The pelote which Bid-
loo directed to be placed in the axilla, in order to push the breast for-
ward while the arm was  directed backwards, would not deserve to
be mentioned, if M. S. Cooper had  not  recommended a precaution
which  is somewhat analogous and not less curious: he advises that,
in order to keep the arm  separated  from the trunk, to command the
movements of the patient, and to force  the pectoralis major to be-
come stretched, a baton should be fixed upon each side in the hollow
of the  axilla,  between the chest and the limb !
  A. A second assistant raises up the tumor with  one hand, and with
the other  sponges up the  blood in  proportion  as it runs out.  The
surgeon makes traction upon the skin in an opposite direction; com-
mences with  the lower semilunar incision ; then depresses the mass
to be removed and stretches the integuments above;  applies the bis-
toury to the outer angle of  the first wound;  and makes the upper
incision by conducting it to the other extremity of the lower division,
and in  this manner completes his ellipse.  He then seizes the scirrhus
or causes' it to be  grasped, dissects it  freely, first from below upwards
and then from above downwards ; proceeds in such manner that the
tumor  may continue surrounded by a margin of sound tissues  and
not be  elevated exclusively; cuts down to, or ought not to fear cut-
ting down to, the  muscular fibres, and  even as far as to the ribs of
the  thorax, should the extent of the disease require  it.
  B. If, as I  prefer, unless  there should  be large arteries that they
should not be tied, the surgeon directs  them  to  be closed with the
finger  in  proportion as the bistoury divides  them, and may in this
manner terminate  in a few  seconds  the  ablation of a breast of the
largest volume.   Upon the  supposition  that some morbid layers or 
           TUMORS AND  EXTIRPATION OF  THE BREAST.         505

peletons have at first escaped the instrument, we must afterwards re-
turn  to  them without delay.  When they belong to the soft parts,
they  are to be excised by the bistoury or the scissors, and should the
bones be affected, the rasp might become necessary.  Having arrived
at this point we should not even  hesitate to exsect one or more por-
tions of the ribs, should  it appear that their removal would enable
us to destroy  all the parts diseased; but if before  commencing, this
change had .been indicated  by any sign, it would in my opinion be
much better not to undertake the operation.
  C. If there should be found in the arm-pit, glands which create
some apprehension, they are  when not too remote  to be laid bare by
prolonging over them  the external angle of the wound.   In the con-
trary case it is better to  cut down to them by means of incisions in-
dependent of the first.   Their position, which is  calculated to pro-
duce some alarm at first view, nevertheless allows of their being ex-
tirpated in almost every case without the slightest danger.  They
are in fact almost always constantly found upon the outer surface of
the serratus magnus, so that  in order to separate the brachial plexus
from them, we have only to raise up the arm and to hold it at a slight
distance from the  trunk.   Nothing moreover is easier, when we are
under an apprehension of wounding  any vessels of considerable size,
than to embrace  their pedicle with a  ligature  after having isolated
them in a proper manner, and  then to excise them  external to the
thread.  This practice, which had already been recommended by J.
L. Petit and Desault, and which Zang and Dupuytren adopt, deserves
to be retained.  As to the division of the veins it  is rarely alarming
in respect to hemorrhage.   I  have  seen  the axillary vein itself
wounded during an  operation of this kind, and tamponing suffice for
the effectual arrestation of the effusion of blood.
  D. If, after having cleansed the wound and the surrounding parts,
the operator is desirous of attempting immediate reunion, he gently
approximates  the  borders of the division and keeps them in contact
by means of the thumb and forefinger of each hand, while the assist-
ant applies the adhesive plasters.  In general, the longer the adhesive
plasters are, the better.  Being stretched over a great extent of sur-
face, their action becomes much  less irksome at the cutaneous divis-
ion, while they are kept on infinitely better than if they were short
and more  numerous.  Some persons, however, allege the contrary,
and Prof.  A.  H.  Stevens of New York, among them, recommends
that they should be as short as possible.   It is necessary that they
should cross the wound at a right angle.  When the loss of substance
is considerable, or that it  becomes difficult to bring the  integuments
into coaptation, there is an advantage in attaching them behind the
sound shoulder and then  bringing them above the clavicle and con-
ducting  them to bslow the axilla or upon the diseased side.  We
begin with those  of the  middle and  finish with those at either end.
Their number should  vary according to the extent of the wound, in
front of which they are to form a kind of grillage sufficiently close.
A plumasseau besmeared with cerate, and one or two gateaux of dried
lint with long compresses, supported  by a body bandage or the cir-
culars of a long  band, passed  moreover  once or twice  in the  form 
506
NEW ELEMENTS OF OPERATIVE SURGERY.
of a quadriga around the shoulders, complete the dressing, when the
patient is immediately removed to his bed.
  E.  AVhen we cannot, or do not wish to attempt immediate reunion,
adhesive plasters are  generally of no use.   We then surround the
wound with  bands  of linen  besmeared with cerate,  or we cover it
with  a  fine linen uniformly imbued with ointment and perforated, in
order that the lint which  is  to be placed  over this may be easily
removed at the first dressing.  If afterwards there should appear the
slightest vegetation or tubercle of doubtful character, it should be
destroyed without hesitation  and as quickly  as possible, either by the
cutting  instrument, the red hot iron, zinc paste, or any other caustic,
such, for example,  as those recommended by La Poterie, F. Come,
A. Dubois, &c.  I will add  no remark  in this place  to what I have
already said  of caustics  in the chapter which  is devoted to them in
this work artcf under the  article on tumors.  The cancers which pre-
sent,  in this respect,  the least hope of success, belong especially to
the cerebriform, melanotic and scirrhous tissues.  Those which seem
to be, and are in fact, prolonged into the surrounding cellular tissue,
by a number of divergent radii or roots, are the most formidable of
all, and  rarely fail to be reproduced ; while on the contrary, the extir-
pation of colloid cancers, and hydatiform, encysted and tuberculous
tumors, is quite often  followed by a radical  cure.
  F.  If the case is that of a man, as in the examples related by Bar-
tholin and MAI. Sedillot  and  Petrequin, and  in those which belong to
myself,  the operation should be nevertheless performed after the same
rules.   But in cases of cysts,  whether milky, like those mentioned by
Volpi, (Nelaton, These, 1839, p. 48,) M. Cumin, (Trans.  Med. Chir.
of Edinburgh,  p. 594,) &c, or  sanguineous,  or  sanguinolent, or
serous, purulent, or hydatid,  or osseous and mucilaginous, like those
which I have elsewhere described, it would be better, unless there
should be  a considerable number of them,  to treat them  with injec-
tions of iodine or by incision, and even simple excision,  than to attempt
their extirpation.  I have only to refer, moreover, for  what relates to
the different  kinds of tumors  of the breast, to what I have said of the
processes that are applicable  to tumors in general, and also to my spe-
cial memoir (Traite des Mai.  du Sein., Paris, 1838,) upon this subject.

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

  The  cases, first of  a  hypertrophied mamma weighing sixty-four
pounds, observed by Durston, (Nelaton, These de Cone,  1839, p. 5,)
another which weighed twenty  pounds, as mentioned  by AI. Ko-
ber,  (Ibid., p. 7,) the  three  examples of gynecomasty,  noticed in
man by M. Bedor, (Ibid., p.  17,) those of osseous tumors described
by Morgagni, Bidloo,  Wolf and Cooper, of tuberculous masses extir-
pated by AI. Gerdy, (Ibid., pp.45—47,) of milky calculi encountered
in animals by Ruysch and  Morgagni,  and in man or  woman by
Rufus, Bassius, Kulm, Morgagni, Dupuytren, (Ibid., p. 59,) &lc, will
have  to be  added  to those  which I myself have related.   A vast
erectile tumor, which  occupied the side of the chest and the hollow
of the axilla, was extirpated with success by Marechal, (Arch. Gen. 
EMPYEMA.
507
de Med., t. XXVIIL, p. 149.)  Having treated in detail, in the chap-
ter on loupes and other tumors, of tumors upon the  thorax and in
the  axilla, it is  unnecessary for me to recur to this subject in this
place.
                        CHAPTER II.

                EFFUSIONS INTO THE THORAX.

                    Article I.—Empyema.

                       § I.—Indications.

  The operation of empyema,  performed in the remotest period of
antiquity, owes its origin, according to fable, to the despair of Phales
or Jason, who, seeking death in the midst of battle, received the thrust
of a lance in the chest, and was thus relieved of an empyema, of
which no person had ventured to undertake the cure.  Galen alleges
that in Greece it was performed by plunging a red hot iron through
the  thorax.  At  the time of Hippocrates, after having satisfactorily
ascertained the existence of a collection, an opening was made into
one of the lowest intercostal spaces  with the  bistoury or a  large
lancet protected by linen wrapped around it.  Others,  for fear of
evacuating all the liquid too rapidly, perforated  the fourth rib by
means of a trephine, and then closed up the hole with a plug or tent.
  The Arabs appear to have  proceeded  in  the same manner in this
respect as the Greeks and Romans.  Among both it  is perceived
that the operation for empyema, first  recommended and employed
without repugnance by most practitioners, ended in being no longer
recommended by any person.  Paul of Egina, among the first  class,
recommends that it should be replaced by cauterization of the thorax,
and Haly Abbas, among the second class, formally rejects it.  G. de
Salicet and Guy de Chauliac speak of it with extreme dread.  A.
Benedetti, J. de Vigo, and Pare did not succeed but in temporarily
rescuing it from the discredit into which it had fallen, and it required
all the efforts of J. Fabricius to bring it again into repute; so that it
is only in reality during  the last two centuries that its advantages
and inconveniences have  been discussed, and that it has  again at-
tracted the attention of surgeons.
  A.  Sanguineous Effusions.—Whether the blood which has  accu-
mulated in the  pleural cavities  proceeds from the  intercostal arte-
ries, or from the  deeply situated vessels, whether it proceeds  from a
traumatic lesion, a perforating wound, or a spontaneous laceration,
or whether it be  arterial or venous, the dangers nevertheless which
result from it, and the remedies to be employed for its relief, are
nearly the same.  The advice that we should immediately proceed
to the extraction of the effused  liquid, either by placing the patient
on the wounded side, by enlarging  the wound, or  by making use of
the  mouth, a cupping-glass,  or  a syringe,  to suck out the fluid as it 
508
new elements of operative surgery.
were with a  pump, far from  being advantageous, appears on the
contrary to be extremely dangerous.  Is it not moreover probable,
that after the first hours, and until time shall have been given for the
blood to become again liquefied, it will be found in  part at least in the
condition of clots in the chest, and that in such cases it would be
impossible to  extract it by a puncture?  The vessels wounded can-
not be  obliterated or  closed up except  by means of clots more or
less solid, and a  greater or  less degree  of strong  compression.  If
in place of being retained in the chest, the blood escapes to the out-
side by this compression, the clots will not be made to form and the
hemorrhage will end only in death.   Reason therefore instructs us
to close up the wounds of the chest  immediately at first, in place of
dilating them, and to imprison the extravasated blood in the interior
instead  of procuring  an exit  for it.   If the effusion is inconsiderable,
it will generally be removed by absorption; in the contrary case, its
source cannot be surpressed but by  itself and by the mechanical re-
action which it soon exercises against the wounded organs; so that
the operation for empyema is under no circumstances proper for
recent traumatic  hemorrhages of the thorax.  Some facts  collected
in the time of Vigo and Pare, a passage in Francois d'Arce, another
in G. Horst, and  the remarks of Sharp, and especially of Aralentin,
would have naturally  led to this  suggestion ;  but it was  reserved
for A. Petit and M. Larrey  to have  the honor of demonstrating and
satisfactorily establishing, that the   first indication in  perforating
(penetrantes) wounds of the chest, whether with or without effusion,
is to close them up immediately.   If afterwards the system, aided by
judicious general treatment, should  be found incapable of effecting
the dispersion  of the .morbid collection; or if when  the wounded
vessels  have had  time to  become obliterated, this collection threatens
in itself to give rise to serious accidents, it is then allowable, but only
under such circumstances, to have recourse to the  operation, and to
perform what is denominated  a counter opening.   The  memoir of
M.  Priou, on wounds of  the chest, (Mem. de VAcad. Roy. de  Med.,
t. I.,) will give the reader every information necessary on the sub-
ject of effusions of blood in the thorax.
  B. Effusions of Pus.-^-As purulent collections in the chest are far
from constituting always the principal disease, the operation for em-
pyema  in such cases, in  its  turn, is  far from being always a source
of any  great benefit.  If they have originated from a tuberculous
vomica, or any other incurable lesion  of the  pulmonary organ; if
they are the product of  a deep-seated alteration still existing in the
heart or pleural  linings,  we should, by giving  exit to them, only
hasten the death of the patient.   If,  on the contrary, they have been
caused  by a simple  phlegmasia, or  pleurisy for  example, or by «"-"
abscess in the lung which has  made its  way into  the pleural cavity,
the operation presents some  chances of success  and  ought  to be
made trial of.   A vomica opened into  the pleural cavity and ulti-
mately  presented itself at the left hypochondrium.  The pus which
flowed out from this  part in  abundance, was also ejected through the
bronchi.  When  the patient vomited the wound  in the side closed
up;  but when, on the contrary, the pus issued at the hypochondrium
the vomiting was arrested,  and this condition of things did not ter- 
EMPYEMA.
509
minate until after the expiration of fifteen months.   I have met with
two other cases of this description, and MM. Jaymes, (Journ. Gen.
de Med., X. 48,) Roc, Wioley, and  Davies (Revue Med., 1836, t. IL,
p. 260,) have mentioned other similar ones.  A peasant in the envi-
rons of Tours, operated upon in 1814 by M. Gouraud, was perfectly
restored.  Freteau, (Journ. Gen. de Med., X. XLVIL, p. 121,) Ollen-
roth, (Dict.de Med., 2d edit., t. IL, p. 431,) and Audouard (De I'Em-
pyeme, &c, 1808,) were no less fortunate.  In the cases under  con-
sideration the effusion approximates in its character  to external ab-
scesses.  The organism, in most  cases, has adopted the precaution
of surrounding it with adhesions, which more or less accurately cir-
cumscribe its limits; from whence it  happens that after an opening
has been  made,  the remainder  of the pleura has nothing to appre-
hend from the contact of the air.   In proportion  as it is evacuated
its walls may collapse  upon themselves, and soon completely close
up the void.  The  same remark, moreover, is applicable to sanguine-
ous effusions, which almost always also ultimately become contracted
to more or less circumscribed dimensions, under the influence of the
adhesive inflammation ofthe surrounding surfaces.
  C. Effusions  of serosity.—Serous effusions  do  not present  the
same chances of success.  The surfaces which supply them  are  not
sufficiently irritated, at least in general, to  contract adhesions with
each other.   The lung gently pushed back towards its root, and soon
deprived of all permeability, is then incapable of resuming its natural
dimensions,  and  the chest being once opened into, may  place  the
whole  extent of the pleura in contact with the  air;  so that many
surgeons, in such cases, reject  even  the very idea of the operation.
Nevertheless if all  the  means that reason or experience point out
have  been tried in vain, if it be not  positively ascertained that an
incurable organic lesion is the cause of the effusion, and if the alarm-
ing symptoms and suffocation threaten  the life of the patient, the
operation  of empyema is a last resource, which it would be unjusti-
fiable  not to perform.   M. Gouraud effected a remarkable cure by
it in 1808.  We  owe one also to M. Tuson,  (Lond. Med. Gaz., June,
1837, p. 396,) who,  in this manner, extracted nine pints of liquid from
the thorax after a  pleurisy.  M. Caffort (Private  Letter, October,
1837,) informs me that he has succeeded in four cases out of six; and
scientific collections in various places, contain other  examples, which
I shall  shortly speak of.  The  artificial  subtraction of a portion of
the effused liquid,  so actively promotes absorption in the pectoral
cavity, that several practitioners have considered that the  operation
of empyema should be laid down as a rule after pleurisies whose re-
solution can be no longer hoped for.  It must be confessed, however,
that it rarely succeeds  under such circumstances.  The patient men-
tioned  by M. Martin  Solon, (Journ. Hebd., 1830,  t. II.,) who  de-
clares himself its advocate, perished.   The same was the case in the
patient operated upon in 1830 at La Charite, and with the one whose
thorax was opened into at the hospital of St. Antoine, while I was in
service there.
  D. Effusions of Gas.—The presence of air or gas in the interior
of the pleural cavities, which so many physicians have noticed since
Itard made it the  subject of an interesting memoir, whether it be 
510           NEW ELEMENTS OF OPERATIVE SURGERY.

caused by the laceration of a pulmonary cell, the decomposition of
certain liquids or by a pure and simple exhalation, is also one of those
cases which  might possibly  require  the perforation  of  the  thorax.
Riolan and H. Bass have had evidence of this in patients in whom
the chest, instead of the pus they expected to find there, contained in
reality nothing but air.  The researches of A. Alonro and  Gooch,
and  especially of Hewson, leave not the slightest doubt upon  this
subject.   Nevertheless it  is not to be forgotten that under such  cir-
cumstances it is a  symptom of but trivial  importance in itself, that
may disappear spontaneously, and that if it is accompanied with a
deep-seated organic alteration, the operation of empyema will afford
but temporary relief.

                      § II.—Appreciation.
   The successful results obtained from the operation for empyema,
moreover, are very numerous  at  the present day.  Besides those
above, Baillou, (Bonet, Corps de  Med.,  X. IY., p.  558,) who made
his incision between the fifth and sixth ribs, also mentions one; Alar-
chettis (Ibid., X. III.,  p. 247) mentions two;  and  Rey,  who left a
canula in  the wound, two others.  We are indebted also  for two to
M. Martini  (Bull,  de  Fer., X. VII., p. 162;) for  one  to  M. Norfini
(Ibid., X.  XVIL,  p. 648;)  three to M.  Herpin  (Precis  d'Indre et
Loire—Gaz.  Med., 1833, p. 417 ;) three to M. Reybard, (Arch. Gen.
de Med.,  X.  XVIL, p. 648.) and two to MAI. Tourdes  and Malle,
(Bull, de I'Acad. Roy. de Med., X. L, p. 402.)   Out  of six cases,  M.
Rey (Arch. Gen. de Med., 2d ser., t. XII., p. 338) counts  four cures;
M. Dieffenbach (Gaz. Med. Chir., X.  IL,  p. 56) bas cured three  out
of four ; M. Roque  (Bull, de FAcad. Roy. de  Med., X. I., p. 457) three
out of five, and AI.  Davies (Encyclogr. Med.,  p. 49) eight out of  ten
cases.  M. Faure, (Bull, de f Acad., X. L, p. 02,) however, has obtained
only one or two cures out of eight  cases, and though AIM. Roux,
(Ibid., pp. 65, 101,) Bricheteau, (Ibid., p.  124,)  Brigham,  (Gaz Med.,
1833, p. 324,) Larrey, (Bull, de FAcad. Roy.  de Med., X.  I., p. 100,)
and Caffort (Private Letter, October, 1837)  have each in their turn
seen it succeed, and that M. Guerard, (Arch.  Gen. de Med., X. XIII., p.
270,) performing it twice on the same subject at an interval  of forty
years, has been no less fortunate ; though in  spite  of a syphilis and
carious rib, another patient (Gaz. Med., 1833, p. 418) has also been
restored  by  it, and that  M. Reybard has cured almost all those
whom he  has operated upon,—this operation, nevertheless, has been
unattended with success in an infinity of other cases.  Performed by
M. Begin (Elem.  de  Chir., 2d edit., t. IL,  p. 37)  on four different
patients, two  of whom were attacked with effusions of serum, one with
a sero-sanguineous collection  caused by hemorrhagic inflammation,
and the fourth with effusion of pus, it did not prevent all the four from
terminating in a fatal  issue after having undergone numerous punc-
tures.  I have performed it or seen it performed twelve  times my-
self,  in the hospitals of Paris, and every one  of the patients died.
The dangers  that it involves moreover may be readily conceived.   If
the lung, after having been a long time compressed,  has  not lost its
natural permeability,  the air is  inhaled into it with force, and may
thus become  the source of an irritation or violent inflammation imme- 
EMPYEMA.
511
diately after the abstraction of  the  liquid.   Upon the  supposition
that  this  organ has shrunk  so much as to yield  but slowly to the
mechanical action of the atmosphere, the  species of void which  is
immediately left about  the parts, which  up to that  time had  been
steadily supported, necessarily disturbs  the  pectoral circulation and
the respiration.   The  air without  being irritating  or injurious  in
itself, nevertheless, most usually exercises a pernicious influence upon
the subsequent symptoms of  the disease.   Being introduced into the
chest it becomes  heated  and combines  as  it  decomposes with the
remains of the effused matter, which speedily  acquires  acrid  and
putrid properties which it did  not possess before,  and the action of
which is not sustained by the system without danger.   It is this new
material,  not the air, properly so called, which  inflames the cavity
and  produces  a  general  reaction, which  is sometimes exceedingly
intense and too often  fatal;  it  is this  also which,  penetrating  in
greater or  less proportion into  the  mass of the  circulating  fluids,
infects them and gives rise to adynamic phenomena, to which a great
number of the unfortunate persons  thus treated fall  a prey.  The
danger therefore would - be in  proportion  to the extent of the walls
ofthe collection, the degree of exhaustion, the irritability, force, and
vital resistance of the patient, as well as in relation with the charac-
ter of the matters effused, and with the conditions of the organs con-
tained in  the chest.

              § III.—Examination  of  the  Methods.

   Three  points especially in the operation of  empyema require the
attention  of the surgeon ; 1st, the part of the chest at which it is  to
be performed; 2d, the  most suitable  instrument for performing it;
and 3d, the kind of dressing which becomes necessary.
   A. Place of Election and Place of Necessity.—When the effu-
sion  is not circumscribed by  any adhesion, and  when the pleural
linings are entirely free, it is  recommended to open into the pectoral
cavity at  the part which is the most depending  and  most favorable
for the egress of the liquids, and this  point is denominated the place
of election;  when on the contrary, the collection is  situated only
in one region of the  chest, and  that  it is so exactly  circumscribed
that neither the position nor the movements of the  patient can cause
it to  change its locality, the  opening  should be  made  in a determi-
nate  point,  and this is what is  termed the place  of necessity.   This
latter has  never varied, nor can  it vary at the pleasure of practitioners.
The  other, on  the  contrary, being  an affair of choice,  necessarily
cannot be nor has it been  in fact the same with all  surgeons.  Some,
for example, with F. Walther, have placed it in the fourth intercostal
space, counting from above  downward; others, with Leonidas and
F. ab Aquapendente, in  the fifth; and others, with Sharp, B. Bell, &c,
in the sixth.  Heers recommends that it  should be in the seventh.
There are those who,  like G. de Salicet and Lanfranc, prefer the
eighth; others, with A. Par6,  the ninth.  Solingen thinks that it  is
better to select the tenth,  as  recommended by  A. Lusitanus, for the
left side, and the ninth for the right; finally,  Vesalius and Warner
consider that it is the eleventh which offers the most advantages. 
512           NEW ELEMENTS OF OPERATIVE SURGERY.

  1.  In our times we generally prefer, at least in France, the third
intercostal space for the left side and the fourth for the right.  Lower
down we might wound the diaphragm or liver, or we might run the
risk of passing the instrument into the peritoneum and strike below
the collection; higher up we should  miss the  most depending part,
and  the liquid would not flow with all  the facility desirable.   To
these arguments  it is true it might  be objected:  1.  That  in laro-e
collections the /diaphragm, and the liver with it,  is too powerfully
crowded  downwards to  be wounded even when we  penetrate  be-
tween the second  and third rib; 2. That we may change at pleasure
the depending point of the thorax by giving this  or that  position to
the patient, and that under this point of  view the sixth or ninth in-
tercostal space is nearly as advantageous as the third; but as there
is  moreover no inconvenience in  following  the precept  adopted
among us, it would  be as advisable  to conform to it  as to seek for
another;  so much the more so as the sensation of suffocation which
usually distresses those who are afflicted  with  effusions in the chest,
renders any other position difficult for them than that which more or
less approximates to the vertical one.  Only that I do not consider that
we. should restrain ourselves too rigorously to perforate above  the
third rather than  the fourth rib, when any difficulty should exist in
distinguishing them.
  II.  The intercostal space having been once decided upon, it remains
to be determined  upon what point of  its length the operation should
be performed.  If very  near the  sternum, the internal  mammary
artery might be wounded ; farther to the outside is found the descend-
ing branch and anastomosing branches of this vessel.  In the direc-
tion of the spine is situated the mass of the  sacro-lumbar and longis-
simus dorsi muscles; a little farther  upon the  side, the trunk of the
artery not being yet concealed or protected by the lower border of
the rib,  might be  easily opened into.  It  is therefore with reason
that a choice has  been made of the point at the union of the poste-
rior third with the two anterior thirds of the contour  of the thorax.
At that part the incision strikes in front of the latissimus dorsi mus-
cle, between the  bundles or digitations of the serratus magnus and
obliquus externus abdominis.  AVe have nothing to divide but the  in-
teguments, the intercostal muscles and the pleura.  The artery now
lodged in the infra-costal groove is not yet bifurcated, and the space is
sufficiently large to admit the extremity of the finger.  Nevertheless
if this place should not offer moreover the very important advantage
of being the most depending when the patient is slightly inclined upon
his side, or seated  or lying down, there would be no inconvenience in
making the opening farther behind or in front, as  David and several
other practitioners have recommended.
  III.  Many methods have been proposed to determine with precision
the position of the third intercostal space.   If the patient is thin, all
that we have to do is to count the ribs from below upwards; but when
oedema or a thick layer of  cellular or adipose tissue covers the ribs,
we are obliged to proceed in another manner.  According to some,
when the hand of the patient  is placed  over the front  part of  the
sternum and  the arm left pendent upon  the side of  the trunk,  the
elbow when slightly pushed backwards,  corresponds exactly to  the 
EMPYEMA.
513
 space sought for.   This mode of exploration, besides being very in-
 exact,  is much better calculated to conduct us  between the two last
 ribs than between the ninth and tenth; and that which consists in
 descending to six fingers' breadth  below the lower angle of the
 scapula in order to perforate the chest, would be infinitely rnore cer-
 tain and more rational if this locality had really the value which was
 formerly accorded to it.
   IV. Formerly it was a matter of great importance  to mark out the
 place of necessity in the operation for  empyema.  If there was  no
 manifest tumor or thickening of the tissues externally, if a cataplasm
 which should become dry  at an earlier  period, according to some, or
 remain  on the contrary a longer  time moist,  according to others,
 when placed over the effusion, indicated nothing, it would be neces-
 sary to depend upon  the sensations experienced by the patient, or to
 succussion or other means still more fallacious.  But the labors  of
 Avenbrugger,  Corvisart, Laennec, and M. Piorry, have  fortunately
 dispelled this uncertainty;  so that now it is almost as easy to recog-
 nize the precise seat  and  limit -of collections in the  interior of the
 chest, as if they were upon the surface ofthe body.
   B. Instruments.—Whether for  the purpose  of  guarding against
 hemorrhage, or for obtaining a wound with loss of substance, or be-
 cause they considered escharotics  to possess  particular  virtues, the
 ancients and many authors of the middle ages, in order to open into
 the chest, frequently had  recourse to cauteries either chemical  or
 metallic. The cotemporaries of Leonidas  made use of a cautery in
 the form of the kernel of  fruit.  It was also by means  of the iron
 heated  to a white heat that the Cinesias  mentioned by Galen was ope-
 rated upon.  The cautery  of Rhazes was slender and pointed, while
 that of Albucasis was of a  triangular  form.   A.  Pare  recommended
 that it  should  be  provided with a  concave plate at some distance
 from its point.  But this method, long since abandoned, would scarcely
 merit notice, if it  had not  been still eulogized by M. Gouraud, who
 especially uses it  for effusions of  pus, and  gives to the hot iron the
 advantage of enabling the abscess to empty itself of  its own accord
 upon the fall  ofthe eschar,  and to the wound that of resisting the en-
 trance  ofthe air from the tumefaction of its borders.   The scolopo-
 machairion of Paul of Egina, the phebotome of the Arabs, and the
 sagitella of Arculanus, which were formerly made use of, have also
 disappeared from practice.   The ordinary  bistoury and  trochar, at
 the present time, are substituted for all other kinds  of instruments,
 when it is our intention to make an opening into the chest.  Though
 Pare had already proposed the paracentesis trochar, in order to per-
 forate one rib rather than the intercostal space, it was not however
 until after Drouin and  Nuck that attention was really  turned to-
 wards this point.   Dionis, Heister, and Morand especially advocated
 the employment of the trochar, which has still a considerable number
of partisans at the present day, and  which possesses the advantage
of rendering  the operation  easy, prompt, and attended with but little
pain, and the entrance of air into  the cavity almost  impossible; of
not making it necessary to evacuate the entire collection at first; and
of permitting in fine the repetition of a considerable number of punc-
tures successively in cases  in which this should be judged necessary.
                                33 
514          NEW  ELEMENTS OF OPERATIVE SURGERY.

But as on the other hand  its canula possesses  the  inconvenience of
not always allowing a sufficiently free exit to matters that are some-
what inspissated, or grumulated pus, or  blood partially coagulated,
for example, it is far from  being applicable in all cases indiscrimi-
nately.   Moreover the preference is not generally  given to it except
in hydrothorax and extensive pleuritic effusions.  There  would be
no difficulty moreover in transforming a simple  puncture immedi-
ately into a large wound, if the liquid at first  did not run with suffi-
cient freedom; nor can I  perceive how the lung or  diaphragm would
incur more risk of being wounded by such an instrument than by
any  other.  Paracentesis thoracis moreover is governed in  other re-
spects by the same rules as paracentesis abdominis, which Will be
treated of farther on.
  C.  Auxiliary Resources.—If our object  in  the operation is to re-
lieve an effusion of air,  the wound generally  requires no dressing.
In other cases, the course  to be  pursued is not so precisely estab-
lished.  In truth, the pyulcon of Galen, the cupping glasses, syringes,
and suction, so much boasted of in the sixteenth and seventeenth cen-
turies, in order to remove the very last drop of extravasated liquid;
the different kinds of canulas employed during  a long period of time,
in order to prevent  the  pleura from  closing up too  rapidly, and to
enable us to evacuate the chest only by degrees, have lost almost all
their importance, although practitioners still ask the question whether
we ought or ought not to evacuate at once  the morbid  collection, or
to maintain a foreign body there under the character  of a filter, or
throw up medicated injections into the  cavity rather than  to unite
the external opening by first intention.
  Unless the lung  should possess all its natural expansibility, which
is  a  very rare  circumstance in hydrothorax, there would be an un-
doubted  advantage in not allowing the serosity to escape except by
degrees, and in introducing  the extremity of a band of linen or meche
of lint into the  plural cavity, in order that at each  dressing  we may
procure an  additional discharge.   Perhaps also repeated punctures
with  the cataract needle or a very narrow bistoury, would deserve
to be made trial of under  such circumstances ;  nor  can  I see why the
employment of this meche ought to be neglected in cases of empyema,
properly so called, or in effusion of blood, so  long as we attach impor-
tance to the circumstance of air not penetrating into the cavity.  To
perform  the paracentesis, moreover,  no other instrument is required
than  the trochar.   The  employment of injections requires all  the
attention of the surgeon.  It was the  abuse which the ancients made
of these, which has induced  the  moderns  to proscribe them almost
universally.  They are not applicable either  in hydrothorax or in
those effusions which are not limited  by any adhesion.   In the other
cases, on the contrary,  it would be difficult to contest their advan-
tages.  As soon as the suppuration has a tendency to become degen-
erated, they alone appear to be capable of preventing adynamia and
the decomposition of the fluids, by modifying and cleansing the surface
of the morbid  cavity, and by favoring  the discharge  externally of
the  altered matters in proportion  as they are  formed.   M. Billerey,
and  M. Recamier (Bull, de VAcad. Roy.  de Med., X. I., p. 182,) after
him, wh} substitute and  retain in  the cavity emollient, detergent or 
EMPYEMA.
515
 antiseptic liquids, in place of the pus which they have extracted, have
 had every reason to be satisfied with this practice.  It is seen there-
 fore that the precaution of strongly stretching up the skin while we
 are perforating an intercostal space, in order to prevent the parallelism
 which, unless,we  should do this, would be left between the opening
 into the pleura and that of the integuments,  can scarcely be neces-
 sary,  and that It is far from  meriting the importance which has gene-
 rally  been accorded to it since Bass laid it down as a precept.

                   §  IV.—Operative Process.

   A convex or straight bistoury, or a trochar, a vessel to receive the
 liquid, a stripof trimmed linen, a yard long and one finger's breadth
 in width, some gateaux of lint and compresses, and a body bandage,
 form, together with a canula of gum-elastic, and a syringe, all the
 articles that we can require.
   A.  Ordinary Process.—The patient being seated on a bed, rather
 than  on an  arm or common chair, and more or less inclined to his
 sound side,  is to  be supported in this position by assistants in such
 manner that the intercostal space which is  to be opened  may be
 widened as  much as  possible and  altogether free.   The  surgeon
 being placed upon the right and in front, stretches the skin with his
 left hand, and with a bistoury in his right hand  divides it in  a direc-
 tion parallel to the superior border of the rib  below, from left to right
 on the right side, and from himself if  it is on the left side; divides
 successively, and  in the same direction,  layer by layer,  the adipose
 covering, a  thin layer of  cellular tissue,  the  external muscles of the
 thorax, if there  are any at  the point which he has selected,  and the
 external  and internal intercostal muscle; reaches the pleura, and in
 order to perforate it without danger of wounding  other organs, then
 makes use only of  the point  of the bistoury, resting at its back on the
 pulp of the left forefinger, which serves him as a director;  gives to the
 internal opening an extent of from six lines to an inch, and penetrates
 in this manner into the interior of the cavity, from whence he will
 perceive that the liquid instantly escapes.  If, as frequently happens,
 layers of a new formation should have become adherent to the inter-
 nal surface of the pleura, the  operator will  have so  much  the less
 reason to be  deterred by this difficulty, inasmuch as we may, if neces-
 sary,  plunge  into the tissue  of the lung  itself, when the  abscess has
 its seat in that part.   The important point is not to strike outside of
 the morbid collection.   In event, however, of making a mistake of
 this kind, it would be better, unless the matter was at so  small  a dis-
 tance  that we could appreciate its fluctuation with the finger, to make
 another opening  in a suitable place, than to persist in detaching the
 neighboring  adhesions, either by means of the finger, handle of the
 scalpel or sound, or what is more objectionable, by means of a blad-
 der introduced empty into the wound,  and  then  filled with air or
liquid  while it is in the thorax, as some of the ancients recommend.
  B. Process of the author.—The reasons adduced for laying  down
so many precautions in perforating the parietes of the  thorax, appear
to me  to be but little worthy of the approbation  they  have received.
What  danger can there be in penetrating at once into the pleura, or 
516
NEW ELEMENTS OF OPERATIVE SURGERY.
even in going into the lung ?  But this accident is not possible, except
the instrument should not be directed upon the collection.  Moreover,
the lung is free and sound behind the wound, and then the pleura is
no sooner perforated than the pressure of the atmosphere pushes the
lung towards the spine ; or intimate adhesions unite it to the walls of
the chest, and  in this case what danger could arise from a slight
puncture of  its  parenchyma ?  I am of opinion, therefore, that the
operation for empyema would be infinitely more simple, and in everv
respect as safe, if in  order to perform it we should suddenly, and
without  hesitation, perforate the intercostal  space  by means  of a
puncture with the bistoury, held in the second or third position, that
is to say, in  the same manner as in external abscesses, which are
opened from within outwards.   We would  in this way combine  in
some measure the advantages of paracentesis with those of incision,
and the opening into the chest, which  appears so formidable at first
sight, would in reality scarcely deserve the name of an operation.  I
have performed the operation five times by this process, and have
not been able to comprehend what advantage there would have been in
making use of others.   M.  Caffort also writes  me that he has several
times had recourse to it with success.
  V.  Dressing.—I designedly  omit  speaking of the  precept of
those  who recommend  that before  incising the integuments, we
should  take up a large  fold of them perpendicular to the ribs, in place
of stretching them with the hand, and that of some others who have
supposed that the incision  of the skin ought  to be vertical and not
horizontal.   It  suffices to  mention  such opinions, to enable every
person to appreciate  them  at their just value.  I shall take still less
notice of the method of Mercati, which consists in  penetrating only
as far as the pleura, and without wounding  that membrane, in order
that the liquid  may of itself effect  the  perforation.  It  would be
equally absurd to finish the operation with a lancet, after making use
of the bistoury for its  commencement.  The object is to arrive with
certainty and without danger into  the morbid cavity.  Nothing,
certainly, can be less difficult, and it  is not assuredly in  this point of
view that the operation of empyema should be deemed formidable.
  A. An effusion to such  extent as to  require surgical  aid, might
cause the death of the patient, if it should be  formed  at the same
time in both sides of the thorax, before we could venture to attempt
the operation.  Upon the contrary supposition, it would be necessary
to follow the rule formerly laid down by A. Benedetti: that is, not
to open into the  two pleural cavities, until after an interval of some
days,  and  to adopt  all  the precautions necessary to  prevent the
crowding back  and contraction of the  two lungs.
  B. If the operator  does not wish the wound to remain open,  he
approximates its lips  as soon as there  is no longer any liquid to ex-
tract from the thoracic cavity, keeps  them in contact by means of a
strip of adhesive plaster,  then covers them  with a gateau  of lint,
followed by a compress, and secures the whole by means of a body-
bandage drawn moderately tight.   If the whole of the matter has
not been evacuated,  the  flat  dressing with lint  besmeared  with
cerate, is generally sufficient to  prevent the too speedy adhesion  of
the borders  of  the perforation.   In order, however,  to  have our 
EMPYEMA.
517
minds at  rest on this point, there is  no objection to the surgeon in-
serting into the solution of continuity, by means of the meche-holder,
a small cone of lint or  one of the extremities  of a linen band pre-
pared for this purpose : in other respects he is  to proceed as above.
The  tents which  were formerly employed for  this  purpose,  and
which were attached outside  by means of a thread, besides the in-
convenience of forming a plug, also possessed, as in the example re-
lated by Guy, that of the possibility of their escaping into the morbid
cavity and becoming lost there.
  C. So long as the fluids that flow  out at each dressing, preserve
their primitive character and do not deteriorate, injections could not
but be injurious.   We ought to have recourse to them, on the con-
trary, upon the slightest change being manifested.   Under this point
of view, tepid water at first, sweetened  barley water, diluted lime or
lead water, or a weak decoction of bark,  are to be successively or alter-
nately used, also other detergent, astringent, or antiseptic liquids, which
the practitioner will know how to select according to the indication.
M. Bache, (These,No. 66,Paris, 1827,)  avers that this method which
has been  for a long time adopted at the Hospital of Grenoble by M.
Billerey, who, moreover is in  the habit of closing the wound in the
interval of the dressings, by means  of a plug  of gentian, has  been
frequently attended with complete success in that establishment.
  D. The apparatus'-contrived by M. G. Pelletan, (Bull, de  I'Acad.,
X. I., p. 227, or Gaz. Med.,  1830, p.  185,) and which  by means of
canulas and valves, (soupapes,) permits the establishment of a double
current for the liquid, while preventing at the same time the intro-
duction of air into the thorax, which apparatus moreover is based
upon the same principle  as  that of AI. Heroldt, is  too  complicated
and of too litle importance for practitioners to assent to its employ-
ment.  I  would make  the same  remark of those which have  been
since proposed by MM. Bouvier, (Bull,  de I'Acad.  Roy. de Med., X. L,
p. 73,) Maissiat, Recamier,  (Ibid., p. 182,)  &c.  The  small canula
provided with a perforated sac of goldbeater's skin,  made use of by
M. Reybard, (Mem. sur les Anus Artific &c, p. 157,) would be at once
more certain, simple, and  convenient, if it were' advisable to  adopt
any precaution to prevent the  entrance  of air into the thorax.
  [Paracentesis of the  Thorax.—M.  Trousseau,  (Arch.  Gen. de
Paris, 4e ser., t. VI., Sept. 1844, or Journal de Medecine de Paris,
.Movembre,  1843, and Aout, 1844,) advocates this operation, where
there is decided effusion and displacement  of the heart, not only in
chronic but also in acute cases  of pleurisy.   He has performed it
once in acute, and twice in chronic pleurisy, and in  both the latter,
as he thinks, it saved the life of the patients.  Laennec had also long
since recommended it as a dernier resort in such cases, to prevent
immediate suffocation.   Our  remarks  on tracheotomy, (see notes
supra,) apply to paracentesis thoracis.  As to the danger of the lungs
being  suffocated,  as Laennec considered, by  the  compression of
the diffused fluid in the pleural  cavities, this is doubtless  possible,
where active depletion has  been neglected.  But certain it  is, that
one lung may be gradually  almost entirely absorbed by compression
from such fluid, without causing death.   While  at the Seamen's Re-
treat, I saw  a striking case of this in a patient who died of a protract- 
518
NEW ELEMENTS OF OPERATIVE  SURGERY.
ed hydrothorax and general dropsy.  One lung was reduced down
to the size of a dog's ear, and was floating in an ocean of circumam-
bient transparent serum in  the  pleural cavity, and this without the
normal organic structure of the  lobes of this miniature lung being
apparently in the least degree altered !  T.]

     Article II.—Wounding of the Intercostal Artery.

                               § I-

  Upon the supposition that the diaphragm had been wounded, during
the  operation of* empyema, an instance of which was witnessed by
Solingen, we should have no other resources than those of medicine
to oppose to it, and the wounding of the intercostal artery is, in fact,
the  only accident which in these cases  can require the interposition
of surgery.  Though rare, this wound,  however, has occupied much
of the attention  of authors, to so  great a  degree in  fact,  that the
number of remedies that have been proposed  for its relief, perhaps
exceed that of the number of times that the accident has occurred,
unless perhaps it be that it  has been frequently overlooked and the
proper remedy neglected, even in those cases in  which the effusion,
which it has produced, has resulted  in  a  fatal  issue, an example of
which has been  published by M. Thierry (Bibliot. Med., 182S, t. I.,
p. 240.)   The  cases in which it has been especially met with, are
those from wounds penetrating into the chest.   It  is recognized by
the  hemorrhage which it occasions, the symptoms  of effusion which
follow, the paleness, syncope, &c.   A piece of card introduced into
the  bottom of the wound  and curved into the  shape of a gutter,
enables us to ascertain the direction from whence the blood escapes.
The finger glided under the rib will frequently distinguish a hot or
pulsating jet of blood difficult  to be  mistaken, and  forms one of
the  surest diagnostic marks when its employment is practicable.

                              §H.

  Gerard,  by means  of a  thread introduced  into  the wound, and
brought from within outwards by the aid of a curved needle, through
the  intercostal space above, conducted a tent below the artery, which
he hoped in this manner to  compress by constricting the entire cir-
cumference of the rib.  Goulard, with the view  of rendering it un-
necessary  to  withdraw  the whole of the conducting instrument
through the new wound, contrived a needle with  a curved handle,
like that of Gerard, pierced with an eye near its point, and hollowed
out upon its convexity with a groove which  was  intended to receive
the  thread.  Heuermann alleges that by means of  a needle strongly
curved and fixed at an angle upon its handle,  we may surround the
bone in such manner as to bring out the two extremities of the thread
through the same wound.   Leber, after having made a second open-
ing above the rib, used this  opening to conduct  a thread which he
caused to come out through the  wound, and the two ends of which
he  afterwards  knotted  upon a compress after the manner of Gerard.
To  effect this, he made use of a  flat and flexible sound, which Steidtle 
WOUNDING OF THE INTERCOSTAL  ARTERY.          519
has replaced by one of silver, curved into the shape of an S, and for
which Boestcher has,  according to Sprengel, substituted a smooth and
blunt-pointed steel  sound.   Finally, Reich, instead of fastening the
thread by a knot, recommends  that its extremities should be passed
through a gum-elastic canula, which is to be secured outside ;  but all
these processes are  useless, as wrell  as the double plate of Lottery, the
jeton of Quesnay, and the machine of Bellocq.

                             § III.

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

                              § IV.

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

        Article III.—Paracentesis  of the Pericardium.

                        § I.—Appreciation.

  The idea of opening into the pericardium when filled with seros-
ity, pus or blood, appeared so bold at first that many persons still look
upon it as rash and unwarrantable.  Timid surgeons have been de-
terred  by it from the fear of wounding the  heart.  Others reject it be-
cause it might excite an inflammation which, from its situation, would
speedily  result in death.  The difficulty of recognizing the  disease
with certainty during life, and the objection that we should give re-
lief only to one symptom, is the argument  which the most judicious
have adduced against it.  None  of these various objections, how-
ever, are of a character to cause  it to  be absolutely proscribed.
The skilful  practitioner, aided by the explorative resources that sci-
ence possesses at the present day, will rarely find himself incapable
of establishing a diagnosis of effusion in the pericardium.  The heart
may be always avoided.   By evacuating a serous membrane of the
liquid  which  has  accumulated within it,  we disembarrass  it of a
foreign body, and the puncture is in this  sense more calculated to di-
minish than to give rise to  inflammation.  It is  true  that with the
operation the  patient is exposed to great  danger; but  without it he
is devoted to a speedy and certain death.   If the paracentesis does
not cure, it may at least afford momentary relief.  Nevertheless it is
unfortunate that experience should have furnished scarcely any elu-
cidation ;and that it should still present only ideas that are purely the-
oretical upon a subject of so serious a nature.  Senac, who has been
erroneously thought to have been  the first to propose  puncture of the
pericardium, gives no instance  of  it, and the case imputed to him by
Sprengel relates, in reality, to hydrothorax.  Van Swieten  and H.
Welse, referred to by M. Rayer, express themselves  still more con-
fusedly.  Nor does Riolan* who speaks of  it as a general suggestion,
assert  that it had been performed  in his time.  It is well known that
the pretended pericardium  that  Desault supposed  l\e  had  opened,
was nothing else than  an accidental  cyst.   AVe do not  find  that M.
Skielderup has furnished anything conclusive in support of his opin-
ions.   It is also evident that the collection  which was opened by M.
Larrey was situated external to the pericardium.   The three obser-
vations related by M.  Romero, (Bull,  de la Fac. de  M-d., X. I A7"., p.
273,) and the substance of which has been given by AI. Merat, are
too imperfect  not to leave the mind in considerable doubt.  The one
that M.  Jowet  (Bull, de Ferr., X. XIIL,  p. 233.) has published in
1827, as the first instance of a successful result, is also incapable of
removing all doubts upon this subject.   But though  it  may  still re-
main to  be demonstrated that paracentesis of the pericardium has
ever been performed  upon living man, except perhaps in  the case
which M. Warren  has communicated to me ;  facts are not  wanting
to show  indisputably that the  perforation of this membrane  does not
necessarily cause death.   The thesis of AI. A. Sanson furnishes many
proofs of this.  M. Larrey also relates several, and I myself have col-
lected other examples.—(See Wounds of the Heart, Vol. IL) 
PARACENTESIS  OF THE  PERICARDIUM.
521
                    § II.—Operative Process.

  The pericardium, in its natural state, is accessible at a great num-
 ber of points to surgical means.  Effusions, by  distending it to an
 abnormal degree, would enable it to be still more readily attacked.
  A.  Riolan maintains, and  others have agreed  with him, that we
 may puncture  the  pericardium by trephining the sternum, an inch
 above the xiphoid cartilage.  This opinion,  revived  as a new one,
 and with all the necessary details, by M. Skielderup, has found some
 partisans among the moderns.  Laennec, among others, adopts it,
 and  endeavors  to  demonstrate  its advantages, which are that  of
 avoiding with certainty the internal mammary artery, that of going
 down inevitably upon the distended pouch, and of not making an open-
 ing into the pleura.   Senac recommends that we should  make  the
 opening in the fifth or sixth intercostal space, a little  to the left of
 the sternum, and that the trochar, introduced at that point, should  be
 introduced very obliquely  downwards, and to  the  right, until it
 reached the  collection to be evacuated.  Desault, in order not  to
 wound the mammary artery, made his incision more  to the outside,
 and did not penetrate into  the morbid collection  until after having
 identified its fluctuation by  means of the finger.   This also is  the
 method which is eulogized by  M. Romero, who, in place of the tro-
 char of Senac, or the blunt-pointed bistoury of Desault, preferred the
 scissors for dividing the  pericardium, after  having raised up  a fold
 of it  by means of the forceps.  Finally, M. Larrey considers it better
 to perforate from below upwards, the space which separates the left
 border of the xiphoid appendix, from the cartilage of the  last true
 rib;  that we would in this manner avoid the pleura, incur no risk of
 wounding the  peritoneum,   diaphragm, or internal mammary  ar-
 tery,  and would  strike upon the most  depending part  ofthe peri-
 cardium.
  B.  Trephining of the  sternum  unquestionably is  the most simple
 process which  has  been  proposed.  The bone which  is thus perfo-
 rated is soft, and superficial, and destitute of vessels on both its sur-
 faces.  It enables  us to see and to  touch  the pericardium before
 opening it, and to forego the  last stage of the operation, which is the
 only one that is dangerous, should the surgeon have misconceived the
 situation of the  hydropsy.   The  fluid  cannot be effused  into the
 pleural cavity.   I  see no other  inconvenience in  it  than that of
 occasioning  a loss  of substance, which renders the immediate  re-
 union of the wound difficult, and which unavoidably  places the in-
 terior of the cavity in contact with the atmospheric air.   But is it not
 better to leave  the  perforation of the pericardium  open,  than to shut
 it up  before having removed the source of the mischief? Is not the
 action of the air,  in such cases, a result which is rather to be desired
 than to be dreaded  1  The danger which the pleura incurs, whatever
 precaution we may take to avoid it, and also the internal mammary,
 in the method of Senac, slightly modified by Desault and  MM. Ro-
mero and Jowet, are certainly  not considerations  that ought to out-
weigh the preceding process.   The  process of M. Larrey, which
might possibly procure  the same result as the  trephining of the
sternum, is not so easy of application as its inventor  supposed  in 
522
NEW ELEMENTS OF  OPERATIVE SURGERY.
subjects in whom oedema, infiltration, or embonpoint exists, to such
extent that  the skin does not come into immediate contact  with the
externa] surface of the bones or cartilages of the thorax.  The branch
of the mammary artery, moreover, which crosses  the anterior face
of the ensiform prolongation,  is sometimes so voluminous that  its
division, which is almost unavoidable, might give rise to an  alarming
hemorrhage.  In conclusion, therefore, it would  appear to  me pru-
dent  to adopt the  advice of Riolan, which is  also sanctioned  by
Boyer. The  crown of the trephine should be applied upon the left
half of the sternum, immediately above the xiphoid appendix, in order
that it might fall upon the broadest portion of the anterior space  of
the mediastinum.  The left forefinger introduced into the bottom, of
the wound  would then  enable us to identify the fluctuation, and
would serve as a guide for  the bistoury.   Having  opened  into the
pericardium, it would  become advisable to turn the patient upon his
left side, and  more  than ever to keep his chest  in a position almost
vertical, in order  to give egress to the liquid, which  should be allowed
to flow out  gently.  The'dressing would  consist of a meche intro-
duced into the orifice of the  serous sac, a plumasseau besmeared with
cerate, some compresses, and a body bandage, in  order to support
the whole, precisely as in the operation for empyema.
   C.  Injections.—The idea of treating hydropericardia in the man-
ner of a hydrocele,  and of injecting an irritating liquid into the dis-
eased cavity in order to promote adhesive inflammation, has nothing
in it repugnant to sound reason, and those who have reproached Ai.
Richerand for having suggested it, have done so  improperly.  If the
puncture, besides evacuating the liquid, does not in itself cause adhe-
sion,  it is  useless  to  count upon its affording relief, except  as a sim-
ple palliative.   The radical cure of hydropericardia without oblite-
ration'of  the altered sac is no more possible than that of hydrocele.
If it ever has been obtained, it is because the practitioner, without
having intended  it, has  carried out the indication  first proposed  by
M. Richerand, and since by Laennec.   The contact of the  air, more-
over, would perhaps suffice to  bring about the necessary degree of
inflammation.  When there is no organic lesion,  tepid water or some
other liquid only slightly irritating, should be  first made trial  of.
Should the case  be one of  effusion  of pus,  the  injection should be
varied according to the  indications, in the same way as after empye-
ma.   In whatever manner  performed, I should recommend that the
incision into  the pericardium,  when  the bistoury is made use  of,
should be large, and that it should be kept open until the termination
of the treatment.  The  treatment would be then analogous to that
of hydrocele by incision or excision, and the effusion which  generally
follows the  injection of the tunica vaginalis after  puncture would not
jeopardize  the final result.   If the case should  be one  of serous
effusion, I should  prefer after having laid bare the part, to plunge in a
trochar and after having emptied it  to  inject it, with a solution of
tincture of  iodine, as is  my general practice in hydrocele.   It is pro-
bable that  we might in this manner effect  an  agglutination of the
pericardium to the  heart.  These however  are nothing more than
suppositions.  Before attaching any value to them or applying them 
                PARACENTESIS OF THE ABDOMEN.              523

to living man, we  ought,  by experiments  upon living animals, to
ascertain how far they are founded on truth.   It is a point in practice
which cannot cease to be interesting.   The rarity of the cases which
would enable us to take  advantage of it is the only plausible reason
which appears to me to diminish its importance.
PART  FOURTH.

       ABDOMEN.
                        CHAPTER  I.

                EFFUSIONS, CYSTS AND FISTULAS.

                   Article I.—Paracentesis.

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

                       § I.—Indications.

  When the ascites is the result of an  incurable affection of one of
the  organs contained in the belly, it is  evident that puncture cannot
cure it,  and that we must then resort to this only for the purpose of
procuring temporary relief to the patient.  But if the dropsy is essen-
tial and idiopathic,  the extraction of the effused liquid  cannot but
favor the action of the general treatment and co-operate in the re- 
524
NEW ELEMENTS OF OPERATIVE  SURGERY.
establishment  of the health.  In the first case we should not operate
but at as late a period as possible, and to prevent suffocation; in the
second  case, it would be advisable to adopt the recommendation of
Duvemey and Bertrand, as revived by Broussais, and give egress in
good season to the effused liquid.
  A. Compression.—It is so seldom that we see ascites  terminate
fortunately, that after  having unavailingly made trial of the means
that experience appears to have placed most confidence in, for exam-
ple, compression, which I have seen succeed in one instance in a boy
fourteen years of age at the hospital of Tours, in 1818, and the advan-
tages of which are eulogized by M. Speranza (Bibl. Med., 1829, t. IL,
p. 242,) and M. Godele, (Revue Med., 1831. t. L, p. 12,) and the good
effects of which were  recognized at the Hotel Dieu in 1831, and its
efficacy since  placed  beyond all  dispute by AI. Bricheteau, (Arch.
Gin. de Med., X. XXXIIL, pp. 75—93,) it is allowable to appeal from
these modes to the operation, however feeble may be the hope of its
success.  It must be that MM. J. Darwell and J. Copeland, (Cyclop.
of Pract. Med., vol. L, p. 169,)  who were desirous of having it pro-
scribed in practice, and who have advanced against it a great number
of unmerited reproaches, have not seen it employed in practice, or
have been rarely witnesses to  the  distress which ascites sometimes
occasions.
  B. Temporary blisterings, recommended by Trouv6, (Arch. Gen.
de Med., X.  XVIIL, p. 200,) have been employed  by myself of a size
which might be called monstrous, and in my opinion deserve farther
trials.
  C. Encouraged  by what Thouvenot says of his needles  and small
canulas, by what I have  seen  myself, and by what has been stated
in England, of  acupuncture  in hydrocele,  I was desirous also of
making trial of this method,  after the maimer of M. King, in ascites.
Having plunged in upon  five  or six points of  the belly a long com-
mon or cataract needle, and having repeated this process three or four
times in  the space of  fifteen days  upon two women, I saw an im-
provement take place which surprised me,  and which would justify
additional trials ofthe same description.

              § II.—Examination  of the Processes.

  A. The red hot iron formerly used, caustics by which an  ulcer was
first made, and which  it was  afterwards necessary  to lay open in
order to reach the peritoneum, together with the seton, as recom-
mended by others,  have long since given place to more rational pro-
cesses.  The method of Paul of Egina and Guy de Chauliac, which
was still  lauded  by Pigray, and which consists in dividing the integu-
ments by means of a bistoury,  and then perforating the aponeurosis
or muscles a little  higher up,  in order to  be enabled to shut up at
pleasure  the deeper wound, by allowing the  skin, which  had been
previously raised up, to glide over in front of it,  has been  also aban-
doned, as well  as all  those which were performed by means of a
cutting instrument.
  B. The needle, and  the  small canulas of Thouvenot,  (Planque,
Bibl, t. V., p. 665,) or of Barbette, evidently indicated by Rhazes, the 
                PARACENTESIS  OF THE  ABDOMEN.              525

instrument of Block or Girault, and the trochar canula of Sanctorius,
the invention of which Camper pretends to trace up to Hippocrates,
variously modified  by others, especially by J. L. Petit, who con-
structed from it the instrument  known at the present day under the
name of trochar or trois-quarts,  render the puncture of the abdomen
so simple and  easy, that for a  century past there is no longer any
more question of the bistoury or  lancet than of the cautery, when our
intention is to penetrate into the peritoneum for ascites.
  C. Some modern surgeons, however, seem desirous of reviving the
method by incision.   Physick, among  others, alleges that the opera-
tion is  much less  painful with the lancet than with the trochar, and
Dorsev says that in America this last mentioned instrument will soon
fall  into disrepute.  M. Callaway, a surgeon  of London, has more
recently endeavored to prove that wTe ought in reality to give prefe-
rence  to the lancet in puncturing the lower belly.  Guided by the
left  forefinger, which  serves as  a point d'appui to it, we  introduce it
with the right hand on the linea alba above the pubis; we  then im-
mediately insert, through the wound into the cavity of the  peritoneum,
a female catheter, when the operation has no longer anything parti-
cular.  This process,  which had already been  proposed  by Petit-
Radel,  and which is the same  in fact as that of Ccelius Aurelianus,
might be followed without inconvenience ; but it  is doubtful if in fact
it possesses any real advantages over the method adopted among us.
If the cutting instrument encounters any  vascular branches, it divides
them unavoidably, and all the organs within its reach will be exposed
to the  same casualty; while the trochar separates  apart, and rather
displaces than divides the movable organs which present themselves
in front of it.   The wound  made by its passage immediately closes
as soon as the instrument  is withdrawn.   That which the lancet
makes, on the contrary, remains open,  and presents no obstacle to
the egress of the serum through  it.
  D. The flat trochar of Wilson, or the flattened one  (meplat) of
Andre, which, by the advice of  B. Bell, many practitioners  in Great
Britain prefer to Petit's instrument, because as the^y assert it scarcely
differs  from  a cutting  instrument, is wholly  undeserving of such a
predilection.   The jointed trochar, those  in which  the point is con-
ical, serpent-tongued, or more or less flattened, in place of being tri-
angular, together with  the fifty other  descriptions which have been
extolled, are not worthy of being mentioned.  The one which has re-
ceived the approbation of the French surgeons leaves  nothing to de-
sire, and the modifications which have been attempted upon  it since
the time of J.  L. Petit are calculated only to render it less perfect.
  I. Place of election.—All parts of the belly are not equally suita-
ble  for paracentesis.   The left flank would be more favorable when
the spleen is sound, if the epiploon, which extends further  upon this
side, did not present any obstacle to the egress of the liquid. Upon
the right side  we should have  to fear  the presence of the liver:
while were we too near to Poupart's ligament, we might  encounter
the sigmoid  flexure  of the colon or the  caecum.   Posteriorly, we
have the last false rib or crest of the os  innominatum, and we might
readily wound the lumbar portion of the colon.   The supra-umbil-
ical zone corresponds to the transverse portion of the large intestine. 
526
NEW ELEMENTS OF OPERATIVE SURGERY.
Far down upon  the  median  line we encounter the bladder.   We
must select, nevertheless a depending part. The linea alba, preferred
by the ancients, and even still by most English surgeons, has no ad-
vantage  in  this respect;  and it is far  from protecting us with as
much  certainty as has been  supposed, from  every kind of hemor-
rhage.  A large vein sometimes runs over its posterior surface, and
M.  S.  Cooper mentions a cfetse in which  more than a pint of blood
came from a wound which he made in this place with a bistoury.
  a. In women there is found  between the womb and  the rectum at
the bottom of the pelvis, a cul de sac, by which we could readily reach
through the postero-superior part of the  vagina.   This, which is the
most depending point of all, would also be perhaps the most suitable,
if the  peritoneum were free throughout  its whole extent, and if any
change whatever in the relations of the bladder, uterus, or intestines,
would not unavoidably expose to the risk of perforating one of these
organs.  We ought not therefore to select it,  nor to conform to the
rule laid  down  by Henckel,  Watson, Bishop, and Noethig, until  after
having satisfied ourselves  by the  touch,  that the  serum  had de-
scended down as far as the pelvic cavity, and that it has  a tendency
to depress the upper part of the vagina.
  b. In penetrating by the rectum above  the vesiculas seminales, as
some other practitioners recommend, there would be still greater dan-
ger of wounding the bladder.  The danger Of finding stercoral matter
afterwards passing through the rectum into the peritoneal cavity, will
be  sufficient to cause this  route always  to be rejected, though it
might  be adopted  in certain cases as an exception.
  c Even the bladder has been perforated for the purpose of empty-
ing the peritoneal cavity of dropsical patients.  M. H. Berard men-
tions a case in his  thesis.   A case was thought to be ischuria.  The
sound was forcibly introduced into  the urethra, when several  pints
of serum escaped, and the patient died.   The opening of his body
proved that it was ascites, and that  the instrument had entered into
his  belly.   A surgeon of London, M. Watson, has  gravely proposed
to penetrate designedly by this route, and what is not less surprising,
one of his countrymen, M. Buchanan,  states  that he has done  it in
three instances  with success ; but it will never be necessary among us,
I think, to seriously undertake the refutation of a principle like this.
  d. The scrotum, which is  the best route, as the observations of Le
Dran  and Morand show, when  there is at  the same time ascites
and congenital hydrocele,  can be  applicable only under these cir-
cumstances.  If we should meet with a region in the abdominal pa-
rietes more attenuated  than others, to such degree as to be  formed
only by the skin, and to have  acquired a sort of transparency, this is
the place we should select, however unfavorable it may  be in other
respects.
  e.  The  navel,  which frequently presents this  peculiarity,  and
which Lanfranc and the two Fabricii recommend, is the  point which
M.  Ollivier, (Arch. Gen. de  Mid., X. VI., p. 178,) on the  strength of
a fact occurring in his own practice, and on another in that of M.
Bigot of Angers, proposes to perforate in pregnant women.  Scarpa,
(Bull,  de Fir., X.  IL,  p. 256,) on  the contrary, and  after him M.
Langstaff,  (Arch.  Gin. de  Mid.,  t. VIIL, p. 267,) or M. Cruch, 
PARACENTESIS  OF THE ABDOMEN.
527
recommend that during pregnancy the puncture should be made in
the left hypochondrium, that is, a little below the third false rib.  Like
M. Emery, who says he hag performed it six times in a single female,
I have had recourse several times  to paracentesis in women in  the
state of gestation, and three times, among others, during the same preg-
nancy.  The whole extent of the left flank and all the points on this
side where the trochar is usually applied, have seemed to me, separa-
ted from the womb by an interval of too great an extent to make it
necessary to attach much importance to the precepts of Scarpa.
  f. A little to the outside of  the linea alba where the puncture was
formerly made according to the recommendation of Celsus, we incur
some  risk of wounding the epigastric artery.   The middle of the
space that separates the ribs from the spine ofthe ilium, as indicated
by Sabatier, would have the  inconvenience of being  too  near  the
 chest, should the spleen and the liver be affected with  any engorge-
 ment  ; so that, as a general rule, the middle of the line which extends
 from  the  umbilicus  to the antero-superior spinous  process of the
 ilium  is still  the one which should have the preference.   Here the
 instrument can touch neither  the bladder nor the womb, unless  either
 should be very much developed, nor the epigastric artery which is on
 the inside, nor the anterior iliac artery which is to the outside, nor
 the colon which is behind and below.   This place, which the ma-
 jority of operators have recommended should be chosen since  Palfin
 first suggested it, is therefore the true place of election, and any of
 the others the place of necessity.
   g.  In ordinary ascites the wounding  of  the  intestines or their
 arteries is next to impossible.   The contained serum must naturally
 push  them towards the diaphragm or  in the direction  of the  spine.
 Though they should even remain free  and floating, the mesentery is
 not  long  enough for the trochar to reach them.  But should a
 noose of intestines have become adherent to the walls of the abdo-
 men, there is no doubt that the instrument might open into them and
 give  egress to foscal matters, examples of which are on record.
   II. Encysted dropsy, which may have its seat in an ovary,  in  the
 cavity of the epiploons, in a portion of the  peritoneum limited by  ad-
 hesions, or in some particular accidental sac, would also  incur  the
 risk of  the same accident.  Being surrounded by thick walls we  are
 compelled in most instances  to penetrate deeper, sometimes, accord-
 ing to  Mouton, to the distance of four inches before reaching  the
 collection, which consequently makes it necessary that  it should be
 identified if possible before commencing the operation.
   III. Position of the patient.—No one at the present day recom-
 mends  that the patient should stand up during the operation, nor ex-
 cept  under certain circumstances is it convenient for him to be  seated
 in a chair.  The proper position for him is upon his  side and very near
 the edge of the bed.   While the  liquid  is running out, an assistant,
 stationed upon  the opposite  site, gently compresses  the wTalls  of the
 belly by means of his two hands broadly spread out. Without this pre-
 caution, which the ancients neglected, the viscera and the large vascu-
 lar trunks, suddenly deprived of the pressure to which  they had been
 habituated, might give rise occasionally to syncopes, swoonings  and
 convulsions, all of which it  is important  to avoid.  The species of 
528
NEW ELEMENTS OF  OPERATIVE SURGERY.
bandage or corset contrived  by Alonro, as a substitute for the hands
of an assistant, and to be used after the operation as  the dressing,
though very ingenious, does not, inasmuch as it but imperfectly fid-
fills the indication, merit  the, preference which some  persons have
accorded to it.  To apply it  beforehand and tighten it by degrees as
the belly is emptied, to maintain  opposite to the  proper place, the
hole which it has on its side for the passage of the trochar, and after-
wards to pad the cavities which might be  left in the direction of the
iliac fossas, &c, are details too trivial to engage the attention of sur-
geons, unless  they should be necessary.   The folded sheet passed
around  the belly,  and the two extremities of which are gradually
drawn upon by two assistants  while  the  water is running  out, as
recommended  by  M. S. Cooper, would be still more objectionable.
If the effusion has its seat in  the peritoneal cavity, it is  possible that
the epiploon, or a noose of intestine, or a flocculus of albumen or an hy-
datid, may become entangled in  the extremity of the canula and shut
it  up  before the liquid is completely withdrawn.  A stilette or any
blunt-pointed rod  whatever, passed through the instrument, will be
found sufficient to push aside these substances, and to give the pas-
sage of the liquid  all the freedom it had at first.  As serous cysts do
not scarcely ever contain  anything but limpid serosity, they are gen-
erally exempt from this  inconvenience;  but dropsy of the ovarium.
which almost always consists of an oily or gelatinous matter, more or
less inspissated, of a yellow,  reddish or darkish color, and rarely of
great fluidity,  sometimes presents this difficulty, and requires at least
the employment of a canula of somewhat large dimensions.
  IV. Extraction of the  liquid.—Many authors  have  considered
that we  ought not. to remove  all the contained fluid  at once, but
that it would be  better  to extract it  by degrees.  It was for this
purpose  that Paul of Egina, Guy de  Chauliac, &c,  avoided per-
forating  the skin and  peritoneum  at the same point; that already
at the time  of. Hippocrates  they were  in  the habit  of placing
in the wound  a  small canula  which has since  been  modified  in
a thousand different ways, and which was  made use of  in some re-
spects as a faucet for plugging up or unplugging the  opening  at
pleasure; that  others  extracted first only a  small quantity of the
liquid fluid to return afterwards to the repetition of the same ope-
ration  a greater  or  less  number  of times;  and that  it was pro-
posed, after having opened into the belly with a lancet, to leave the
matter to ooze out gently  and imperceptibly of itself.  But as expe-
rience has furnished no positive evidence of the utility of this method,
it  appears  to  be  more rational not to leave  in the belly anything
but that which cannot be  extracted from  it.  The exhaustion and the
syncopes which the ancients  expected to prevent by acting in this
manner, are still more effectually prevented by means of a bandage
suitably applied, and patients, after  having submitted to this operation,
would be poorly satisfied if their belly was but partially  emptied.
  V.  Dressing.—The compressing bandage after the puncture, not
only has the advantage of supporting the viscera, but is also a power-
ful auxiliary in effecting a radical cure.  The authentic facts in sup-
port of this assertion are now sufficiently numerous to induce us to
add to their number more and more.  In the spring of 1831, I was 
PARACENTESIS.                      529
desired by M. Rousseau, a physician at Batignolles, to puncture the
abdomen in a child five years of age, affected with ascites during trie
previous 8 months.  We withdrew six litres of limpid water from the
abdomen.  No alteration in  the viscera could be recognized through
the walls of the belly.   A methodical and gentle pressure was imme-
diately applied ; the effusion was not reproduced, and the little patient
soon recovered its former health.  M. Fenoglio. (Gaz. Med., 1832, p.
588, 589,) in operating on a woman 22 years of age, whose belly
contained 36 pounds of water, and  afterwards  on a man aged 40
years, and from whom 40 pounds of serosity were extracted, succeed-
ed equally well in both cases.   The  manner of applying compression
in such cases, must be left to  the discretion of the operator.   Whether
we make it with a flannel banc1, as recommended by M. S. Cooper,
after the advice of Bell, with Monro's  bandage, or with a sort of lo-
sange terminated in a scapulary above, and  by infra-crural bandages
below, in such a manner that it may  be conveniently tightened trans-
versely; or make  use simply of a  body bandage, and compresses or
other  napkins folded in various ways upon the hypogastrium  and
flanks ;  provided the compression  is  methodical and regular, the rest
is a matter of little importance.  Large temporary blisters after the
puncture in patients who cannot support  compression, would proba-
bly afford more chance of success  than before the operation.
  VI. Injections.—Some persons  think that the radical cure of as-
cites might be accomplished after the puncture, by adopting another
method.  Noticing what happens  in hydrocele, they have proposed
to throw up into the peritoneal  cavity irritating  liquids, in order to
favor  its adhesive  inflammation.  Brenner, who appears to have been
the first to make this  suggestion, and who had no other object than
to give tone to the viscera, proposed a solution of camphor, aloes and
myrrh in brandy.   Warick  made  trial of it and  cured his patient.
Repeated with rei wine and tar water, these injections were not at-
tended with the same success, and the two  women died.   Warrick,
after having made trial of the process of Hales, who recommended
that a canula should be placed on each side ofthe belly, in order that
the liquid might be enabled  to run out of one vyhile the injection was
thrown up through the other, ultimately gave a preference to Bristol
waters and simple puncture. Though since  recommended by Heuer-
mann, Bossu, and  others, injections in ascites were wholly proscribed,
until a few years since the annals of Broussais brought to their support
two cases of success obtained by  means of  the  vapor of wine.  M.
Lhomme, (Arch. Gen. de Mid.. X. XIII.,p. 282,) emboldened by these ex-
amples, ventured to make trial of the  same process in an adult who had
already several times undergone puncture.  The result exceeded his
hopes.   His patient, as well as that of M. Gobert, and that of M. La
Faye, (Lancette Franc, X. IL, No. 88,) continues to  enjoy excellent
health.  A question of so serious a character, requires more conclu-
sive facts before it can be solved. - There is nothing to show that M.
Lhomme actually caused the vapor of wine to pass  into the belly.
He filled, he says, a syringe with it, but the linen wet with cold  water,
and with which he thought  it necessary to wrap the canula, through
which the vapor had to pass, must have necessarily condensed it im-
mediately ; so that very probably  it was  air, and not wine, injected
                              34 
 530          NEW ELEMENTS OF  OPERATIVE SURGERY.

into the abdomen.  The patient operated upon with it by M. Dupuy,
(Arch. Gin. de Med..  February, 1832, t. XXVIII., p. 271,) died.
The cases of M. Jobert, (Lane Franc, No. 70, 73,) like those of
Heuermann, Litre, Garengeot and Bossu, appear to have reference
only to encysted dropsies, or not to have been followed by a radical
cure, while those of Warrick are too imperfect to claim any great de-
gree of confidence.   The patient  cured  by M. Arassal, (Soc. de Med.
Prat.,  1833, No. XIL, p. 8,) by means of puncture, massage and irrita-
tions with the beak of a canula of a trochar, was followed by too many
serious accidents to embolden practitioners to make trial of the remedy
that saved her life.   Nevertheless, it is not improbable that we may
succeed ultimately in obtaining from  these trials an important point
in practice.
   Reasonings based upon numerous facts induce me to believe that
the cure  of ascites only takes place by means of adhesion of  the
parietal lining of the  peritoneum with the  abdominal viscera.  The
colics which those who  have escaped from  this disease habitually
experience, and  the disturbance that they are troubled with in their
digestive functions, would constitute the proof of my assertions.  A
man about fifty years of age, cured of an ascites fourteen years be-
fore, and who died  of pneumonia at the Hospital of Tours, in 1N17;
and the young girl nineteen years of age, cured  at fourteen years
of age of a similar  dropsy at the Hospital des Enfans, and who died
in consequence of a cerebral lesion in 1824 at the Hospital of Perfec-
tionnement, had  both  of them all the intestines glued together and to
the walls of the  abdomen by innumerable cellular lamellas  and fila-
ments.   Such being the fact, it remains to ascertain whether pru-
dence and  humanity would  authorize us to imitate, under  these cir-
cumstances, the processes of nature.  With a  view of elucidating
this fact,  M. Bretonneau and myself, in 1819,  made some experi-
ments  upon  dogs.  We injected  into their  peritoneal  cavity, first
pure water, then brandy dilated with water, and finally water strong-
ly impregnated with muriate of soda; but no inflammation  could be
excited in these animals, and all the liquids injected were absorbed at
the expiration of a few days.  A patient  in whom there was no hope
of effecting a cure  by the usual remedies, and who was threatened
with immediate death, was submitted to  the  same experiment.  He
died, but in consequence of his dropsy and  from a portion of the
liquid which had  become effused  into the substance of the walls  of
the belly having caused  there a gangrenous  erysipelas.  M. J. Clo-
quet has frequently mentioned  to me a patient in whom a vinous or
alcoholic injection for congenital  hydrocele  had, contrary  to his in-
tentions, passed into the  abdomen, but who nevertheless after some
unpleasant symptoms was ultimately cured.   Without wishing to
deduce from those various trials conclusions which are not tenable, I
nevertheless think them worthy of attracting attention.  They go to
show at least that  injections into the peritoneum are not as formida-
ble as is  generally supposed, and  that before passing upon them an
absolute  condemnation,  it would be advisable  to  make them  the
subject of varied experiments and of an impartial and  profound in-
vestigation.  M. J. V. Roosbroeck, (Rev. Mid., 1832, t. L, p.  250,)
having been struck with the diuretic  and sudorific  property of  the 
PARACENTESIS.
531
gaseous oxide of azote, (gaz oxidule d'azote,) concluded  to inject it
into the abdomen of dropsical patients after puncture.  Three pa-
tients, a man and two women, submitted by him  to  this  treatment,
derived such advantages from it that Broussais in  his turn ventured
to make trial of it,  but in a patient who was in so desperate a con-
dition that it was surprising to find he survived  it even the period of
eight days.   The author puts two gros of nitrate of ammonia in a
glass phial,  to which  he adapts a bladder with a faucet: lutes this
apparatus and plaees it over the flame of an alcohol  lamp; allows
the bag to become filled with  gas by the  decomposition of the salt;
unlutes it and waits until the whole has cooled ;  places the extremity
of the faucet in  the opening of the canula of the  trochar, and then
immediately proceeds to injecting it.   If there  is no error in the ac-
count of M.  V. Roosbroeck, there is no doubt that practitioners should
be solicitous to repeat his  trials, which M. La Faye has  also found
reason to be satisfied with.   From what I have  seen of iodine injec-
tions in hydrocele  and  serous  cysts, I am induced  to believe that
they would afford  much better chances  of success  than wine, in
ascites  and  cysts of  the abdomen.
  VII.  A bladder of gold-beater's skin.—A bladder of gold-beater's
skin, in the  manner it is applied in the radical cure of hernia, as pro-
posed by M. Belmas, introduced empty, then distended or filled with
a suitable liquid while it is in the  peritoneum or cavity of the cyst,
and maintained at  the outside by its extremity—could it have, as
the  author thinks, the advantage of graduating  the irritation at plea-
sure, and of even suspending it if necessary by enabling us to with-
draw the foreign body which has produced it ?   I  would not dare to
hope for this result.
  VIIL  On the supposition that nothing of this kind has been done, and
that the effusion has reappeared, the puncture must be repeated again
and as often as becomes necessary, proceeding in  other respects ac-
cording to the rules laid down above.
  There are patients  in whom life may be thus prolonged for many
years, and  in whom we have to have recourse to it  every two or
three months.  Dropsy of the ovarium, which  is  a purely local dis-
ease in most cases, is  the one which  supports these repeated opera-
tions the best.   Partial or encysted dropsy has  also, in certain cases,
been unquestionably  benefitted by it; but it is doubtful  if general
ascites can be classed in the same category, or continue after the ope-
ration of paracentesis so long a  time without terminating fatally.
Thus, when we find it affirmed that puncture  has been  performed
9 times on the  same woman by  Saviard, 11 by Litre, 29 by Grew,
57 by Cheselden, 47 by Laub, 86 in the space of 26 years by Marti-
neau, 52 by Schmucker, 65 by Mead, 100 by Callisen, 187 by M. Ro-
loff, (Revue  Med., 1826, t. IL, p.  148,) in a woman whoperformed it
upon herself 62 times, near 200 times in another case, (Journ. Univ.
des  Sc Med.,X. III., p. 119,) and even 655 times by Bezard, (Bull, de
laSoc. Med. d'Em., No. 12> Dec.  1812,) and that the fatal issue of
this malady has been  thereby procrastinated, it is next to certain that
the  cases under consideration were dropsy of the ovarium and  not
ascites, properly so  called.   It was in the case of an ovarian cyst 
532
NEW ELEMENTS OF  OPERATIVE SURGERY.
that I was obliged to perform it 37  times in one woman, and 29 in
another in less  than three years.

                     § III.—Operative Process.

   The various articles are composed  of a trochar of two lines in di-
ameter, armed with its canula  and besmeared with cerate ; a tub or
any large vessel whatever suitable for receiving the liquid ; a smaller
and deeper vessel which can be held near the belly, if the serum does
not run with sufficient force to render it unnecessary; a portion of
adhesive plaster; various compresses folded several times; a napkin
in the form of an  ecusson; another napkin folded in a triangular
shape and with infra-crurals and its scapulary attached.  An assist-
ant is stationed near the head,  and one towards the feet and the side
upon which the patient is laid, in order to support his chest and the
upper part of  the thighs.  A third stationed upon the opposite side,
or even on the bed, should he apprehend  that he  may be otherwise
too much fatigued, holds himself in readiness to place his hands flat-
wise over  the whole surface of the belly, in-order to  make gentle
compression upon it in proportion as the liquid escapes.   The sur-
geon seizes the trochar and plunges it with his right hand through the
abdominal wall, the teguments  of  which he has kept stretched with
his left.  Forced in suddenly, and in an energetic manner, the instru-
ment scarcely gives the patient  any pain.  Many  authors, fearing
that it might go too deep and wound  some of the viscera, prefer in-
troducing it gently while  turning it upon its axis, and  suppose that
they escape still better by this  means  the danger of wounding any
arteries.   Arguments like these have no  foundation.   The organs of
the lower belly are, as I have  already said, too  remote from  its pa-
rietes in ascites, for the trochar to  touch  them, even though it should
be plunged in  up to its handle.   Nor is there any greater necessity
of obtaining a point d'appui with the  two last  fingers  on the  skin,
while we are introducing it.  Such precautions moreover are only
calculated  to  render the operation more difficult and protracted.
The forefinger or  thumb  elongated upon the  stem of the  trochar,
while the palm of the hand firmly  embraces the handle of the instru-
ment, leaves naked only so much of it as we  wish, and as is required
for reaching the collection of liquid, and will secure us from wounding
the viscera.   Should  the  walls of the belly or cyst be one, two, or
three inches in thickness, so much  so in fine as to embarrass the ope-
rator, an instance of which Saviard states that  he has met with;  or
should they be so flabby as to yield under its pressure, we would em-
ploy another instrument,  and it would be under such circumstances
that the bistoury or lancet might be substituted with some advantage.
When there is no longer any resistance  to the instrument, it shows
that we have entered into the peritoneal  cavity.  The canula, which
is to rest in its place with the mouth directed downwards, is held
there by means of the left thumb and forefinger, while the trochar is
being withdrawn from it.  The  liquid  escapes  immediately  with
more or less force, and with a jet which  may then be readily direct-
ed  into the tub destined to receive it.    The  blunt-pointed probe
chest sound, &c, are only useful in cases where some  foreign body 
PARACENTESIS.
533
has got introduced into the canula.   All the water being extracted,
the operator withdraws the canula by rotating it on its  axis, and at
the same time supports by means of the two first fingers of his other
hand, the periphery of the aperture he has made, to prevent the skin
from being drawn upon it; applies  over this  point 1 he  plaster, and
compresses; in this manner dresses the whole front of the abdomen
and the sides ; adjusts the body bandage and immediately places the
patient in the  middle of his bed, and in the position which is  least
fatiguing to him.

                       § IV.—Accidents.

  Hemorrhage occasioned by puncture, though a rare  occurrence,
is however the inconvenience  which has most attracted the attention
of practitioners.  M. C.  Smith has collected ten examples of it.  It
is easily arrested when it arises from a wound of the epigastric arte-
ry, or any other vessel in the  parietes of the abdomen.   Various
means are used for this  purpose ; one of them employed in the last
century as recommended by Petit-Radel, and which M.  Cruveilhier
states  that  he has made use of with advantage, consists in including
a large fold of the soft parts in  the track of the trochar, then com-
pressing it, and even making friction upon it slightly with the thumb
and forefinger until the blood  has ceased to flow."  A small plug of
wax, the extremity of a rat de cave candle, cut in the form of a peg,
as recommended  by Bellocq, or what is better still, a piece of gum
elastic or plastic bougie,  such  as we  make use of for the  urethra, in-
serted into the wound in  such  manner as to fill it up exactly, is a re-
source which in this respect appears to me to leave nothing  to be
desired.  I do not  know  however  if a  piece of prepared sponge
would not  answer still better.   This substance, by imbibing the  li-
quid at the bottom of the wound, would evidently make compression
outwardly  in the most  advantageous manner;  but it would also pos-
sess the inconvenience of being liable to be  broken when it was
found  necessary to  withdraw  it.   If the  blood, instead  of escaping
outwardly, should have accumulated in the interior, it would be diffi-
cult to recognize it before death.  In supposing moreover the  con-
trary case, the surgeon would  not be benefitted by it.  What  could
he do under such circumstances, and where could he go  to seek for
the deep-seated vessel  which furnishes  the hemorrhage 1   We must
not moreover allow  ourselves  to be imposed  upon by appearances.
We sometimes meet with, upon the surface of serous membranes, a
sanguineous exhalation so abundant as to  communicate to the water
drawn from a dropsical patient, the dark color of venous blood ; so
much so that at first sight we  might be induced to believe that it was
blood instead of serosity which was running from the wound we had
made.   A striking example of this occurred in  an adult affected with
hydrothorax at the hospital of St. Antoine, in the wards of M. Rayer,
while I had charge of the surgical department in this establishment,
and there is no doubt that the  same phenomena might take place in
the peritoneal cavity.  The hemorrhage mentioned by M. S. Cooper
as resulting from  a puncture upon the median line, might well belong
to this  description.   Upon the supposition that the one which was 
534          NEW ELEMENTS  OF OPERATIVE  SURGERY.

noticed at La Charite, in  1824, was not produced by a pure and sim-
ple wound of the  epigastric artery, it might also be explained in the
manner I have mentioned much  better than by the alleged lesion of
a mesenteric vessel.  M. Piegdagnel however relates an instance of
a copious effusion of blood, caused, as he  believes, by a puncture of
an  artery of the epiploon.

          Article IL—Humoral  Tumors of the Liver.

  Abscesses, hydatid cysts and  encysted dropsy of the liver, have
been for  a long time, and  are still  regarded by  many persons as
placed beyond the reach of all surgical resources.  The difficulty of
recognizing them with certainty during life ; the danger of producing
an  effusion into the peritoneal cavity, and  allowing the action of the
air  on the walls of the collection, are the  reasons why an artificial
opening  has been generally  proscribed.  There are,  however, re-
lated instances of cures  obtained  by means of a puncture with the
trochar, or by means of an  opening made with caustic  potash.  On
the other  hand, the mode  by incision  having been the subject of spe-
cial researches, and  M.  Recamier having succeeded  in obtaining
very fortunate results by  combining those different resources, I have
thought it proper to treat of them in this place in a separate article.
Puncture alone would be insufficient should the cyst contain anything
else than limpid serosity.  Moreover, it would cause the effusion of
a certain quantity of liquid into the belly, should there not have been
established protecting adhesions around  the part  that is perforated.
The employment  of the  bistoury would  be still  much  more apt to
give rise  to the apprehension  of this  accident:  it cannot be appli-
cable except in  cases where the  diagnosis leaves no  room to doubt
the  nature and anatomical relations of the  cyst.  Caustics, by acting
too  slowly, incur the risk, it is said, of general peritonitis, in conse-
quence ofthe  local inflammation  which is.produced by their applica-
tion.  A young lady, however,  whom MM. C.  Broussais, Sedillot
and myself treated in 1838, by means of the free application of po-
tassa, was perfectly re-established. In the process of M. Recamier,
potash is  first applied upon several  points that  are nearest to the
morbid  projection, in order that  by their  reunion they may make a
large eschar, which is laid  open at the expiration of a few days by
means ofthe cutting instrument.   Another portion of caustic is then
applied  to the bottom of the wound, and which is destined  to act
much rather in its depth than in  its breadth.  Repeated in this man-
ner in succession, the cauterization is certain to promote  the adhesion
of the hepatic portion of  the peritoneum with that of the abdominal
walls, and enables us to  plunge into the cyst either  the trochar or
the  bistoury, as soon as the  finger clearly recognizes the fluctuation
underneath the incised eschar.  After having extracted all the liquid,
M.  Recamier, imitating  the practice of M.  Billerey  for empyema,
substitutes for it medicated  injections, which he renews every day,
and which he retains in  the morbid cavity, in the intervals between
the  dressings, by shutting up the  wound with a pledget  of lint or
sponge.  By this means the action of the  air is prevented, the pus,
diluted as soon as  it is  produced, cannot stagnate or pass into a pu- 
           CYSTS AND TUMORS OF THE  OVARIUM, ETC.          535

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

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

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

                       § I.—Appreciation.

  Le Dran, Housson and Garengeot had already remarked  that
puncture scarcely ever  succeeds  in this  affection, while it is some-
times cured by freely incising the cyst.  The patient of M. Holscher
(Arch.  Gen. de Med., 1838) was cured  after puncture,  by  means
of an injection  of two  litres of  wine.   Morand maintains that ex-
tirpation  of the  diseased organ  should  be performed  at the very
first. 
536          NEW ELEMENTS OF  OPERATIVE SURGERY.
  A.  Successful Results.—Facts communicated by Delaporte and
Lieutaud  were adduced in favor of this operation, the  process of
which had already been given by Thumin, and  which two English
physicians, Power and Darwin, hastened to advocate with zeal; but
in spite of the efforts of M. Ischier, (These de Montpelier, 1807.) the
successful result  attained  by  Laumonier, the  cure  of  Aid me.  de
Choiseul, and  the similar result related by M. Kapser, the proposi-
tion of Morand,  nevertheless,  remained without  any adoption in
practice, until M. Lizars (Bull, de  Fir., X. IV., p. 144,) undertook to
recall attention to it in 1825, while on their part AIM. McDowell,
Nathan and Alban  Smith, (Journ. des Prog., X. V.,  p. 273,) made
trial of it in America, and MAI.  Dieffenbach,  Chrysmer (Bull, dc
Firr., t. XVIIL, p. 86,) and Martini sought  to render it  popular in
Germany.   At the present day the operation has been performed a
sufficient number  of times  to enable us to appreciate the extirpation
of the ovaries at its just value.   Leaving  aside the operation  as
formerly performed by Lemman, the one published by M. Lafflise
of Nantes, and anpther which belongs  to Delpech,  I will confine
myself to an enumeration  of the most important cases.  The tumor
removed by M. McDowell from Mrs. Crawford in 1809, weighed
15 pounds, and the cure was completed on the 35th day.   In another
patient, M. McDowell  finding both ovaries affected, made his  inci-
sion upon each ; a quantity of  blood was effused into the  belly, but
the  operation, nevertheless, was attended with  entire success.  In
1816  he removed an  ovary  from a negress, which weighed six
pounds, but which was also followed by a perfect cure.  Two other
women whom he  treated in the same manner were not so fortunate;
one remained  in feeble health and  the other died.  Dzondi in one
instance succeeded by means  of an incision, the  employment of
tents, and afterwards  by extirpating the mortified cyst.   Pure and
simple extirpation performed in  a case in  1821 by M. Smith, was
not  followed by any accident.   The tumor removed  by M. Lizars on
the  27th of February,   1825, was as large  as  a foetus at the full
term.  It became necessary to prolong the wound of the  belly  from
the  xiphoid appendix down to the pubis.  The other ovary was also
affected, but  the  patient,  who was 36 years of age, nevertheless
ultimately recovered.   Dr.  Chrysmer, sent for to a woman 38  years
of age, had every  reason to be satisfied with his resolution to perform
the  operation : at the  expiration  of six weeks the  patient was in a
condition to return home.  M. A. Smith operating on the 6th  Alay,
1822, on a young lady, extracted  the  cyst  after having taken six
pints of liquid from it,  and after having strangulated it at its base by
means of  a strong ligature, which came away at  the expiration of a
month and a half.  In  1824 this lady was still in the enjoyment of
the  most  perfect health.   M.  Jeaffreson (British Annals of Med.,
vol. II., p. 140,) incised the cyst, extracted twelve pounds of serum,
drew it outwards  and  extirpated  it, and  also cured  his patient.  M.
King (Ibid., vol. II., p.  141.) obtained a similar successful  result.  In
the  case of  M. Weitenkampff, (Encycl. des Sc. Med., 1836, p.  342,)
a spontaneous opening in  a  similar cyst into the.vagina was also
succeeded by a cure.    M. Quittenbaum, (Ibid., p. 306,) in extirpating
the  tumor, after having extracted from it 20  or 30 pounds of liquid 
           CYSTS AND TUMORS  OF THE OVARIUM, ETC.          537

by puncture, even alleges that he effected a cure of his patient in the
space  of ten days!  After numerous  punctures,  M. Rogers (New
York Med. and Phys.  Journ., 1830, p. 285,) extirpated the cyst and
succeeded.  The same result followed in the case of M. Ehrharstein,
(Arch.  Gen. de Med, X. I., p. 427 ; Med-Chir. Rev., July, 1833, p.
242,) who removed in  this manner  a degenerate  tumor of the  ova-
rium, and in that of M. Ritter,  (Tahere  These,No. 85, Paris, 1839,)
who was no less fortunate.
  B.  To these cases of actual extirpation, followed  by a successful
result, we have to add others in which the tumor was not entirely
removed, and where the operation was not completed in the manner
proposed before commencing it.  It was in this  way for example,
that M. Lizars, finding a simple  adherent mass in front of the sacro-
iliac-symphisis, instead of an enormous cyst  as  he had at first sup-
posed it to be, deemed it proper to restrict himself to the first stage
of the operation, that is, to the  incision of the parietes of the abdo-
men;  immediately closing up the wound, he considered himself suf-
ficiently fortunate in saving the life of his patient. In another case,
M. Granville,  (Journ.  des  Prog., X. L, p. 274,) perceiving that the
cyst could not be detached from the surrounding parts without  diffi-
culty, confined himself to laying it open freely, and carefully empty-
ing it.  By this course he  obtained complete success.  M. Dieffen-
bach, alarmed by the size  of the base of the tumor,  and  of the ves-
sels it contained, and seeing moreover that blood only issued from a
puncture made in its centre, did not  venture to remove it, and im-
mediately united the wound, when the patient also recovered.
  M. Galenzowski,  (Journ.  des  Progr., X. XVIIL, p. 222,) also per-
ceiving that the tumor was  too adherent to be removed, emptied it by
a large opening, broke  up its different cells, traversed its deep-seated
wall with a thread, drew it  towards  the wound in the abdomen to
prevent all effusion into the peritoneum, closed up in the best manner
he could the incision, in the  abdominal parietes, and obtained in this
manner a perfect cure in  the space of a few weeks. M. Mussey,
(Gaz. Med. de Paris, 1838, p. 393,) who after having freely incised the
walls of the abdomen, confined  himself to the puncture of the cyst,
and afterwards the  employment of a meche, also succeeded.   M.
King,  (Press.  Med., X. I., p. 634,) who, deterred  by  the  fainting of
the woman in one case, and from  not  finding in another any tumor
in the  belly when he had introduced his hand there, closed up the
wound by suture  and had no serious accidents follow !  M. Dohlhoff,
(PExperience, X. I., p. 634,)  after having made  an  incision  of five
inches, and finding no description of tumor, also closed up the  wound
and saved his patient!
  C. Failures.—Other trials  have  been less fortunate.   A woman
40 years of  age, operated upon on the 20th September, 1822, by M.
McDowell, died on the morning  of the 24th.  M. A.  Smith, deterred
by the intimate and very extensive  adhesions of  a tumor  ofthe ova-
rium, in a patient who herself had  punctured it more than 80 times,
restricted  himself to  the incision  of the walls of the belly, and did
not dare to  terminate  his  operation.  He had the misfortune, how-
ever, to see  this lady perish on the 42nd day.  The patient operated
upon by M. Lizars on the 22nd March, 1825, died on the  second day 
538
NEW ELEMENTS OF OPERATIVE SURGERY.
 after.  The one which was operated upon by MM. Hopfer, (Bull.
 de Fer.,  X. XVIIL, p. 86,) and Chrysmer, survived only 36 hours.
 Another operated upon by M. Chrysmer himself was not less unfor-
 tunate.  The young girl whose case is given by M. Martini, also died
 at the expiration  of 36 hours.   The patient operated upon by AI.
 Warren, died  at the end of three hours, and M. Dohlhoft, (L'Expe-
 rience, X.  I., p. 625, 626,) who. though the special pupil of M. Dzondi,
 never heard him  speak of the successful results that AI. Lizars im-
. putes to  him,  speaks:  1st, of a woman operated upon  by him, and
 who died of peritonitis  in 36 hours, (Ibid., p. 630 ;)  2nd, of a female
 operated  upon by M.  Grath, (Ibid., p. 631,) who died from hemor-
 rhage at the expiration of sixteen  hours ; 3rd, of another in whom
 he opened the belly, and who had the epiploon cribbled with tumors,
 and  who died eight hours afterwards, (Ibid., p. 633,) without of
 course the operation being carried any farther.   M.  Key, (The Lan-
 cet, 1828, vol.  I.,)  in a  case in which he employed puncture and a
 tent, did not succeed.   M. Kapser  obtained only one cure out of
 three cases.  A  woman in whom  the cyst was of the size of the
 uterus in the eighth month of pregnancy, and in which M. Recamier
 (Revue Med., January, 1839,) made  a  puncture in order to introduce
 a meche or seton  from  above downwards through  the  vagina, also
 died.  M. Marjolin, (Thaere These, No. 85, Paris,  1839,) who con-
 fined himself to an injection of sweetened barley water, was no less
 unfortunate.
   D. Real  Value.—Extirpation of the ovarium, though dangerous, is
 nevertheless a resource which requires examination.  The ovary is not
 so indispensable to the existence of  life that  a woman cannot be de-
 prived  of it  without  very  great danger.   The gelders of  beasts
 remove them without any apprehension during the first weeks of the
 life of the animal, in the female of the hog, and I am enabled to assert
 that in their hands this  operation is scarcely ever followed  by any
 accidents.   Diemerbroeck relates, that according to  Atheneus, Adra-
 metes,  and  according   to  Suidas,  Gyges, king of  Lydia,  treated
 the women  in their kingdom in this  manner.  Alexander-ab-Alexan-
 dro says  the same of the Creophagi and the Egyptians.  Wierus
 states that a gelder  suspecting the chastity of  his daughter, opened
 her belly, and drew the  womb to the outside in  order to excise the
 two ovaries, and that this cruel operation was followed with complete
 success.  Franckenau,  Pott,  Lassus,  (The Lancet,  1828, vol. I., p.
 878,) and AI. Deneux,  each relate an  instance  of extirpation of the
 ovary, which did not prevent the females  from afterwards enjoying
 excellent health.
   In conclusion, the operation is not in itself either  delicate or diffi-
 cult.   The occasions for performing it are unfortunately but too fre-
 quent.  The diseases which require it, if left to the  resources of the
 system, almost always  terminate in death.  But also, in order that
 there should be any chance for success, it is  necessary that the tumor
 should be movable, that it  should not adhere to the  intestines, that it
 should be susceptible of being detached with facility from all the ab-
 dominal organs, that it should have a root or pedicle of small size, and
 that it should not expose to the risk  of wounding vessels  of too large
 a calibre.   It is necessary also, that it should be susceptible of being 
            CYSTS AND TUMORS  OF THE  OVARIUM, ETC.          539

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

                    § II.—Operative Process.

  The  woman placed upon her back, with her lower extremities mo-
derately extended and held by assistants, should be adjusted in such
manner that the most  prominent portion of the cyst presents itself to
the operator.   This last first makes, in a direction parallel to the axis
of the body, an incision from four to six  or  eight  inches long upon
the most suitable part of the abdomen, makes use of the forefinger
of his  left  hand to guide the bistoury, as soon as the peritoneum is
opened, and then occupies himself with the tumor.  Should it be free
and  movable, and easily isolated,  and  have a narrow  pedicle, the
surgeon has nothing more to do than to tie a ligature firmly around
its root, and to excise  it upon the outside of the constriction by means
of the bistoury or scissors.  Should the adhesions which unite it to
the surrounding tissues be loose or easily destroyed, he detaches them
by means of a careful dissection, and proceeds in respect to the re-
mainder of the operation  as in the other case.  Should it  prove to
be fungous, and to have a large base and blood-vessels  of consider-
able size, it would be better not  to meddle with it and to close up
the wound immediately.  Should  its adhesions to the  wall of the
belly not admit of its  removal, we should plunge the  bistoury into it,
and lay it open  freely in such manner as to empty  it entirely, and
that the cyst may afterwards be gradually drawn into the wound of
the abdomen.  The position, adhesive  plasters or the suture will be
used according to the nature of the cases, to reunite the wound, which
moreover should be dressed in the simplest manner possible.  When 
540
NEW ELEMENTS OF OPERATIVE SURGERY.
the solution of continuity has been very extended, the intestines have
so great a tendency to escape  externally, that the  suture then be-
comes almost indispensable.   The same takes place nearly in all
cases, where in order to remove the tumor, it has not been necessary
to lay it open, nor to occasion any very great destruction of parts in
the interior of the  belly.   It is directly  the reverse when  we have
only emptied the cyst, or have not had it in our power to extract all
that we wished to remove.   Upon the supposition that we purpose to
confine ourselves to  the incision, it would be necessary to put our-
selves  on our guard at  first, against effusion, and to encourage the
previous formation of protecting adhesions, if they did not already
exist, between the morbid mass and the  parietes of the abdomen;
and finally, to act in the same manner as in the case  of an abdominal
abscess or hepatic collection.

       Article  IV.—Tumors of  the  Abdominal Parietes.

   M. MacFarlane, (Encyclog. de la Sc  Med., 1836, p. 54,) who states
that he has removed with success an hydatid tumor in the iliac region,
was less fortunate  in two other cases.   Entering through the punc-
ture into a cyst, between  the  peritoneum and the muscles,  death
took place  on the fifth day.  Compelled to remove the ends of the
two last ribs with  a fibro-cartilaginous  tumor which had become
developed between the muscles, he had the misfortune to lose this
patient by peritonitis  at the expiration of thirty-one hours.  In the
case cited by M. Basletta, (Bull, de Fer., X. X., p. 95,) the removal of
the cyst, containing  a pulpy substance analogous to that of the testicle,
and which communicated with the peritoneum, was followed however
by the cure of the patient.   It was the same with the cyst in  the case
mentioned  by M. Dufau, and which burst during an effort made by
the patient.  M. Monod has shown me a  neuromatic or atheromatic
mass of the size of a large fist, which he had successfully removed
from between the abdominal muscles ; but I have mentioned, under the
chapter on tumors in general, and of tumors of the abdomen in par-
ticular, what  ought to be  the special  operative process in  cases of
this  kind.   The  important indication  is to avoid  the  peritoneum.
Should it have become necessary to wound this membrane, we must
be  guided by the rules laid down for the operation for strangulated
umbilical hernia, the  Cesarean  operation, or that employed in cases
of cysts of the ovaria, &c.
   [Ovariotomy.—The results of the latest researches and examina-
tions of comparative statistical tables on this subject, as furnished by
MM. Jeaffreson, (London  Med.  Gaz., October,  1844,) B.  Phillips,
(London Medico-Chir. Trans., vol. XXVIL, 1844.) Chereau, (Journ.
des Conn. Mid.-Chir., Juin, 1844,)  F. Churchill, (Dublin  Journal
and Archiv. Gen., 4e serie, t. V.) and  Emiliani, (Giornali del Pro-
gressi, January, 1845,) seem to admit of  our establishing the follow-
ing  conclusions,  deducible  from about one hundred cases in which
the operation has been performed, up to the present year, 1846, (see
Archiv. Gin. de Paris, Fevrier, 1846,  4e serie, t. X., pp. 216—219.)
1. That the operation is practicable, and even easy, in most instances.
2  That it has received unmerited reproach, in consequence of enu- 
fistulas in the stomach.
541
merating under its failures those cases which have been abandoned,
and in which the  operation has been left unfinished, from the opera-
tor having ascertained that his diagnosis was false and the adhesions
too extensive, (see Jeaffreson, supra cit.)  3. That the most favorable
indication for it is  the existence of liquid, and especially monolocular
tumors, in which the whole contained fluid may be readily evacuated
by paracentesis as often as it forms, but which therefore, for  the
same reason, are those in which it is least called for.   The next most
favorable, and where, however, it is at the same time most required,
are the  multilocular liquid tumors, because  here the puncture can
have but little, at least only a partial and temporary effect.  Again,
it is in a  great measure contra-indicated, and ought to be forbidden,
as we think,  in solid  or sarcomatous or  fibro-cartilaginous  ovaric
tumors,  from the  very extensive nature  of their adhesions.   Nor do
we except, with Dr. Jeaffreson,  from this  remark the cases where
such tumors  lead to consecutive ascites,  threatening a fatal issue.
4.  The larger the incision,  the less  the chances of cure; and  the
smaller the  incision, the more  the prospect of a successful issue, even
though to facilitate this last, the cyst has to be punctured before it is
extracted.  5. The  proportion of deaths is in the ratio of 49 out of
every 100 cases  operated upon, i. e. 49 deaths and 51 cures, which
is a relative mortality not much greater (Arch. Gen., ibid., loc. cit.,
t. X., p. 219,) than that of amputation of the thigh.  But we are to
deduct in part from this estimate, and in favor of the operation,  the
fact, that in  18 cases out of  the 100, the operation had to be aban-
doned, which of course, in some degree, augmented to the same  ex-
tent the chances of a fatal issue ;  while, on the other hand, there was
a false diagnosis  in 7  out of the same 100  cases,  6.  That so far
fsom adopting the precept of Dr. Jeaffreson, that the operation may
be justifiable where the size of the tumor  gives rise to great annoy-
ance or inconveniences, or to such functional derangements as threa-
ten a fatal issue, we  do not think that it would  even then be admissi-
ble, except under very peculiar and very unusual circumstances.
7.  That,  on the  contrary,  we coincide with  the reviewers  of  the
Archives Generales, (X.  X., loc. cit., p. 219,) in language which seems
also wholly congenial with  the  text  of our own author:  that  the
extirpation  of ovarian cysts, though it cannot be  absolutely rejected,
can be had  recourse to only in cases that are wholly exceptional and
excessively rare, and where every other known therapeutic means
has been  exhausted.   T.]

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

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

     HERNIA.
                         CHAPTER I.

                      HERNIA IN GENERAL.

               Article I.—Anatomical  Remarks.

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

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

                        § II.—Envelopes.
  The coverings in every  hernia comprise as their essential elements,
the integuments, the sac, and the intermediate layers.  The skin presents
nothing remarkable, except in relation to its different conditions  of
thickness, density, and adhesions.   It is entirely different with the sac.
  A. Sac.—The name of sac is given to  that portion of  the perito- 
ANATOMICAL REMARKS.
543
neum, which is protruded by the viscera outside of the belly, and
which forms the first covering of the hernia.  The ancients had very
confused ideas upon this subject. They supposed that the descents or
hargnes, (hernias,) which they also called on that  account ruptures
or rompures, were produced by means of a laceration  of the perito-
neum.   At the time of Dionis, it is true, this error no longer existed,
and the existence of  the hernial sac was already admitted in the ma-
jority of cases; but it was not  until  the  time  of Mauchart and Ar-
naud, about the middle of the last century, in  fact until  the time of
the Academy of Surgery, that the sac was considered  an integral
part of every description  of hernia, so  that at  the  present  day its
presence is always deemed essential.
   I. I am in an error, for the moderns acknowledge that hernias  re-
sulting from wounds penetrating into the abdomen,  the  Cesarean
operation, a ligature  upon the iliac  arteries, and  gastrotomy, may in
general be  destitute of this sac.  Nor does a hernial sac exist when
the bladder is displaced at  its  anterior  surface, or the cas cum upon
the part at which it is adherent.  This is a fact which  M. Colson of
Beauvais has demonstrated  in  opposition to the opinion of Scarpa,
who entered into a long discussion to prove the contrary.  We will
remark, however, that under this last point of view, it  is rather a
dispute about words, than a real difference of opinion.   Scarpa, in
maintaining that cascal and vesical hernias possess a sac, only wished
to say  in fact, that a  greater or less extent ofthe displaced organ re-
mains free  in the tumor, and that a  prolongation of the  peritoneum
is found  there as well as in ordinary hernia.   But  M. Colson does
not pretend to deny this arrangement;  he alleges only, that  inas-
much as the hernia is adherent  in the greatest extent of its surface,
we cannot  give the name of sac to the portion of peritoneum which
covers the  remainder of it.   Some persons, on the other hand, con-
sider that hernias which are caused  by traumatic  lesions of the ab-
domen, have a sac as well as the others, unless they are not protruded
before  the  complete  cicatrization of the  wound  of the peritoneum.
It is a question, however, which does not appear to have been con-
sidered in a correct point of  view.
   II. When a perforating wound closes up and is cured, there is  or-
dinarily produced by it a cicatrix, which has  less thickness, and is
less resisting than the natural walls of the abdomen.  The explana
tion of this is  not that the two lips  of the  peritoneum are not  re-
united, but  because, in place of muscles and aponeuroses, there exists
in this part only a fibro-cellular tissue of new formation.   If then a
hernia should be formed here, whether it protrudes the cicatrix be-
fore it, or does nothing more than to displace it, in order to arrive ex-
ternally, we cannot perceive how it can fail of being surrounded on
every side by the peritoneum, and of possessing a true sac. But this
cicatrix may to some extent remain independent of the serous ab-
dominal layer, as it may happen that the peritoneum may have ad-
hered so closely to the borders  of the wound, which allows egress
to the viscera, that the hernia shall have no sac.
  III.  What takes place in this case is also noticed at the umbilicus.
I am perfectly satisfied, from dissections, that umbilical hernias (exom-
phales) do not usually have an internal tunic which can be separated 
544
NEW ELEMENTS  OF OPERATIVE  SURGERY.
from the other envelopes.   The smooth layer (la couche lisse) which
has been taken for this, is intimately united with the external tissues,
and has been developed by dilatation, and not by displacement of or
traction upon the peritoneum.  These facts authorize me to establish:
1st, either a true sac by transposition of the peritoneum ; 2d, a false
sac by simple distension of this  membrane or of any other descrip-
tion of cellular tissue ;  3d, an incomplete sac in  vesical, and in cascul
and hernias, &c.; that is to say, that the hernial pouch is lined through-
out with a true serous  membrane, m the vast  majority of cases, in
some others but partially only, and. that in a very small number what
we see in its interior is  only a simple  surface in  place of a membrane.
  IV.  The form and size of the sac vary in an almost infinite degree.
Hemispherical,  globular, pyriform, bosselated, conical, cylindrical,
bisacculated, with a duplicate, triplicate, or quadruple neck, &c, it
may scarcely exceed the size of a small nut, or be as large as that of
the head  of an adult.   Its internal surface, which is  smooth and
moist,  does not differ from  that of serous membranes in general.  Its
external surface requires a little more attention.   In the true sac it is
lined with a cellular layer, \vhieh necessarily plays an important part
in the history of hernias.   Being a  portion of the internal fascia
superficialis or of the fascia  propria of  the peritoneum, this layer
exists everywhere, but  under  different conditions of laxity, thickness
and adhesions, which are exceedingly dissimilar upon various points
of the abdominal cavity.  It is in this that we meet with the vessels
which are generally referred to the peritoneum, and it  is this mem-
brane which, by its induration or gradual thickening, produces what
is called the epaississement of the sac, and which, after having under-
gone a filamentous  or semi-fibrous transformation, gives rise, when
it is  torn, to the bosselated or irregular appearance presented upon
the external surface of  certain hernias, and it is this  membrane also
which may be the seat of inflammations, suppurations or morbid
alterations of every kind.  From this in fine come the great majority
of vessels which ultimately terminate beneath  the skin after having
traversed  the muscles and  aponeuroses, and it is this membrane upon
which are found those small adipose masses which gradually escaping
through the vascular orifices of the fibrous or muscular layers of the
walls of the abdomen, ultimately, in certain cases, produce  a projec-
tion under the integuments and lead to the erroneous supposition of the
existence of hernias, properly  so called.  Around a false sac this layer
intimately blended  with the  surrounding lamellae, distinguishes it
from the preceding, and is  so constituted that in  place of a membrane
which may be isolated, it presents only a surface wholly incapable
of being detached.  The name of neck which is given to the portion
of sac which  is confined  in  the hernial  opening, might be  advan-
tageously replaced  by that of root; for the first involves the idea of
a strangulation, which  is far from always existing, while the second,
which is equivalent to the  word origin, would in all cases  precisely
express the thing intended.   The neck of the sac then, and I speak
of the true sac, and which is  generally narrower than the body and
bottom of this pouch, is quite frequently folded  or gathered up like  a
purse in the ring which encloses  it.   Should the hernia be ancient or
the folds have remained a long time in contact, it is readily conceived 
ANATOMICAL REMARKS.
545
that they might become agglutinated and impart to the neck under
consideration, a considerable degree of thickness and resisting force.
  V. The existence of several necks in one hernia, which had already
been sufficiently well explained by Arnaud, and afterwards by Pel-
letan and Scarpa, is no longer a matter of obscurity or surprise since
the labors  of M. J. Cloquet.  Suppose that a hernia,  after having
been a long time reduced, should  afterwards reappear, and that the
neck of  the first sac being too narrow to give passage to the viscera,
shall have been protruded by them at the same time that they draw
down another portion of peritoneum and give rise  to the formation
of a new neck; should ^the same thing  happen a second, third or
fourth time, we shall  have produced a sac in the shape of a chaplet
with numerous necks.  When the first adheres strongly by a portion
of its periphery to the neighboring tissues, it is possible that the other
may only cause that to deviate, in place of forcing it to  descend be-
fore it.  In this double sac (bissac)  the two  pouches are  in front or
by the side of, and not below each other. The production of such necks
is also possible where the hernia  has not been reduced.   This then
constitutes anew protrusion, whicn is situated above the ancient one.
   VI. The adhesion of a cord or  of a portion of the epiploon to the
bottom  of the primitive  sac, is one of the  most  favorable circum-
stances  for the formation of a second neck.   Pelletan mentions a
case in which the epiploon traversed in this manner three contracted
passages, in  order to fix itself  to  the  bottom of  the  lower sac.
I have met with an  instance in every  respect similar,  another in
which the upper sac  also contained  a noose of the intestine, and in
1832 another still at La Pitie, which scarcely differed from the first.
As to the numerous  necks of bosselated sacs,  they are formed in
a manner  altogether different.  These latter are simple hernias of
the sac, through lacerations of the fascia propria, or of any other
fibrous layer which should have  taken its place.   The  sac, instead
of necks, may be divided by actual  septa and  form one Or more in-
dependent cysts below that portion which  continues to retain the
viscera.  A striking example  of this I saw  in the patient operated
upon by the  process of M. Belmas.
   B. Aponeuroses.—The tissues  which separate the s,ac  from the
cutaneous layer necessarily vary according to the seat of the hernia,
and could not be studied with  advantage except in each particular
hernia.  I have therefore no occasion to speak at the present time of
any other than the  common cellular tissue and the superficial or
sub-cutaneous fascia.   When there are neither aponeuroses nor
muscles interposed, the fascia propria and  the fascia superficialis
ultimately become blended in  the  thickness of the hernial pouch ;
that is to say, that  we can  no  longer distinguish any separation be-
tween the cellular  lining of the skin and  that of the peritoneum.
   C. Hernial Openings.—The openings which allow of the forma-
tion of  abdominal  hernias are  of various kinds.   Some which are
accidental lacerations, as occurs  in persons in whom  the belly has
been excessively distended by pregnancy, ascites or  any tumor
whatever, &c, rarely give rise to strangulation.  The same remark
is applicable, in a  great  extent, to those which result from a  pene-
trating  wound of  the  abdomen.
                               35 
 546           NEW ELEMENTS OF OPERATIVE SURGERY.

   There are others also which do not require any farther considera-
 tion.  The orifices which are here and there found upon the differ-
 ent fibrous layers of the oblique or transverse  muscles for the pas-
 sage of  vessels of the third order are of this description, and present
 moreover this remarkable feature, that the masses or adipose tumors
 whose pedicle they embrace, and which augment in size under the skin
 and in the other direction are attached to the peritoneum, may dilate
 these openings and by degrees draw a  portion of the peritoneum
 into them in the form of a sac or finger of a  glove, in which  the
 intestine in its turn may ultimately become lodged or even  strangu-
 lated, and thus constitute a description of hernia which is very em-
 barrassing to the practitioner who shall  not have been aware of its
 possibility.
   Those which it remains for us to speak of are  arranged under two
 orders :  these  are either simple  openings or rings, or passages of
 greater or less length and obliquity, and very generally known at the
 present day  under the  name of canals.  At the  umbilicus, for exam-
 ple, the opening is always annular, while at the fold of the groin it is
 generally canaliculated.
   I.  Rings.—The first species is not met with except upon those
 points of the abdomen where the aponeuroses  and muscles do not
 form distinct layers, as at the  linea alba, upon  the  side, and at the
 vagina, rectum, &c.  From these parts, in fact, being incapable  of
 becoming  separated, and admitting only of an opening for  the pas-
 sage  of  the viscera, the hernia  arrives  under the skin immediately
 after having  passed through them, and escapes in  reality only  through
 a simple circle before it is formed.
   II. Canals.—The second kind of hernial opening  is more compli-
 cated.  Its internal and its external extremity represent two distinct
 circles or two rings, which are sometimes separated at a considerable
 distance  from each other.  It is found only at those parts where the
 different  layers of the  abdominal  parietes  are naturally liable to be-
 come separated.   In the normal state it is usually occupied  by vas-
 cular, nervous, or any  other description  of cords.  Its  track, which
 may be  allowed to have walls, is caused  by its two orifices being
 kept more or less widened by the  muscles or other tissues, and by its
 two rings belonging to  two different descriptions of aponeurosis.  If
 its internal and external openings  are  exactly opposite to each other,
 the canal is straight or  perpendicular.   On the contrary, it is oblique
 when they are situated at an unequal  distance from the median line.
 It  is to be added, however, that hernias, provided they have existed
 ever so  little time, have  a tendency to obliterate the  obliquity and
 canaliculated form of the  openings under consideration, and to trans-
 form them all into simple rings by a process which is easily explained.
 The deep-seated and the superficial aponeurosis  being  pressed upon
 in  an opposite direction by the portion of organs  which  has obtruded,
 and by that which still  has a tendency to  make its escape, gradually
obliterate the interval which naturally separates  them, and  are ulti-
mately found in contact.   An oblique hernial canal,  taken in its en-
semble, is sufficiently well designated  by the  shape of an elongated
Z.   Now it is evident that the  viscera which occupy a canal of this
description, naturally tend constantly to  straighten it  by their own 
RADICAL CURE OF HERNIA.
547
weight, and to bring its two openings in face of each other, and that
afterwards they may, as in the  preceding case, conglomerate  them
into the condition of a ring, which is almost perpendicular.  A hernial
opening, however, whether it be a circle or a canal, almost constantly
flares open in the manner of a funnel in  the direction towards the
abdomen, more so in some persons and less  in others.  As on the
other hand, the vessels which  are sometimes found  in  the neighbor-
hood of the neck of the hernia are  usually situated  in  the substance
ofthe fascia propria, that is to say between the peritoneum and deep-
seated aponeurosis, it results from this, that they are generally found
pushed back to the distance of at least  two or  three  lines from the
fibrous border,  which causes the strangulation, and  upon which we
are compelled to act with a bistoury in order to overcome the de-
bridement.

            Article  II.—Radical Cure of Hernia.

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

       § I.—Topical Applications, Compression, Position.

  The emplastrum contra rupturam of the ancients,  the brick cerate
(cerat de  brique)  of J. Fabricius,  the vinegar bags of Verduc, the
sandal wood, tormentil, turpentine, and topical applications of Baby-
net  and Mile. Devaux, the famous remedy of the Prior of Cabriere,
a remedy which consisted of  an astringent plaster  applied over the
hernia, and muriatic acid given internally; the cataplasm  of iron
filings while diamond was administered internally,  as  recommended
by A. Pare, after  the advice of Guy de Chauliac; the decoction of
dog-grass and spurge laurel,  as used by Arnaud;  the carbonate of
ammonia mentioned by M. Belmas, and a thousand other remedies 
548           NEW ELEMENTS OF OPERATIVE SURGERY.

of the same description, no longer find any advocates at the present
day, except among quacks and old women.

                              §11-

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

                              §  III.

  M. Ravin also expresses a  positive opinion, that topical astringents
and compression may effect a radical cure  of hernia at every period
of life.  But with  him these means are only secondary, the base of
his method being the horizontal position of the patient during seve-
ral entire months.   The observations of Riviere, F.  de Hilden, Re-
neaume, Arnaud, and Hey, and the thesis of Rieck, show all the ad-
vantage that may be  derived  from the treatment proposed  by AI.
Ravin, and which  it was said was in general use in Denmark at the
time of  Winslow ; but besides the uncertainty of success, what pa-
tient would consent to remain in his bed for six months or  a year, for
a tumor which is  so easily kept up by means of a simple bandage 1
The examination of these different remedies however, belonging to
pathology  properly so called, I can speak of them only in a cursory
manner, without pretending  to appreciate  their value or disadvan-
tage.  They have moreover  attracted much attention since I called
the attention of surgeons to them in the first edition of this work.

                  §  IV.—Various  Operations.

   The principal operations  which have been  employed  in practice
for the purpose of  obtaining  a  radical cure of  hernia, are cauteriza-
tion, the ligature, the  suture, incision, excision, scarifications, dilata-
tion, and the closing up of the  ring.
   A. Cauterization.—If all that were necessary to proscribe an ope-
ration were to point out its dangers, and to demonstrate its inutility.
cauterization,  which was so frequently employed at the time of Al-
bucasis, Roger, and Guy de  Chauliac, would not have been extolled
by so many practitioners at different epochs.  But  by denying the
successful  results  that it  has in  reality procured,  and  by attaching
no importance to  advantages  which it really possesses,  its antago-
nists in more than one instance  have advanced the cause of those
who endeavored to  render  this practice popular.  Avicenna speab
of surgeons who laid bare the hernia, raised up its internal envelope
without opening it, and  cauterized the ring to  a great depth with a 
RADICAL CURE OF HERNIA.
549
red hot iron.  Others, like  Franco for example, laid open the sac,
and confined themselves to  touching  its neck with a button cautery.
A number of chemical caustics  were  employed for the same pur-
pose.   The  oil  mentioned by G. Fabricius, the sulphuric acid of the
charlatan Littleton, and which another charlatan  succeeded in ren-
dering popular at Paris in the time of Arnaud, the muriate of anti-
mony, potash, the essence of euphorbium and  ranunculus, &c, have
been successively made use of.
  It was by the oil of vitriol that Maget, sustained by Gauthier, and
who was soon after exposed by Bordenave in the Academy, obtained
in 1773 the pretended cures which induced him to request the patron-
age of the government, and with which he caused the death  of La
Condamine.   The potential cautery was applied upon the skin  in the
form of a line or on a circumscribed point near the neck of the hernia,
with the view of  producing an eschar  there, and of causing the sac
to suppurate after it had perforated  it.  It  appears however that
Monro and  the naval surgeon mentioned by Sabatier, applied their
escharotic to the interior ofthe sac also.  Considered in this point of
view, cauterization embraces two methods which  are quite distinct,
one in which it  is applied only to the hernial coats, the  other, on the
contrary, which attacks the orifice through which the organs have
been protruded.   The first is attended with  the  inconvenience  of
incurring the risk of not penetrating sufficiently deep, or if we  do  so,
of injuring some important organ; the  inflammation which it  occa-
sions may not  be limited to the sac, but extend to the peritoneum,
and in this manner cause the death of the patient.  The second also,
which  does not entirely protect us from this danger, possesses at
least the advantage of enabling us to  avoid with  greater  certainty
the viscera, since the operator commences by laying these bare and
pushing them back into the abdomen.   It  must  be added that this
alone presents any chances of success.
  B. Ligature.—The  mode  of  applying a ligature around hernias,
which we are desirous of curing radically, is far from having been
always the  same  among all authors.   Some apply it  immediately
upon the sac, and others on the  skin, without  any  previous incision.
Pare mentions those who confined themselves to a circular incision,
upon the bottom of which they applied the ligature.  At the time of
Paul, many practitioners  also had recourse to this furrow ; but many
of these afterwards opened into the sac, in order to  satisfy themselves
that no organ was included in the ligature.   Guy  de Chauliac says
that we must first lay bare the sac, in  order to seize it and to stran-
gulate it with greater certainty at its root.  Among those who made
use of an indirect ligature, there are some who, like Thevenin, per-
forate the entire pouch with a double thread, and  afterwards stran-
gulate its two halves separately.  J. L. Petit, who  has slightly modi-
fied this process,  professes to have derived great advantages from it.
Celsus speaks of other practitioners who placed the integuments  be-
tween two pieces of wood and compressed them in the same manner
as with a veterinary pincers, until they had become gangrened.   Fi-
nally, the most ancient process,  and the one  which was adopted by
Saviard and Desault, consists in circularly constricting the neck of
all the hernia] envelopes, in such manner as to effect its mortification 
 550          NEW ELEMENTS  of operative  surgery.

 in a greater or less length of time.   This method, which is less bar-
 barous and less formidable than  cauterization, has certainly effected
 a  number of cures.   If  Lassus had understood better the nature
 of the process, he would not have called  in  question those cures
 which Bichat enumerates  in the  practice of Desault.   Every thino-
 also goes to  prove  that  the  medical societies of Lyon and Paris
 would not have so  unequivocally  proscribed  it in  1812, when AI.
 Martin addressed his memoir to  them in order to revive this prac-
 tice, if they had directed their attention to the nature of the modular
 tissue, which is formed by the ulceration caused by the thread.   In-
 asmuch however as it cannot but be painful, and incur the risk of
 peritonitis, or include even some  portions ofthe viscera, unless it has
 been cautiously performed :  and  as on the other hand umbilical her-
 nia in children,  to which it is especially applicable, frequently disap-
 pears without any application or  under that of a simple bandage, this
 operation scarcely deserves to be  rescued from the oblivion into which
 it  has fallen, and the successful result obtained  by this  means by AI.
 Bal, does not enhance its value any more than those  which are said
 to have been obtained by it in experiments upon chickens.
   C. Suture.—The suture, in  applying which they confined them-
 selves to  sewing up the  sac, which had  been  previously incised or
 merely emptied, is in  the first place  infinitely more dangerous than
 the ligature in the manner it was applied by  Desault, inasmuch as it
 sometimes requires a  very tedious dissection  before we can accom-
 plish it; in the second place, not necessarily leading to  the formation
 of an elastic cicatrix, since it is not attended  with loss  of substance,
 and has no other object in  view than to obliterate the sac, it is clear
 that it must be less efficacious in preventing the return of the disease
 than the first process. ' Moreover it is not susceptible of general ap-
 plication,  as it is calculated especially for inguinal hernia in man, as
 well as  for castration.  Consequently it is  unnecessary for me to
 speak of it in this place.
   D. Incision.—Incision has been long  regarded as  an  excellent
 remedy for the  radical cure of ruptures.   It was not scarcely until
 some time in the last century that  it was abandoned  by surgeons.
 All the tunics  and the sac itself were successively divided according
 to  the same rules  as  for  strangulated hernia.   The viscera having
 been reduced, they proceeded  to the dressing, and  the wound was
 cicatrized in the same way as in the last  case.   The obliteration of
the sac was to be a necessary result of a process like this, and the ope-
rator hoped thereby to protect  the patient from any return  of a pro-
trusion of the intestines from the  abdomen.   It was soon perceived
by practitioners that the question had not been examined in  a correct
point of view.   J. L. Petit, listening to the counsels of Arnaud, and
 contending against his own convictions,  deeply regretted having had
 recourse to this  operation.   One  of his patients  died on the fifth day;
 he was witness also to a similar fatal result, and it was not until alter
 having incurred the  most  serious dangers, that a third patient ope-
 rated on was restored to health.   Acrel, Sharp, Richter, Abernethy,
 &c, in pointing out the same disastrous results, have  also shown that
incision in hernia is in itself much more  formidable than  Lieutaud
 and Le Blanc seemed to consider it. 
RADICAL cure of hernia.
551
  E. Excision.—If incision has had to be abandoned in practice, ex-
cision  has been proscribed for much stronger reasons.  We  could
not in  fact  dissect, isolate, and remove  the sac, after having laid it
open, as is recommended by Bertrandi, without augmenting to a still
greater degree the difficulties attending  herniotomy.   By confining
ourselves to excising opposite the ring, a disc including the entire
thickness of the .envelopes of  the  tumor which has been  previously
reduced, as  is recommended by Lanfranc, we might also give
rise to peritonitis, and  moreover wound  the viscera, should they
be ever so slightly adherent to the interior of the  sac.  Excision
of the whole hernial pouch would, it is evident, expose to still greater
risks.   It is truly painful to read the details of operations of this de-
scription, in the works  of  Arnaud, Schmucker, and some other sur-
geons of a more modern date.
  F.  Scarifications.—In place  of excising  the sac  after having
laid it freely open, Le Blanc  proposed to  effect the radical  cure of
hernia by the dilatation of the ring, which had already  been  extolled
by the ancients, but especially by Arnaud, to overcome the strangu-
lation.   The idea of scarifying the ring, which is  attributed to Leon-
idas, and which is distinctly mentioned  by Verduc, Freytag, &c, is
less extravagant, and Richter perhaps was not conscious of the full
value  of his remark, when he observed that  those small incisions in
such cases, greatly assist the  adhesions which must follow the ope-
ration.  The effusion of lymph which almost necessarily results from
them, favors in fact the prospect of all the tissues  becoming  blended
together at the opening of the sac, and of closing up the ring effec-
tually.  If J. L.  Petit and the surgeons  mentioned by Heister, had
been acquainted with this fact, they, doubtless would not have  main-
tained that scarifications are better calculated to  relax than to con-
solidate the hernial canal or   opening.   It  is evidently  to a want of
this knowledge that we must impute the  contempt of Lassus for  this
process, and the silence which most modern authors have shown in
regard to it.  The principal objection which may be brought against
it, is that of exposing to the same dangers  as incision, of which after
all it is nothing more than a simple modification.
  G.  Organic  Plugs.—The radical cure of hernia has always been
so ardently desired by patients, that the necessity of devising some
remedy has never ceased to be an object of extreme solicitude  in the
minds of surgeons, and  that in our time many additional means have
been suggested for the same purpose.
  I. A plug of the epiploon.—When after the operation of strangu-
lated hernia, we are satisfied that the case is one of entero-epiplocele,
we may, after  having reduced the intestine by inserting the epiploon
into the rings, compel it  to  contract at that place adhesions which
will afterwards resist the  reproduction  of the rupture.  M. Cooper
has occasionally succeeded in this way, and I am informed by M. A.
H. Stevens of  New York,  that he has been no less fortunate.   I have
procured the same result in three patients, and M. Goyrand  has  also
related some instances of the  same kind.   However,  besides that this
process does not always succeed, it possesses also a double inconve-
nience : the epiploon,  stretched like a net or in the form of a bridle
from the umbilical region to the inguinal canal,  predisposes to colics 
552
NEW ELEMENTS OF  OPERATIVE SURGERY.
and  tractions upon  the stomach, and moreover to actual  internal
strangulations ; while, in the second place, it scarcely appears to be
applicable  except to cases of strangulated hernia.  I will neverthe-
less add, that after the operation for every strangulated entero-epiploic
hernia, the epiploon, whether we wish it  or not, becomes  attached
behind or to the interior part of the canal, in such manner as to form
the bridle which I have spoken of above.   It is a process of plugging
therefore which  is in  some respects natural, and which it is as well
to aid under the circumstances just mentioned.
   II.  Plugging  with the testicle  or the sac.—Moinichen and Sculte-
tus speak  of  a  process which consisted of plugging up the ring  by
crowding the  testicle into it; but it is useless to speak of a suggestion
of this kind.   J. L. Petit, or Garengeot rather, who dissected up the
sac,  formed it into a peloton, and then pushed it back into the canal
in the manner of a plug, as is still recommended by M. Steffen, (Fro-
riep, Notizen, &c, b.  41, no. 3,)  must have accomplished the same
result with less danger.
   III. A plug of dissected integuments.—A lady operated upon suc-
cessfully for  strangulated  hernia, being much grieved to  find her
malady return at the expiration of a few months, desired to be relieved
of it at  every hazard.   It was a crural hernia.  M. Jameson, after
having laid bare the ring, cut out at the expense of the neighboring
integuments a lancet-shaped flap two inches long, ten lines in breadth,
and having its root towards the first wound,  then carefully dissected
it in order to reverse it and to introduce its floating portion into the
hernial opening,  fixed it in this position by reuniting the solution of
continuity which  he had just made, by means of some points of suture,
and supported the whole by the aid of an appropriate bandage. The
patient recovered perfectly, and there is every reason to believe that
the plug lodged in the crural canal became engrafted  upon it.  At
first sight we see nothing but what is ingenious in this method, while
all its details are plainly understood.   If, on the one hand, it is more
complicated and painful, and as dangerous at least as incisions and
scarifications,  on  the other it appears to  be of a nature calculated
to procure much more  certain  results, inasmuch as we are sure by
this means  of  closing up  the passage  for the viscera.   Nevertheless
to appreciate  its value with a full knowledge of the circumstances,
we require facts, but  science at present possesses only one.  I will
also remark that  this fact does not possess  all the authenticity desira-
ble, and  that  it is difficult to comprehend how M. Jameson, out of
respect to  the wishes of his patient,  should  have consented to have
only the  femme de chambre as an assistant and witness in an opera-
tion  of this description.   So much mystery,  in  fact, is naturally
calculated  to create doubts in the mind of a person of  the least sus-
picion.
  IV. Plug with the  invaginated skin.—The  invagination of the
integuments in the manner performed  by M. Gerdy, or by the modi-
fication of M. Leroy,  or  that of M. Signorini, (Gaz. Med., 1827,
p. 236,) would appear  at first sight  to possess a greater degree of
efficacy.   I have performed  it in one instance with  success.   M.
Gerdy appears to have operated in  this  manner upon about thirty
patients;  but though  many of them  appear  to  have been  cured, it 
RADICAL CURE  OF HERNIA.
553
would be prudent, I think, to wait before adopting this method exclu-
sively.  In fact the plug which is fixed in this manner in the inguinal
canal, cannot contract any adhesions but such as are very feeble, and
everything unfortunately  induces  us to believe that either  a  little
sooner or a little later  the viscera will again crowd it to the outside
and reappear at the ring under the form of hernia.   Certain it is, that
a young man and two other patients, who were at first supposed to
have been cured, and whom I have since seen, are at the present day
precisely in the same condition that they were before the operation.
I will add, that without being absolutely dangerous or exposing to
any serious risk,  as has been supposed,  of wounding the episgastric
artery, it may nevertheless bring on a phlegmonous inflammation of
a grave character in the iliac region, and  even a fatal peritonitis.
  H.  Method  of M.  Belmas.—In 1829 M.  Belmas  projected  a
method which appeared to him to be at the  same time more easy
and certain and less dangerous than all the others.
  1. First Process.—He recommends that we should introduce and
attach a small  pouch of goldbeater's skin to the upper part of the
hernial sac.  The plastic matter soon spreads and penetrates into the
texture of this foreign  substance, and to some extent combines with
it.  The whole becomes  organized, contracts adhesions  with the
ring or neck of the  sac, is transformed  by degrees into  a  solid
nucleus, and  ultimately establishes  an almost insurmountable barrier
against the protrusion  of the viscera.  Numerous experiments  upon
dogs corroborated the assertions of M. Belmas.  It remained to apply
the process upon man, which was done for the first time  upon the
Sieur Plessys, 54 years of age, who had  been  afflicted with a very
large sized inguinal entero-epiplocele for the space of about 34 years.
The operation was attended with perfect success.   The author  com-
municated his process  to  Dupuytren, urging him to make  trial  of it
upon a boy aged 14 years, who was then at the Hotel Dieu, for a
congenital hernia complicated with hydrocele.   Various circum-
stances rendered the operation long and embarrassing.   Alarming
symptoms were produced by it and caused  much uneasiness during
the space of about ten days.  The patient nevertheless was  gradually
restored, and about the termination of the second month the hernia
as well as the  hydrocele  were found to  have  been radically cured.
A third trial made by M. Belmas, assisted  by M.  Jaquemin, at the
Madelonettes, on a girl ofthe town affected with syphilis and umbili-
cal hernia, was not sufficiently complete to enable us to deduce from
it any positive conclusions.   A solid and  permanent cure,  neverthe-
less, was effected by this attempt, in other respects so imperfect.  In
a fourth patient, 57 years of age, with hydro-sarcocele, M. Belmas
was desirous of ascertaining if his  method would succeed, at least in
closing up the ring and  curing the hydrocele.   The goldbeater's
skin had become consolidated at the upper part of the tunica vagina-
lis, which had  become inflamed and had to be emptied of the sero-
purulent matter with which  it had become filled by the  inflamma-
tion.  Finally, a fifth trial was made by myself, assisted by M. Bel-
mas, at La Pitie, in the month of November, 1830, upon a man about
60 years of age, having two inguinal hernias for a long period of years,
and who, at his entrance into the hospital, had exhibited some symp- 
554
NEW ELEMENTS OF  OPERATIVE SURGERY.
toms of strangulation, and who died in consequence of a gangrenous
erysipelas.   The first of these cases is calculated to confirm all the
anticipations of M. Belmas; the fourth,  that of the  hydro-sarcocele,
possesses, in my opinion, very little value in regard to the principal
question, and scarcely deserves to be noticed.  That  of the public girl
proves nothing in itself either for or against the method.  The child
operated upon by Dupuytren appears to have been seized with an
inflammation of the gastro-intestinal passages, and not with peritonitis.
In my own case symptoms of an abnormal character were developed,
and death was actually produced only by the remote cause of a gan-
grenous  inflammation of the scrotum.
  Second Process.—M. Belmas, carrying out his first idea, considers
that he has at last arrived at a process which will be completely suc-
cessful.   His new method consists in depositing in  the sac, as near
to the ring  as possible, small strips of gelatine or goldbeater's skin.
For this  purpose he  perforates  the whole  thickness of the  scrotum
with  a  kind of needle  canula.   When  the dilated portion  of this
instrument appears to have arrived into the hernial cavity, it is un-
screwed in  order to  separate its two halves in the sac, into which
latter the canula then enables us  to introduce small  strips of animal
matter.   Adhesive inflammation supervenes,  the walls of the sac
agglutinate, and  the  obliteration of the pouch must  be the  result.
Though M.  Belmas has informed me that  he has already succeeded
by this process, I am nevertheless disposed to believe that in most
cases it  will allow the hernia to  be  reproduced, and  that it possesses
still less certainty than that of M. Gerdy.
  I.  A distinguished surgeon of Lyon, M. Bonnet, has introduced into
practice  a more simple method, or one at least of more easy applica-
tion.  It consists in perforating  near the ring the whole thickness of
the scrotum, comprising the sac  also, with several pins, while taking
care to avoid the testicular cord.  These pins, curved  back or short-
ened  at their free extremity by means of small pieces of cork, are
intended to bring the walls of the  sac in contact and  to effect their
adhesion.  Four  patients  are stated to have been  already cured in
this manner, and M. Mayor of Lausanne, who makes  use of a small
seton in  place of a pin, considers it an  invaluable  method, and one
that is almost always infallible.   As far  as I can judge a priori, this
process, which is nothing in reality but a modification of the ligature
which was formerly extolled so much, or of the simple incision, will
not continue in practice.   Not because  it  exposes  to  much risk, as
some persons appear  to apprehend, of wounding the spermatic cord,
but because it can only effect an imperfect agglutination of the sac
and leaves the whole length of the  inguinal canal open.
  J. M. Malgaigne, with  a view to  avoid the cord with certainty,
and to produce a more extended obliteration, recommends that we
should perforate  the track  of the canal with  several needles, and
proceed  to compression  by means  of  a  suitable bandage as soon as
the neck of the sac is slightly inflamed.
  K. Method of the  Author.—Sensible, like other  practitioners, of
the want of a radical cure for inguinal hernia, and convinced more-
over  for a long time, as  I  have  elsewhere said, that we  were wrong
in abandoning  indiscriminately  all  the trials which had this object in 
RADICAL CURE OF HERNIA.
555
view, I also have endeavored to arrive at it by a special method.
The process which  I  have proposed is  the same  as  that which is
employed for the radical cure of hydrocele.  I made up my mind to
it after having acquired the proof that irritating injections in  the tu-
nica vaginalis  are  infinitely less dangerous  when they reach the
peritoneal  cavity than  is generally  supposed.   The injections for-
merly made trial of, and still used in our day for the radical cure of
ascites, had already emboldened me.   The  fact  of  wine  having
penetrated into the belly through  a congenital hydrocele, without
any serious accident resulting therefrom, had afterwards satisfied me
that the treatment of hydrocele in children could not be attended
with much greater danger than hydrocele in adults.  Passing from
these premises to actual practice, I did not hesitate to inject irritating
liquids into congenital hydrocele ; and I soon obtained the conviction
that by means  of the precaution of compressing the inguinal canal
during the operation (see Hydrocele) there was no danger in adopt-
ing the process ; from that point to the idea of the radical cure  of
inguinal hernia the distance was very trifling.  I had also remarked
that a hernia coexisting with a congenital hydrocele had not been
reproduced after an operation had  been performed for  the latter.   I
then conceived the idea at the commencement of 1835 of attempting
the radical cure of hernia by this process, especially after it had been
demonstrated to me by numerous examples that the tincture of iodine
possessed  a decided superiority over wine when the object was to
bring  about adhesive inflammation of the serous membranes.   I had
already waited several  months for  an  occasion  to put this  new
method  to the  test, when I  found  myself in a  position in which I
was, so to  speak, forced to make use of it in the month  of February,
1837.   At that period, in fact, I had at the same  time at the hospital
of La Charite two men who were seized with an acute  hydrocele of
the sac, a few days  after returning  into  the belly the intestine con-
tained in an entero-epiploic  hernia.   I  punctured the  cyst and ex-
tracted eight ounces of serum in one case, and  six  in  the other.   I
injected in their place a solution of six gros of tincture of iodine in
three  ounces  of water, and  no accident supervened ;  the sac was
obliterated and the last time that I saw the patients, which was three
months after the operation, no appearance had yet presented itself
of a return of the  disease.   Considering myself justified by these
trials to attempt the direct cure of reducible inguinal hernia, I sub-
mitted a patient to the iodine injection in the commencement of July,
1837.   I made an incision about an inch long through  the tunics  of
the scrotum down to the external surface of the sac.   Having opened
into this latter  with the point of a bistoury, I introduced into it the
canula  of  the  trochar, guided upon a blunt-pointed probe.  After-
wards securing the opening of the sac upon the canula by means of
forceps, 1 directed an  assistant to inject into it  the  abovementioned
solution, while  another assistant, compressing the inguinal canal, ren-
dered it impossible  for the tincture of iodine  to penetrate into the
peritoneal  cavity.   After having thrown the  injection upon  all the
points of the sac, I allowed it  to run out through the  canula, after
withdrawing which  last also  I was enabled to reunite the wound  by
means of three points of twisted suture.  Up to the present time the 
 556          NEW  ELEMENTS  OF OPERATIVE SURGERY.

 symptoms of reaction have been precisely the same as in hydrocele.
 Without venturing yet to  express a decided  opinion upon  the value
 of this mode of treatment, I consider myself nevertheless justified in
 saying that, a priori, it  presents, to say the  least, as many chances
 of success as any of those which have been extolled up to the present
 moment.  As it is in reality nothing more than an experiment, I shall
 avoid at the present time entering into  a further discussion concern-
 ing its importance;  if I  have alluded to it in this article, it has been
 rather with  the view of fixing  its date  than to show precisely what
 is my opinion regarding it, or  wrhat are  the advantages that  might
 be derived  from it.

                       § V.—Appreciation.

  After having  confided  for a long time upon the efficacy of  t«*ie
 thousand  remedies successively enjoying a reputation for the radical
 cure of hernia, it has been finally concluded that this result is next
 to impossible.  The Openings through which the viscera escape  being
 surrounded  by bones or fibrous cords, have not it  is asserted any
 natural tendency in themselves  to close  up, and the judgment cannot
 perceive at first how the operations proposed could effect their oblit-
 eration.   All the world, it is added,  acknowledge that the operation
 for strangulated  hernia does not exempt the  patient from the neces-
 sity of wearing a bandage.  It remains to know if under this double
 point of view, we have not allowed ourselves to be imposed upon
 by certain prejudices.  Though it be true that herniotomy  does  not
 always secure the  patient from a return of the disease, it cannot be
 denied however that this  sometimes happens  and  even quite fre-
quently.   I  could  furnish many examples of this  fact; one among
others of a young  student of medicine whom I operated on in  1827;
a second,  still more  remarkable, and which  relates to a man  about
 thirty years  of age  afflicted with a congenital  hernia, and whom I
operated upon in 1824, at the Hospital of Perfectionnement; a third,
 that of an adult who had had an entero-epiplocele for several years,
 and whom M. Payen operated upon in my presence about the begin-
ning of the  year  1831 ; finally,  four or  five others whom I have
 since operated upon.   The operation for hernia  almost of  necessity
 produces a wound which  will  suppurate, and the  whole surface of
which  will become  covered with cellular granulations  as high up
as into the ring.   By this means a new  tissue is formed  which  is  the
base of the cicatrix,  and which  by its great elasticity and the  adhe-
 sions it contracts with the surrounding tissues, is certainly calculated
to close up,  by a firm consolidation, the track  of the  hernia.  To
 comprehend correctly the character of cicatrices  under these  cir-
cumstances,  we  have only to reflect upon the displacements caused
by those which are usually produced by burns of some  depth,  small
 pox, &c.
  For  this result to be produced, however, it is necessary that the
wound should have  suppurated, and that  the whole surface of  the
 sac, and even the interior of its neck, should have had time to become
transformed  into cellulo-vascular granulations.  If art therefore pos-
 sesses the power of  effecting a radical  cure of certain hernias, the 
RADICAL CURE OF HERNIA.                 557
mode by which we are to accomplish this object is to plug up their
passage, by causing there the production of an  inodular  cicatrix.
Cauterization is evidently calculated to procure this result, when, for
example, it is applied to the  entire thickness of  the  scrotal tunics,
and is made to reach up  as high as the internal  surface of the neck
of the sac.  The indirect or direct ligature is less  certain, because it
acts only  from without  inwards, and because under  this mode of
treatment the interior of the  ring  may not take on any morbid pro-
cess.  The loss of substance  produced by excision is a guarantee of
success which cannot lead  to  an error.   The simple  incision itself
would also doubtless frequently succeed, if we decided upon closing
the wound only  by second intention.   Scarifications  ought  still to
have the preference over all these processes; in the first place, be-
cause they do not incur the risk of wounding the  spermatic cord, as
is the case in cauterization, nor the vessels, as in excision;  and sec-
ondly, because they produce  as their result  a cicatrix much more
solid than incision  properly so called, and which  they effect more-
over with scarcely any more difficulty or embarrassment.   As to the
method of M. Jameson, should new facts be obtained in confirmation
of what its inventor says of it, I should  deem it preferable to many
ofthe others.  The tegumentary plug which is inserted into the ring,
would replace remarkably  well an inodular mass of the firmest con-
sistence, while allowing at the same time of the immediate reunion of
the wound.  The process  of M. Gerdy, M. Leroy and M. Belmas would
also probably act in the same manner. After the operation for strangu-
lated hernia,  the crowding  back of the sac, a  plug  of the epiploon, or
scarifications, are in my  opinion formally  indicated, and would, I am
certain, result in obtaining  radical cures, if at a later period we com-
bined with it compression properly applied upon the whole track of
the canal or ring.   Except for strangulation, the processes of MM.
Gerdy, Bonnet, Mayor, &c, ought on account  of their  being more
innocuous, to  be  preferred to the ancient methods.   Unfortunately
they can scarcely be attended with success except in rare instances,
if they are applied  exclusively and simply alone.  With me the ob-
ject would be to irritate  and gently inflame the  sac  as far up as to
the iliac fossa, and then to keep its walls in contact for the space of
several weeks.  The method I would adopt  would be according as
the circumstances existed,  the processes of Belmas, Gerdy, Bonnet,
Leroy, Malgaigne or my own; the irritation having been produced
and the pain  subdued, I would establish upon the whole track of the
canal, or upon the hernial openings,  a methodical  compression with
the bandages of M. Fournier.
  This compression being persevered  in and  watched during the
space of a month or two, and which would not prevent the patients
from getting  up  and attending to some of their occupations, would
succeed in at least eight instances out  of ten,  if  the  future  should
not belie what I have already seen of it.  At the  present time, this
cure, as a possible result, cannot as I conceive be  hereafter called in
question.  The question  only arises  to ascertain at what risk it is to
be obtained.   In  itself the  operation is in reality neither difficult nor
very delicate.  The lesion of the  testicle, cord and vessels, and the
different local accidents  which it  mav endanger,  are  not inevitabie. 
558
NEW ELEMENTS OF  OPERATIVE SURGERY.
The general symptoms and  the  peritonitis which have been caused
by it in more than one instance, constitute therefore its principal dan-
gers ; but the  few facts related  by J.  L. Petit, Richter, Abernethy,
&c, should they be deemed  sufficient to put this question forever at
rest ?  The removal of a loup. and the operation for congenital hv-
drocele have  also  caused death ; no one therefore would conclude
that we ought to proscribe these  operations, though they are  used in
maladies of a less serious character than hernia.  Upon the suppo-
sition that we decide upon employing it, we must not however ima-
gine that  the  radical cure of hernia is applicable to all cases  indis-
criminately.   It  is at the period of youth that  it presents the least
dangers and the most chances of success.  The  two extremes of life
are the least favorable to it, because of the intractableness of children,
and the rigidity of the tissues in old  persons.  It should generally be
proscribed in old hernias, and such as are of a large size, irreducible
and complicated with extensive adhesions.   We might nevertheless
have recourse  to it with advantage, should the  enterocele or epiplo-
cele only be restrained at the bottom  of the sac by a bridle, which
could readily be divided by a cutting instrument.  It is clearly indi-
cated for example, when  in  a congenital  hernia certain filamentous
adhesions expose the testicle to painful tractions, and to be drawn
up  to  the ring whenever the viscera re-enter the belly, or when we
endeavor to reduce  them.   The dangers that  Zimmerman encoun-
tered after a similar  operation, were probably owing to the difficul-
ties experienced by the surgeon, much more than to the operation
properly so called, and are no argument against it.   Finally, hernio-
tomy never would succeed better than  in adults or young persons, in
whom the enteroceles were devoid of adhesions, and not voluminous,
or of very ancient date.  As soon as the operation is decided upon,
the patient is to be treated and placed  in the same way  as for  stran-
gulation, whatever in other respects may be the method that we have
adopted.  In  conclusion, the radical cure of  hernia would be too im-
portant a triumph for surgery, and a resource too deeply interesting
to humanity, to permit that we should not endeavor to improve it still
more,  and to modify its processes,  and to make renewed efforts for
the  purpose of attaining  this result.   For myself, I cannot cease to
entertain the idea, that in the experimental spirit of our age, we may
succeed in obtaining a remedy of this description which shah be of
real efficacy.   I  must however add, that it would be imprudent to
pronounce judgment at this time, and that  we should suspend a de-
finitive verdict, until new facts  shall have decisively established the
relative value of the best methods.

             § IV.—Radical Cure of Inguinal Hernia.

   Besides the preceding methods, which are applicable to this as to
 every species of hernia, inguinal hernia has given rise to the sugges-
 tion of a number of  others,  which can only be  described under each
 head ;  such particularly are castration, the gilded point, (le point
 do re,) and the royal suture.
   A.  Castration.—Some of the advocates of excision and of ligature,
 or the crowding up ofthe sac, finding  the dissection  ofthe peritoneal 
RADICAL CURE OF HERNIA.
559
prolongation too tedious, endeavored to geX over this difficulty by
comprising the spermatic  cord and  the sac in the same thread.
From this originated the idea of castration.  To effect this Paul re-
commends that we should make a T incision upon the anterior sur-
face of the scrotum.  The transverse wound serves for  the location
of the  ligature, and  the other for the extirpation  of the testicle.
There are others who, after having laid bare the testicle at its lower
portion, dissected the cord and the sac from below upwards, placed
a ligature around the whole near the ring, and then made their exci-
sion below the  thread.  In the last century there were persons who
strangulated  separately the  cord and the sac before excising them.
Some went so far as to comprise the cord, sac, and scrotum in  the
same ligature.   This operation, which was practised with  a kind of
furor by  the ancients, is at the  present day  interdicted by law.
Constantine,  in order to suppress this practice in his dominions, was
obliged to decree  the punishment of death against those who dared
to have recourse to it.  Dionis speaks of a charlatan who fed his dog
upon testicles which  had been taken out in  this way.  Housse, in
1710, was sent to the galleys for the same crime.  Castration was
employed  not only to cure but  also to prevent  hernia.  Thousands
of children have been mutilated for this purpose.   Even women had
the temerity to meddle with it.  M. A.  Prosse, in  1735,  was  sub-
jected  to  the  punishment of flogging  at Rheims for such crimes.
After this epoch there was, in the same diocese, a  miserable woman
who boasted  of having  operated  in this  manner on more, than five
hundred persons.   Some of our  provinces  have been the scene of
such scandalous practices, only a few years since.  Doubtless it would
be a difficult  thing  to explain how it happens that, even in our time,
certain beings  exist who can make  up  their minds to set at defiance
morality and the laws, by performing this operation.  I am not  so
certain, however, if the  fault is not as much imputable to surgeons as
to the public  itself.  In order to proscribe it, medical men have repre-
sented  castration, in such cases, as  exceedingly dangerous, and fre-
quently liable to cause death. According to them, on the other hand,
it could never effect a radical cure, and must always be useless ; but in
these assertions there is an extreme exaggeration which goes beyond
the object intended.  An attentive perusal  ofthe  ancients proves that
the vast majority of the  patients who underwent castration recovered
perfectly, and that numbers  of them have been, by this means, cured
of their hernia.  It is unnecessary and barbarous, but it must not be
pronounced without efficacy.  The only cases which admit of its
application are  those of a sarcocele or incurable degenerescence of
the testicle, coincident  with a  bubonocele.  Whatever Sharp may
say of it,  I do not consider that adhesions, whether epiploic or intes-
tinal, can require it, when in any process of kelotomy whatever, they
are found to  oppose the reduction of the displaced viscera.  At  the
moment of terminating  the operation for strangulated hernia, it  is  not
sufficient  that the testicle should present a little  more or less volume
than usual, and  that it  should appear to be  slightly diseased; it  is
also necessary  that it should have undergone a profound  alteration
before any surgeon, worthy of this  name, should decide  upon re-
moving it; and it  is with extreme surprise  that I have met,  in the 
560           NEW ELEMENTS OF OPERATIVE SURGERY.
latest work of one of our distinguished masters, two instances of a
course of conduct entirely the reverse.
  B.  The gilded point.—The  gilded point is a process which goes
back as far as to the time of Oribases, and which was invented for
the purpose of avoiding  the loss of the testicle, but of procuring,
however, the  same results  as  castration.   It consists  in passing  a
golden wire around the cord and sac, and afterwards in making com-
pression in such manner that this last only shall be strangulated, and
finally to reunite the wound without paying any attention to the pres-
ence of the foreign body, which the patient was to wear during the
remainder  of his life.   This method, which was used in Denmark by
Buchwall, and by Berrault  in  France, was not employed altogether
in the same way by Pare, who recommends a leaden wire  in place
of that of gold, and that  it  should be withdrawn after the expiration
of a certain time.   The absurdity of so ridiculous a practice is suffi-
ciently manifest in itself to dispense with the necessity of dwelling
upon it.  Any person can immediately perceive  that a ligature ad-
justed in this manner cannot avoid the cord any more than the sac,
and that it would more frequently result  in  atrophy of the testicle
than in the cure of the bubonocele.
   C.  Royal suture.—The suture which was denominated royal, be-
cause, according to J. Fabricius, its object was to preserve the lives
of valuable subjects for the service of their kings, is far from merit-
ing the same reproaches as  the point dore.  In order to  perform this
process, the ancients  first dissected the sac, then isolated it from the
surrounding tissues, and afterwards sewed it up in its whole length
without  interfering with the cord.   But Sharp proposed to improve
this method, by suturing at the same time and near the ring, both the
sac and the integuments.  Whether by one mode or the other, we
perceive that  we  are not under the necessity of sacrificing the tes-
ticle, and  that it must  present a better  prospect of  success than
the gilded  point.   As it is nothing, however,  in fact, but the suture
applied to  scrotal hernia, and that scarifications under  such circum-
stances  possess the  same advantage as in every other region, I do
not deem it necessary that I should dwell  longer on  the importance
of the royal suture.  All the new methods which I have spoken ol
above, are evidently preferable, and as they are applicable especially
to inguinal hernia, it does not seem to me  necessary, to discuss at the
present day, the  relative  value of castration,  the point dore, and the
royal suture.

               Article  III.—Strangulated  Hernia.

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

                                §1.
   A hernia is said to be  obstructed,  (engouie,) when the  matters
 which should escape by the anus, accumulate and  are intercepted in 
STRANGULATED  hernia.
561
the noose  of the intestine, which  forms the rupture.   Strangula-
tion, on the contrary, is produced by the mechanical  constriction
which the surrounding tissues exercise, from without inwards, upon
a portion of the alimentary canal, in such manner as to obliterate to
a greater or less degree its calibre.   It is perceived by this definition
that we may in fact  have an obstruction without strangulation, and
vice versa.  Nevertheless, as>, obstruction rarely becomes dangerous,
except from the strangulation which soon succeeds to it, I see no in-
convenience in following the course adopted by many authors, who
consider these two accidents only in the light of cause and effect, or
of one following the other, and confine themselves only to the consid-
eration of strangulation.  Strangulation  sometimes comes on slowly,
at other times suddenly, exists to a greater or less degree, and is or
is not complicated with inflammation, but it is nevertheless always
strangulation.
  The term of incarceration, which Scarpa employs for those cases
in which  the  intestine is  only distended in the hernia, and without
having undergone any serious lesion,  does not appear to me to pos-
sess any advantage.   The words, moreover, are of little importance,
provided  we  can convey a correct  idea of the thing..  A fibrous
opening in the walls of the abdomen  may yield  and  be temporarily
dilated from some effort made, and allow a portion of the viscera to
escape, and  it  may  from its elasticity or muscular  action then
close up, so as to exert a violent  constriction upon the  organ which
has passed through it.  In such cases  we have strangulation by reac-
tion  of the hernial passages.  In  other cases  the  contained parts
swell  and become more or  less suddenly distended, and by this pro-
truding movement, soon also produce a strangulation,  which under
these  circumstances  is > caused by reaction of the incarcerated  or-
gans.  The first case generally happening suddenly, and in some in-
stances simultaneously with the hernia, or from receiving the addition
of another portion of viscera into the  sac "which  contains it, and being
rapidly followed by inflammation, has received the name of acute or
inflammatory  strangulation.   The  second, developing  itself rarely,
except by degrees, and in  hernias which are not usually reducible,
and giving rise to inflammation only  after  the  expiration of a con-
siderable lapse of time, is denominated chronic or that by obstruction.
Inasmuch as the  openings  by which  hernias are protruded are  en-
tirely of a fibrous character, it has been  supposed that the spasmodic
strangulation suggested by Richter  and some others, was a thing  im-
possible.  Fages of  Montpellier,  who, according to  M. Delmas, still
continued to maintain this opinion, endeavored in order to justify it,
to refer this alledged spasm to the large muscles of the belly ;"but
this view of the subject has not procured it any more partisans, and
I myself have contested it.   New researches, and more exact ana-
tomical notions at  the present  day,  influence me in adopting other
views. From the species of button-holes which the hernial openings
in fact represent, being both contiguously and  remotely continuous
with the muscular fibres, it results that every kind of muscular con-
traction may augment the strangulation of the parts which have pro-
truded there.   (See  on this subject  my Anatomie  Chirurgical,  3rd
edit., 1837.)
                               36 
562           NEW ELEMENTS OF OPERATIVE SURGERY.
                 § II.—Seat ofthe Strangulation.

  Though hernias are  usually strangulated  at  their root, this acci-
dent nevertheless is observed also at their body.
  A.  In such cases, it  is caused either by a laceration  of the sac,
which has allowed the organs to protrude into the surrounding tissues
an imperfect septum, or any retraction whatever, or the orifice of a
lateral cell of this envelope, or by an  abnormal  arrangement of the
displaced  viscera, or by some  bridles or morbid  tumors. The torsion
of the intestinal noose  upon  itself, for example, may occasion  it.
The same may occur from an epiploic band, which  would pass in
front of the intestine, to divide it as it were into two portions, be-
fore becoming attached to the bottom of the rupture ; and also from an
opening made by a laceration in this membrane at the middle  ofthe,
sac, and through which  a part of the intestine shall have  protruded.
The epiploon, rolled  up in the form of a cord, may also become at-
tached at  first upon one side, and then upon the  other, in such man-
ner as to form a sort of bridge, and even to make another bridge by
proceeding to attach itself again upon the first wall of the  hernial
cavity.  Two of its  prolongations sometimes may approximate, after
having  contracted lateral  adhesions, and  may  unite  a little  lower
down, leaving between  them an opening, which is also liable to cause
a strangulation.   All kinds of bridles may also produce the same re-
sult as the epiploon.   Hey gives the figure of one, which, attached
at its  extremities to  the two  sides  of the sac,  formed at its middle
portion  a complete circle, through whicn the intestine  had  protruded.
In a patient, whose dead body I had an opportunity of examining, an
indurated  mass of epiploon ofthe size of a large pullet's egg was the
canse of the  strangulation; the same accident  was produced in a
patient  operated upon  by Pelletan. by an  enormous tumor of the
mesentery.  The appendix ofthe caecum would lead to the same re-
sult, if it should  be found in the hernia, and should adhere by its point.
The  same remark is applicable  to the thousand morbid  alterations
which are calculated to produce pressure upon the noose  of the
intestine and to  interrupt the progress of matters through it.   Even
inflammation  of the sac caused  by external violence, may produce
strangulation, as is proved by the case of the  patient mentioned in
the collection of the theses of Strasbourg, (1803,) and who had re-
ceived a spent ball upon the scrotum.
  B.  At its root the  hernia may be strangulated in the same manner,
at first  as in  the  preceding case,  and afterwards by the  opening
through which  it  has necessarily protruded.  But this opening, as
we now know,  comprises several organs, the constricted  portion of
the peritoneal  prolongation, and the  circle  or fibrous canal which
contains it.
  I. At first  sight it would appear difficult that the neck of the sac
itself could produce  strangulation ; there is no point, however, better
established.  In ancient hernias the  agglutination of its folds has
already caused  a great increase  in its thickness.  Cellular lamellas,
moreover, are  successively accumulated  upon  the external  surface
of this  neck.   The  plastic lymph  which is deposited there  at the
same time unites the whole  together, and  gradually  gives  to this 
STRANGULATED  HERNIA.
563
part a very great degree  of density, a thickness in fact which may
become extreme, since Arnaud mentions that it was more than a half
an inch through in one of his patients, and that AI. Graefe has seen a
similar case.   A lardaceous, and even semi-cartilaginous appearance
has also been seen here  in  certain cases; so that this thickening,
arrested externally by the resistance of the ring, is effected at the ex-
pense of its own proper calibre by a concentric reaction, the whole
of which is exerted upon  the intestine.  The  strangulation in  such
cases is sometimes so independent of the  opening of the abdominal
walls, that  this latter remains wholly free, and so large  as to  enable
the neck of the sac to move in it  with  facility; so much  so, that
we might  easily succeed in returning  the  neck  into  the  belly,
together with the viscera, without in any respect  diminishing the
constriction, unless we had previously divided the latter.   Arnaud,
Le Dran and others were the first to point out this arrangement, which
Riviere, Schenck, Litre and Nuck  had only  imperfectly explained,
and  the knowledge of which  Scarpa,  after Pott,  AVillmer,  Hey
and  Sandifort succeeded in diffusing.  In  France Dupuytren is
among the number  of those who  pointed it out in the strongest
manner.  M.  Lawrence,  who  at  first denied its existence, himself
admits it   in the last editions  of  his work; while at the  present
time this species of strangulation is no longer called in question by
any one.   It presents  even  several varieties which are sufficiently
distinct; it may be altogether  annular, or very circumscribed for
example,  and  be situated only  at the  entrance, exit,  or middle
portion of  the neck, or it may occupy the whole of this prolongation,
and transform it into  a sort of case or sheath, which is more or
less contracted.
   II.  The  aponeurotic opening, which was  almost the  only part to
which strangulation was formerly attributed, also produces it in fact.
in a good number of cases.  But  since we have  understood  the
difference  which exists between  the simple  ring and the  hernial
canal, & distinction has become indispensable on this subject, in the
same way  as  for the  neck of the sac ; that  is  to say, that  in  the
openings which are in the form  of a canal, the strangulation, far
from existing always at  the external orifice, as  had been supposed,
may also  be situated at the internal  orifice, or  at an  intermediate
point, and  sometimes even upon these different parts simultaneously.
   HI. Si<rns of strangulation.—The mOst difficult, and at the same
time the most important point to ascertain in strangulation, is to dis-
tinguish it  accurately  from every other kind of disease, and not to
confound it with any other lesion.
  A.  If the tumor is small, and has not attracted the attention of the
patient, too superficial  an examination might  give rise  to the belief
that there existed a violent phlegmasia, a  volvulus, a  poisoning, &c.
These kinds of mistakes are far  from being uncommon, even though
the hernia may not be very small.  A surgeon  in the  environs  of
Paris was called to a patient, whom he supposed to be laboring under
an attack of gastritis,  and whom he treated accordingly.   The ac-
cidents continued, when  a second surgeon was called in, who re-
cognized a strangulated  hernia.   A domestic of one of the public
functionaries  died of  an  alleged  inflammation  of the  intestines:  it 
564           NEW ELEMENTS OF OPERATIVE SURGERY.

proved to be a strangulated hernia, which was not ascertained until
after her death.   A very strong and robust man was seized with vio-
lent colics and convulsive movements.   It was supposed to be a case
of gastritis;  leeches  were applied to the epigastrium, and a state
of rest  recommended for  the space of three days, when the  pa-
tient was brought to  La Pitie.  He had a bubonocele, which  I was
enabled to reduce immediately.  A little more knowledge and pre-
caution in such cases  would readily prevent mistakes ; but this is not
always  the  case, and the  most  skillful surgeons  sometimes err
on this  point.  In 1817 a woman, who was the directress of the
nurses of the Hospital of  Tours, was attacked in the  night with
colic, vomitings, &c. ;  I questioned her, and found she had never had
a rupture.   M. Bretonneau examined her on the following day, and
there was no trace of rupture found either at the abdomen or  the
groins.  Nevertheless, the  pain increased under pressure made at
the fold  of the thigh, and  it was from this point  that  the olit-s
appeared  to  derive their  origin.  A strangulation was  suspected;
but what could be done ?  AVe waited the event, and death occurred
on the following night.  A  portion of the intestine of the size of a
nut, had become strangulated  in the left crural ring, and  made no
projection externally.
  B. Peritonitis.—A number  of  circumstances may lead to  the
misapprehension  of  a constriction of  the  intestine  in  individuals
affected by hernia, as for example, peritonitis when it is accompanied
with constipation and vomiting.  Pott, upon the recommendation of
two consulting physicians and against his own opinion, decided upon
operating  on a young man in whom the hernia appeared to be stran-
gulated.   No lesion was found in the tumor ; the patient died, but of
an acute peritonitis.   Pott,  called to another case, was unwilling to
operate.   The death of the patient  enabled him to ascertain that the
hernia was not strangulated, and that the inflammation of the perito-
neum had caused all the symptoms.  AI. Earle, in 1828, was no less
unfortunate.   The operation  proved that he had been deceived by
an enteritis, and that there was no strangulation.  It is to be observed,
however, that in these cases  the  disease is usually announced by a
chill  of greater or less violence, that the pains are much  more acute
in the belly  than in  the tumor, that the vomitings  are glairy and
greenish, and not stercoraceous, and that the face has a tendency tn
become shrivelled and not hippocratic.
  C.  An inflamed sac.—A no less difficult case is the following:  the
sac of an irreducible  hernia, or the  intestine which it encloses, may
become inflamed and  give rise to all the symptoms of acute strangu-
lation.  Hernias that are destitute of adhesions are liable  to the same
accident.   Sometimes, however, the ring remains free and makes no
pressure whatever on  the organs which pass  through it.   To cause
this inflammation, it is  requisite that the pain should have commenced
at the body or base, and not at the root of the tumor; that the skin
itself should have been involved in this inflammation from the be-
ginning, and the  laxity of the hernial openings capable of being re-
cognized  by the aid  of the finger.  This  result  sometimes actually
takes place, but when  the  hernia  has  but little volume, how can we
avail ourselves of such circumstances ?  Fortunately in such cases, as 
STRANGULATED HERNIA.
565
in actual strangulation, the operation is the best remedy to be em-
ployed.  The viscera have been reduced  and the tumor reappears.
Symptoms of strangulation  supervene ; the operation is performed,
and the surgeon finds nothing but a pouch  filled with liquid, either
purulent or flocculated, or serous or sanious.   This  pouch is the in-
flamed  sac, the inflammation in which  has closed up the orifice.
Numerous examples of this kind have been related by Dupuytren and
MM. Duparcque, Sanson  and Janson.  M. Key has  also been  de-
ceived in this manner, and the error could not be dispelled but by the
fact that it is almost always practicable to obtain some evacuations,
and that the stercoral vomitings do not take place as in true hernia.
  D. Certain hydatoid tumors are to be ranged in the same class, as
is  proved by a case published  by M. Pigeotte de Troyes, and by
those which have been  mentioned by Desault,  Dupuytren and M.
Roux.  A simple suppurating lymphatic tumor, a cold abscess or one
of an ordinary  character, also come under this description.
  AL Baud in a case supposed he was operating for a strangulated
hernia, but it proved to be nothing but a lymphatic tumor, upon the
pedicle of which  he applied a  ligature.  The  symptoms became
worse, and the  patient died,  when it was  ascertained that the thread
applied to the prolongation of the diseased gland, included at the same
time a portion of the intestine.  Purely fatty  tumors expose  to the
same mistakes,  and have occasioned them in more than one instance.
Scarpa, under  the  impression that  the case  was one of strangu-
lation, laid bare the supposed hernia,  and met  with  nothing but  a
pediculated adipose mass, which he  excised.  The  woman, after
having passed through a number of serious symptoms,  ultimately re-
covered.  M. Cruveilhier relates  a  case  in which the operator, less
fortunate, lost his patient.  A woman was seized with  colics, vomit-
ings, constipation, &c.  She  had an ancient tumor at  the  umbilicus.
Being sent for to this case, I found all the symptoms of a hernial stran-
gulation, threatening peritonitis.   Before proceeding to the operation,
I deemed it proper to prescribe a bath, leeches, cataplasms on the
belly, and enemata of various kinds.  They forgot to send her into
my service  from a medical  ward, where she was  at  La Pitie, and
death took place on  the third day.   An acute peritonitis was found,
originating from an old lesion in  the sexual organs, and the supposed
hernia was nothing more than a pediculated fatty tumor.   A peloton
of epiploon may be transformed into an hydatid, or into a hard and im-
movable tumor, and may inflame and suppurate, and become a source
of no less embarrassment, especially if there exists simultaneously  a
noose of the  intestine in the  hernia.   A mower was suddenly attack-
ed with colics and a desire  to vomit, and  at the  same time noticed
that a tumor as large as his  fist had descended into the scrotum.   He
was admitted into La Pitie   on the seventh day.  The hernia was
composed of two portions ; one above which was soft, and  but slight-
ly sensitive, and which I succeeded  in reducing; the other exceed-
ingly hard, and of larger size* which I found it impossible to return.
The symptoms, without being very alarming at first, continued for
the space of three weeks, and had become  aggravated to such de-
gree, that the  patient was  at the point of death, when the  suppu-
ration of his  tumor put an end to  his sufferings, by restoring him to 
566
NEW ELEMENTS OF  OPERATIVE SURGERY.
 health.  A case nearly similar is found in the clinique  of Pelletan.
 The epiploon may mislead also in another manner.   A patient affect
 ed with abdominal hernia, died with symptoms of strangulation. The
 autopsy shewed that the epiploon, which was scarcely affected with
 any disease externally, was  intensely inflamed in the interior of the
 belly, where it formed a sort of hollow cone, the  base of which em-
 braced a perforation of the stomach.

                § IV.—Indications of Strangulation.

   It must have  been noticed by what precedes, that strangulated her-
 nia is a  dangerous disease, and  that without the succor of art, it
 would be almost constantly fatal.   As soon as it is recognized,  it is
 important therefore to put an end to it, and to apply the proper rem-
 edy.   To obtain its reduction, or to put a termination to the strangu-
 lation, are the objects that are to be had in view.  To say with Rich-
 ter and Callisen, that we  should first subdue the inflammatory tenden-
 cy, pain, &.c, in order to diminish the constriction of the parts, would
 be to mistake the effect for the cause, and to attack the consequences
 in place of destroying the principle.  To accomplish this purpose the
 operation is not  the only remedy which the surgeon has at his com-
 mand ;  this is only his last resource.  Before proceeding to this point,
 the taxis, bleeding, baths, injections, anodynes, and various topical
 applications may and should  be made trial of.
   A.  Taxis.—The first idea that occurs to us when called to a pa-
 tient with strangulated hernia, is to endeavor  to push it back into the
 abdomen, and this  in  fact is the  first step that we generally com-
 mence with.
   I. To perform the taxis, the patient is to be placed in a recumbent
 posture, and in such manner that his muscles  may be readily brought
 into a state  9/ relaxation, commencing as La Sourdiere has  shown,
 with the sterno-mastoid muscles.  The surgeon, placed upon the right,
 embraces the tumor with one hand, draws it slightly towards him,
 as if for the purpose of disengaging it from the ring, seizes it at its
neck with the two or three first fingers ofthe other hand, then push-
es it back by small portions at a time, commencing with those that
have  protruded  the last, and causing  them to follow the axis of the
hernial opening.   In proportion as he returns  one part of it, the fin
gers of his other  hand secure it and prevent it from coming out, while
the right hand is prepared to push up another part,  and  in this way
in succession, until  there no longer remains any thing  more than
quite a small mass, which is to be  pushed up in its totality by means
of pressure properly applied.   When the reduction is  effected with-
out difficulty, this last portion, introduced by the extremities of the
five fingers  of the first hand, passes  through the ring without being
arrested there, accompanied immediately with a characteristic sound
which is called gurgling, a bruit  which, is caused  from the liquids
 which had been  before imprisoned in the noose of the displaced intes-
tine, being now  suddenly left to resume their passage along the whole
course ofthe alimentary canal.
   II.  Epiplocele, which is moreover  distinguished  by its irregular
grumulous form,  and its soft cakey consistence, does not produce any 
STRANGULATED  HERNIA.
567
gurgling sound, nor does it yield with as much facility as enterocele.
The taxis, however, should be performed after the same  rules in
both cases, except that in the  second the pressure may be carried
much farther without inconvenience than in the first.   When, after
various efforts, a portion of the hernia is observed to disappear sud-
denly, accompanied with a bruit, while the rest  remains fixed in the
sac, we may then conclude  that there has been an entero-epiplocele,
and that it is the intestine which has resumed  its position.   It is im-
portant, however, not to forget that an  enterocele which has become
strangulated from  obstruction, may readily cause  us to mistake  it
for an epiplocele, and  that its  reduction is not always accompanied
with a gurgling sound.
   III. If the tumor is  small, the fingers of the  left hand are confined
to supporting its contour, while those of the right  hand make  pressure
upon it in every direction.  Even in cases  where  it has acquired  a
certain volume we may still make the attempt to return it bodily, pro-
vided the strangulation has nqt yet been developed to a great degree,
and that it has been caused  by the intestine passing through  a simple
ring.  AVe may also,  when it is  very large,  embrace  it with both
hands and compress it over  its whole surface at the same time, in the
same way as we  would  for emptying a bladder filled with liquid.
The gas and semi-fluid matters thus crowded back, sometimes return
into the belly so completely that they put an end  to the strangulation,
or give a remarkable degree of facility for the subsequent  reduction
of the viscera.  This  is a process which has succeeded with me in a
great number of instances.
   IV. After having in vain  made trial of one mode, we must  have re-
course to another, and the taxis after all is an operation, the perform-
ance of which is learned much better by the practice, anatomical
knowledge, and intellectual  resources of each person, than by details
laid down in the best works.  In conclusion, to place the walls ofthe
belly in a state of relaxation ;  to support the neck of the tumor with
one hand, while we push  back this  last with the other, and in such
way that it may not fold up on the borders of the ring in place of
passing through it; to disengage it a little and to elongate it, and so to
speak, to knead it, in order to disperse the matters which it contains,
over as great an  extent of  surface  as possible ;  to  embrace it with
both hands, or only with the ends ofthe fingers, according to its, vol-
ume ; to cause it to be grasped even by the hands of an assistant,
when it is exceedingly large, while the  surgeon supports its root;  to
make it pass up in an inverse direction by the  route which  it has
taken, when it protruded ; and to suspend our efforts, and to return to
them at a proper time, and to vary their direction and force  without
however going at any time so far as to render them dangerous : such
are the only rules that the operator is under the  necessity  of calling
to mind, when  he is about to undertake  the taxis.
  V. Prolonged taxis.—I should add  that  in large  sized hernias,
especially in the epiploic  or those that are obstructed, it is frequently
advantageous to continue the taxis by means of a methodical com-
pression, until the surgeon resumes it with his hand, when he has not
completely succeeded at  first.  It is this species of prolonged taxis
that M. Amussat and others have extolled in extravagant terms under 
568
NEW ELEMENTS OF OPERATIVE SURGERY.
the title of compulsory taxis, since the period when  I recommended
it in 1832.   In 1825 a man aged forty-seven years, and affected with
an  enormous  entero-epiplocele, was admitted into the wards of the
Hospital of Perfectionnement.   Attempts at  reduction, frequently
repeated the evening of his admission and on the following  morning,
were attended with no  success;  but as  there  was no  evidence of ♦
inflammation, and that the symptoms developed themselves slowly, it
was considered safe to delay.  On  the second day a trial  with the
hand was again resorted to, and the intestine partially returned.  To
prevent its reprotrusion I embraced  the whole of the tumor in a sus-
pensory  padded with compresses.   I  succeeded by  this means in
acting upon it with methodical and sufficiently powerful compression,
which reduced it to one half during the  night, so that the  taxis af-
terwards completed the work without difficulty.   The .smoothing
iron, a piece of sheet lead, and a bladder filled with mercury, applied
as weights  upon the hernia, and from which Wilmer, as  well as
some other English surgeons, state they have derived so much advan-
tage, together with the large  cupping glass of M. Koehler are in re-
ality notbing more than compressing  means, for wThich an appropriate
bandage may  be always advantageously substituted.
  VI.  Compulsory Taxis.—Though  the taxis may frequently possess
the advantage of rendering a dangerous and painful operation un-
necessary,  it is far in  itself  from being always  devoid of danger.
The viscera, whose circulation is performed with difficulty, being
irritated  by the constriction and already more or less inflamed, must
necessarily have this inflammation increased to a still greater degree
under the influence of such compressions.   Every one knows that if
we did not proceed with  all precaution possible, it would be very
easy tQ contuse them, to cause  their  mortification or lacerate them,
and  to expose the patient  to the most dangerous consequences.  It
has also  been long remarked that  the operation had so much the
fewer chances of success in proportion as  the attempts  at reduction
had  been  oftener repeated.   There are persons, says  Petit, who
boast of  reducing all descriptions of  hernia ; they compress, destroy
and  inflame the  intestine, and I have always had recourse with
repugnance to the operation in  patients who have been subjected to
such trials.   Pott recommends that we  should not  wait over two
hours,  and from  the period  when he adopted this  prompt course,
almost all his patients were cured.   Before that he lost the half of
them.
  Desault holds nearly the same language.  Comparative trials had
at the Hotel Dieu, had demonstrated to him, as they had to Saviard,
(Nouv. Obs. Chir., p. 105,) that the proportion of cures after kelo-
tomy was much greater in such persons as were operated upon with-
out having been fatigued  by the  taxis,-than in  others.   At the Hos-
pital of Orleans, where  the operation was performed at the begin-
ning, Le Blanc rarely failed of  success, while at Paris, where it was
not  decided upon until at a late period, most of the patients died.
So that Richter was induced to proscribe the taxis.   He avers that
he has rarely seen a hernia that was  really  strangulated  reduced by
this means, and alleges that those  which have yielded to it would
have returned of themselves  a few hours later.  These  fears, which 
STRANGULATED  HERNIA.
569
are somewhat exaggerated, have no  foundation however, except in
cases* of enterocele and  inflammatory strangulation.   In the case
pointed out by Arnaud, the trials must have been very injudiciously
prolonged to have caused the suppuration of the epiploon, or the im-
mediate gangrene of an enterocele strangulated by obstruction, &c.;
but it may be very readily conceived, that in acute strangulation, the
taxis might, if it had not succeeded, become dangerous and render the
operation infinitely more formidable than if  it had been practised
with moderation.  Nevertheless  in abandoning it  too soon, we ex-
pose ourselves to the danger of unnecessarily  performing a more  se-
vere operation.   In  many  instances,  by renewing  it twice, thrice,
four, and even six times, a painful hernia, which had  resisted up to
that period, has  been made  to return into the  belly.   In other cases,
not  less numerous trials, though unattended  with success, have not
prevented herniotomy, though performed at the expiration of two or
even three  days, from being  followed with complete success.  Fi-
nally, it has been so frequently noticed that a strangulated hernia has
been successfully reduced by one surgeon, after having been in vain
manipulated  by another, that it would be  wrong not to hesitate when
the question  is presented of abandoning the taxis.
  A porter living near me had an ancient hernia, which had become
strangulated the same morning only, in consequence of an effort made
and in spite of his bandage.   Three times during the course of the
day attempts made to reduce  it had failed.  I saw him in the even-
ing  at eight  o'clock, and his  suffering and agitation were extreme.
The slightest touch1 caused him to shriek out.  All the pains came
from the tumor, which could  not endure, it appeared, the slightest
degree of pressure.   I nevertheless did  not venture to decide upon
the operation until I had performed the  taxis  again.   I failed in the
first attempt, but a sudden and involuntary movement  of the patient
while I was making  a last trial,  finally caused the whole intestine to
return.  The accidents  immediately ceased,  and on the  following
day this man was enabled to resume his  customary  occupations.
  In the month of March,  1825, M. Demay desired me  to see with
him a woman who had been suffering under a  strangulated merocele
for the last  36 hours.  The tumor, which was of the size of  a small
egg, was hard  and  painful, and evidently formed  by the intestine.
After  having submitted  it   to  the taxis,  it appeared  to  me to have
been slightly diminished, and I was unwilling to operate.   I went to
see her on the following  day and attempted the reduction, but with
no greater success than  on the  evening before.  But as I found  it
still further diminished I hesitated, and the operation was again defer-
red  a second time.  At my  third visit, 24 hours afterwards, we were
all disposed to wait no longer and to proceed  immediately to the re-
moval of the strangulation;  but  when  I had no longer any hope of
success the hernia disappeared under my fingers, and two days after
the patient was in perfect health.
  Although these facts tend to  prove that in general we ought not
to follow to the letter the advice of Pott or Richter, and to lay aside
the taxis after the first trial, I would not be willing however that
they should give too much  hardihood to  young practitioners.  It  is
but  too  common in  our day, too, to  find what Petit could still ex- 
570           NEW  ELEMENTS OF OPERATIVE SURGERY.

claim, in his time :  " how often  have we  seen patients perish on the
same day even that the reduction has been made !   In some the >mt
has been found gangrened, while in others  it had been torn and the
fascal matters dispersed  in the belly."   This accident happened in
the month of April, 1831, in one of our great hospitals, the very same
day even on  which the surgeon had earnestly inveighed against the
danger of a compulsory taxis.   I am aware of the fact also, that this
accident occurred a short time after in the same establishment.  The
intestine had  been  lacerated  in both cases, and similar results have
happened in the hospitals of London, and one especially in the ser-
vice of  M. Calloway.   The case mentioned by Lassus is in no way
surprising, since the young man took the singular idea in his head of
making use of a stick, and to apply one end of it upon the tumor to
make it return while the other was  supported against a wall. Since
that period I have  collected a greater number of these facts.  The
pernicious  practice having found  new  defenders  in  MM. Herpin
(Journ. Hsbdom., 1835, t. III., p. 216) and Diez, and in a surgeon of
Paris, who considered himself the  author of it, and who has had the
boldness to boast of it in a full sitting of the  Academy, was speedily
followed by numerous victims.  A person  in the city  was seized
with a  strangulated bubonocele;  the surgeon  had recourse to the
taxis, and prolonged it to an excessive degree.  The hernia returned
and the patient was supposed to be cured, but  he died on  the next
day  but, one.   The hernia from having been  complete had been
merely  made  incomplete, without the strangulation  being removed.
Another case  was treated in  the same manner  during the space of
three days ; he was  brought to the hospital, and upon opening the sac
the intestine was  found lacerated.   Seven patients who were admit-
ted to my department  in the years 1836,1837 and 1838, were brought
in after 4, 6, 8 and 11 days of similar attempts, and with their intes-
tines gangrened or  ruptured.  The  idea  of a forced taxis ought so
much the more to be  proscribed, as it is  infinitely to the taste of a
great number  of practitioners.   Fearful  of alarming the patients, in
proposing a dangerous operation, having little practice in the opera-
tion  itself,  and justifying themselves upon  such recommendations,
they make use of  all sorts of manipulations and thus cause acci-
dents which have multiplied in a frightful manner in Paris, since 1831.
In this question moreover they have set out upon a false principle.
The operation for strangulated hernia is rarely dangerous when it is
well performed, unless there should be already  existing a peritonitis
or some dangerous lesions in the displaced organs.   In other respects
it is one of those operations which  succeed the best and occasion
the fewest accidents.   It is to be added,  that by performing it, there
is a prospect, if we follow the rules which I have pointed out in speak-
ing of the radical treatment of hernias, that we  shall effect a perma-
nent cure for  the patient;  moreover  it is evident  that hernias that
are decidedly  strangulated may be  utterly irreducible at the begin-
ning, and that  a considerable number of them cannot sustain the taxis
without the greatest danger.  The  taxis, for example, must  necessa-
rily be injurious in all cases where the obstacle to the progress of the
matters is situated in the scrotum, and when the  intestine has arrived
to that degree of inflammation that it is upon the point of becoming 
STRANGULATED  HERNIA.
571
 perforated or gangrenous.  If the strangulation is at the neck of the
 sac or at the  posterior  ring, or if it is  produced by certain bridles,
 the taxis pushes back the tumor between the two rings  and into the
 tissues of the parietes of the abdomen  between the peritoneum and
 the fascia transversalis; it causes the hernia to disappear externally,
 but the  strangulation nevertheless continues and  the patients perish
 without it being possible to afford them any efficient relief.
  V. Therefore the question is not to reduce the bernia  at any sacri-
 fice, but to know only how to make use of the taxis in a  proper man-
 ner. Those hernias that are small, recent and painful, support it with
 difficulty, because the opening which  has given  passage to them is
 usually narrow and very much contracted ; and because  on the other
 hand the intestine thus bridled  becomes inflamed  and altered, or
 passes into gangrene with the greatest rapidity.   The same remark
 nearly applies to hernias which suddenly reappear and become stran-
 gulated, after having been for a long  time kept up by a bandage.
 The taxis is so much the more dangerous, as  the patient is younger
 and more robust and more excitable.
  In chronic strangulation it would be imprudent • to operate before
 having made repeated  trials with  the  taxis  and even with a certain
 degree of force.   Most old hernias come in  this class.   The pres-
 ence of a portion of epiploon, of any adipose tissue whatever, or of a
 portion of large intestine in the sac, diminishes  its dangers, because
 these different organs are better enabled to sustain  the pressure than
 the small intestine. Moreover it is not the time which has elapsed since
 the appearance of the first accidents, which is to be our guide in em-
 ploying it, but the condition of the parts.  In some patients the gangrene
 or ulceration come on almost as soon as the strangulation.  M. Larrey
 says that he has seen this happen at the end of two hours; Richter
 at eight, and  M. Lawrence at twelve;  while in other cases, which
 are apparently similar, and which I have witnessed, these results had
 not yet  shown themselves upon the fifth or sixth day.   In 1824 I
 operated at the hospital of Perfectionnement upon a woman named
 Moliere, who had been laboring under acute strangulation for the
 space of four days.   The intestine though livid was not mortified, and
 the cure took place  promptly.  Some months after another woman
 was brought into the same establishment to be operated upon for a
 similar  difficulty.  The  symptoms, which had only existed twenty-
 four hours,  exhibited less intensity than in the  first case, and the
 hernia was also crural.   Nevertheless the noose of the intestine was
 perforated, and notwithstanding it was liberated, death took place  in
 the  course of the night.   Upon opening  the body it was found that
 the  alimentary matters  had passed into the belly, and that the gan-
 grene had invaded a great portion of the digestive canal.  So long
 as the skin  has  not  yet become exceedingly sensitive nor positively
 inflamed, that pressure  upon the tumor does not increase the pain  to
 too  great a degree, and  that there are no evident  signs of an actual
 peritonitis, there is  no reason why we should refrain  fnom the taxis,
 unless  it has already been put to the test by experienced persons.
 In the  contrary case it would be better to  renounce it, unless no
attempt  has yet been made with  it  We have then everything  to
fear even in supposing  that we do succeed, that we may return into 
572
NEW ELEMENTS OF  OPERATIVE SURGERY.
the belly an  intestine which is  half mortified  if not perforated,
together with the dark colored putrid and more or less acrid matters
which usually surround it in the sac.  When the  hernia, all other
things being equal, is greatly inflamed, the operation is the most certain
relief to be proposed for the patient.  Being at this moment scarcely
more dangerous than the taxis, it has the advantage over it of remov-
ing the difficulties immediately and of not aggravating the condition of
the viscera contained in the  tumor.  At a later period  the case will
no longer be the same.  The  organs  being then contused, greatly
injured, lacerated and gangrenous, no longer authorize us to  form the
same expectations, and the  operation  would  only accelerate  the
extension of the  disease to the interior, and the fatal  termination.
  VL- Position.—Instead of  placing the patient as above mentioned,
some surgeons, and Winslow among others, in the last century were
in the habit of placing him upon his knees, with the head low down
and  supported on his  elbows, during  the  time while  the taxis was
being performed.   Some credulous or bigoted  persons were in  the
habit of urging the patients, who were thus prosternated, to occupy
themselves with fervent prayers, pretending  that if the  hernia re-
turned while they were in this posture, it would be the interposition
of Divine Providence that they would have to thank  for it.   A much
more ancient practice,  and which was still used by Louis, Hey, AI.
Ribes, &c, consisted  in seizing the patient affected with hernia in
such manner as to hang fflm by his hamstrings upon  the shoulders of
an assistant,  who  shook him gently, while his head and  his back
rested on the bed, or that another person performed  the taxis.   It is
probable that a process of this kind may not  be of very great im-
portance, but it does not appear to  merit the oblivion  into which it
has fallen, nor the ridicule that has  been cast  upon it at the present
day.  M. Lawrence is evidently deceived when  he makes the re-
mark that the abdominal viscera  are too exactly supported in every
portion of them  for the mere position ofthe patient to draw them
either in one direction  or  another.   We may  be  made at any time
sensible of the contrary of this, by noticing in  ourselves that the in-
testines always tend towards the most  depending part of the belly,
as for example, towards the  hypogastrium in the Vertical  position,
and  either to the one  or the other side according as we are lying
upon the right or left flank.   I can therefore conceive that by hold-
ing up a patient  by his  hamstrings, there may be some chance that
the displaced organs will leave the  hernia to be carried towards the
diaphragm, which has become in  this manner  the  lower wall of the
abdomen.  There  would for  the same  reason be danger in doing this
if the intestine or peritoneum  were already inflamed,  or  if for any
reason whatever there were  grounds  for apprehending danger in
any kind of traction made in  the direction of the abdomen or hernia.
  Linacier of  Chinon, with the view of regularizing this succussion
into a method, and in order to generalize it, contrived in 1819 a kind
of vibratory bed or tumbril, provided with  cushions,  and upon which
the patient was adjusted in such manner as to  enable us to move him
more or less violently by successively  relaxing and elevating the up-
per part of the apparatus.  This  bed,  however ingenious it may ap-
pear to be, has not  been and ought not to be adopted.  In the first 
STRANGULATED HERNIA.
573
   place, it has the disadvantage of not always being at command, and
   of not being indispensable ; while in the second place, the patients are
   stretched out and  extended upon it; whereas in suspending the pa-
   tient by his hamstrings, we may keep him flexed and strongly incur-
   vated on his anterior surface.  If therefore we  were  disposed  to
   make trial of succussion, this last mode of operating ought to be pre-
   ferred as more simple  and less dangerous, and as efficacious as any
   machines contrived.  There is no necessity of remarking that the
   taxis should  be renewed  with care, during the time  that the  assis-
   tant or assistants are holding the patient raised up or suspended ; that
   it would be advantageous also to draw upon  the wall of  the belly on
   the side opposite the hernia; and that the succussions that are  made
   upon  the pelvis are not  absolutely necessary.  M. Kramer, (Klei-
   nert's Repert., June, 1835, p. 25,)  who makes his patient stand up
   and supports his loins writh one hand, wnile with the other he pushes
   back the hernia, would, in my opinion, very frequently  fail.   As  to
   gliding in the thumb underneath  the spermatic cord in  order  to di-
   late the ring, as is recommended by Thomson, this cannot be applica-
   ble but to inguinal hernias.
      a. Baths.—However little resistance the hernia may make, the
   taxis ought not to be employed alone.  The bath, under such circum-
   stances, is an auxiliary which is scarcely ever omitted.  It calms or
   diminishes the pain, spasms,  and  rigidity of  the tissues,  the fluxion-
   ary movement, and even the inflammation  itself, if that should al-
   ready exist.   The temperature we give to it is 28 or 30 of Reaumur,
   that is, we make  it somewhat hot.  The patient is to remain in  it
   for the space of one or even  two hours.  Desault recommended, that
   a sheet stretched at its  four  corners, should make in the  bathing-tub
   a sort of bed upon which the patient might be laid in a gently flexed
   position, and subjected  to new trials at reduction.   Some practition-
   ers return to the taxis one or several times in the course of the day,
   that is to say, so long  as  the operation  has  not been decided upon.
   If however more powerful means  have been  already had recourse
   to, it would be useless to return to it, and to waste the  time which is
   precious by fruitless essays.   Although  the hot bath is applicable to
   almost every  description of strangulation,  it is  more especially
   adapted to that which  is acute, inflammatory, and intestinal, and in
   young and robust subjects.   As however, unlike the taxis, it has not
   the disadvantage when it fails of augmenting the dangers; and as
   in the supposition even that the operation should become indispensa-
   ble, it cannot but  favor the successful issue, I see no reason for
   omitting its employment except in cases  where it is no longer allow-
   able to delay.
      b. Bleeding.—The unanimity which prevails among  surgeons  in
   relation to the utility of hot baths  in  cases  of strangulated hernia,
   does not exist  to  so great a degree upon  the subject of bleeding.
   Eulogized beyond measure in such cases by Dionis, by almost all the
   Academy of Surgery, by Pott more than by  any  other  person, and
i   recommended by the most distinguished authors of our epoch,  it has
   nevertheless, so to speak, been proscribed by Wilmer, Alanson, and
   Sir A. Cooper.  Hey acknowledges also that in most cases it is useless,
   and that it is important to make some restriction in its employment. 
574          NEW  ELEMENTS OF OPERATIVE SURGERY.

By producing, however, a general suspension, this resource is calcu-
lated to facilitate the return of the displaced organs, to diminish the
resistance of the muscles, the engorgement of  the tissues, the local
congestion,  and consequently the volume of the  strangulated parts,
and above all the inflammatory symptoms.   Bleeding  pushed as far
as syncope frequently gives such activity to the peristaltic movements
of the intestines, that  under its influence they will of themselves
completely return into the belly.  It would also be  advisable, when
we wish to attain  this object, to open largely  into  the vein, and to
keep  the  patient in a vertical position while we are bleeding him.
As for  the  rest, to understand properly the importance of bleeding,
it becomes necessary to specify the cases which  require  it.  Obstruc-
tion, epiplocele,  and every kind of strangulation  in- old men would
be rather aggravated than relieved by it.  Nor would delicate patients
and  ancient  hernias always  support it without risk, unless it should
have been positively indicated by very decided  inflammatory symp-
toms.   In robust and young persons, and in intestinal, acute, and re-
cent strangulation,  it is on the contrary of unquestionable utility, and
should rarely be neglected, were it only for subduing or moderating
the inflammatory action  which has  a tendency to invade the abdo-
men'.   AVe should be wrong,  however, to accord to it in any case the
exaggerated importance which Pott has  given to it.  It would be
also unreasonable to count upon its efficacy after having repeated it
two or three times, even in  patients in whom it appears to be most
indicated.   It is an auxiliary remedy, which like the bath rarely suf-
fices of itself, and is unworthy of so much reliance in fact, except be-
cause it serves  at  the same time as a precaution against accidents
which.might supervene.
  c.  Purgatives.—Le Grand, a surgeon  of Aries, proposed, in the
last century, the administration of Epsom salts,  promulgating it as a
kind of  panacea  for strangulated hernia; according to him, this sharp
medicine  titillates the intestine, and frequently induces it to return
into  the belly, where  it disembarrasses it of the matters which may
have  accumulated  in  it.  More  violent purgatives, and emetics to
nauseating doses, as ipecacuanha, for example, have also been recom-
mended.  Richter and Heberden, who made use of these, allege that
they have  obtained great advantages  from them.  In  France these
remedies have never enjoyed much reputation, and the  medical opin-
ions which have been  current since  1815 have not been calculated to
bring them into favor among us, though their irritating action may
be infinitely less dangerous  than  many persons  have  imagined.   I
would cheerfully have recourse to them where  there  was  only an
epiplocele or adipose hernia, when in fact the progress of the matters
has not been mechanically interrupted in  the alimentary canal, and
even  in enterocele which  has become strangulated only by obstruc-
tion  and  does  not threaten  inflammation.  As they encourage the
secretion or exhalation of a greater quantity of liquids, a more decided
peristaltic movement in all the upper portion of  the canal, which may
in this  manner  re-establish the stools  or  the  softening of  the ob-
structed matters, we may readily conceive  that under such circum-
stances they may have  been attended with  some success, and that
 here are  still at the present day advocates of this practice,  as an in- 
STRANGULATED HERNIA.
575
stance of which we may particularize  M. Gaussail, (Journ. Hebd.,
t. IV., p. 93.)  A woman, thirty-two years of age, had reached the
fourth day of a strangulated  crural hernia.   Everything had been
made  trial of, baths,  bleeding, the taxis, and all kinds of injections.
The belly was distended and painful, which with the vomitings, con-
stipation, condition of the pulse and aspect of the countenance,  left
no doubt upon the danger  of the symptoms  that this woman must
succumb to if the operation was not performed without delay.  The
patient peremptorily refused to submit to it.  Having nothing farther
to hope  for,  I granted her anything she desired.   At her urgent re-
quest, milk and a purgative were administered to her.  She took two
ounces of castor  oil in the course of the day.  The symptoms con-
tinued until five o'clock in the  evening, but afterwards became more
moderate, and at the time of my visit on the following morning, the
pupils who had been watching her were with myself perfectly aston-
ished  to  find her out of all  danger.  Her restoration was complete.
I have since collected five similar cases, and I consider this  remedy
to be a resource which should  be made trial of more frequently than
it  is.  The dose  I prefer is composed as follows: castor  oil two
ounces, weak infusion of mint four ounces, and syrup of lemon one
ounce; a teaspoonful every  fifteen minutes.
  d. Opiates.—Antispasmodics, opium, and  other substances calcu-
lated to modify the system in general, either alone or associated with
purgatives, as was  the practice of Richter, Heberden. &c, scarcely
deserve to be brought before the attention of the reader.  The only
advantage  that they could promise would be to  calm momentarily
and to palliate the colics, nausea, severe pains, "and some of the symp-
toms, in  fine, caused by the strangulation; but to put an end to the
strangulation itself is not their province.  I cannot see how belladona
administered  in large doses, as is  recommended by M. Chevallier,
would act better  than  opium.  The essence of turpentine, which
MAI. Swal and Mac Williams administer to the amount of two ounces
at each dose, and  in such manner that the patient may swallow to the
extent of eight ounces in twenty-four hours, will never probably be
made use of in France, and  for  that reason itself scarcely requires
more than a passing allusion, notwithstanding  the successes that are
attributed to it in  America.
  e. Enemata.—At the  same  time that we are using either one or
several of the preceding means, we are in the habit of soliciting a
movement in the large intestine.  The  principal object of this being
that of effecting the egress of matters lying below the strangulation,
or at most to produce an anti-peristaltic motion in the entire  alimen-
tary canal, some persons confine themselves to simple lavements, or
laxatives, or  ordinary  purgatives.   Riviere, whose  suggestion has
been revived  by  M. Wood, (Encyclog. des  Sc Med.,  1836, p. 64,)
supposed that by propelling  air through the anus by means of a bel-
lows,  we should  succeed in restoring  the displaced organs  into the
abdomen.
  Hufeland and M. Van Loth,  (Gaz. Med., 1830, p. 14,) professed to
have cured several patients  by injecting in this manner hyoscyamus
or belladonna, which is also recommended  by M.  Pauquy.   Lead
water, eulogized in 1835 by M. Neuner, and which injected to  the 
576
NEW ELEMENTS OF OPERATIVE SURGERV.
 extent of six ounces, procured three decided successes in the practice
 of M. Rennerth,  (Haxthausen, L'Experience, X. L, p. 635,) can vet
 scarcely count in its support  anything  more than mere assertions.
 But in this point of view, tobacco is the substance which has been most
 frequently employed.  It is  administered in the form of tobacco
 smoke, as recommended by Schaeffer, (Acad, de Berlin, X. ArII., Ap-
 pend., p.  141,) by means  of an apparatus which any  person may in-
 vent or construct, or what is at the same time more  convenient and
 secure, in the form of infusion in  the  manner of any other glvster.
 In this last case, a  gros of tobacco to a pint of water is the usual
 dose ; one which it would be dangerous to exceed, inasmuch as AI.
 A. Cooper has seen it cause a sort  of poisoning, which actually took
 place in another case, in which it was administered to the amount of
 two gros, and inasmuch as the same accident  has  since happened in
 the wards of M. Marjolin.  Without agreeing with Heister that it is
 an infallible  remedy, or with Pott, that we have nothing to hope for
 when we have used this in vain ;  and without according to it even
 as much confidence  as Hey, Lawrence, Rose, and most of the Eng-
 lish  surgeons, it cannot be denied that  tobacco injections, have, in
 more than one instance, removed  the strangulation and rendered the
 operation unnecessary.   In a case of this kind everything was ready
 for the operation.  Before operating, however, M. Richerand had oc-
 casion to send for something outside ofthe hospital; during this inter-
 val a tobacco injection was  administered, and  when they came to
 look for the hernia, every one perceived  to his great surprise, that it
 had  completely returned into the belly.   The symptoms immediately
 ceased, and the young man left the hospital on the following day, to
 resume his accustomed  labors.   It is true that I  afterwards saw this
 injection used in the same hospital, and that I myself  have since em-
 ployed it in twenty-five cases at least without any advantage.   The
 oppressio virium, the severe colics, cold sweats, and tendency to
 convulsive movements,  which it usually occasions, are evidences of
 the activity of its powers.  As it determines  at the  same time vio-
 lent  vermicular contractions throughout the whole length of the ali-
 mentary canal, nothing  can be more easily understood than the effects
 which are attributed to it in strangulated hernia.  For the same rea-
 son  that it is powerful, and  of unquestionable utility, the tobacco
 may in some cases be attended with danger.   Prudence would for-
 bid its employment where the  constriction is  very marked, the  her-
 nia recent, purely intestinal, and complicated with inflammation, or
 the strangulation  acute.  On  the  contrary, it  is applicable in  all
 kinds of obstruction or strangulation of the large intestine, or epi-
 ploon, and finally in all cases  where the inflammatory symptoms are
 but  slightly  developed, and  where there  is no danger of making
 tractions upon the  displaced organs with a good deal of force. After
 having tried it to the extent of a gros in such circumstances, we may,
 and ought in  fact,  if no effect has been produced, recur to it one or
 more times, and increase it then to two gros  at  least, provided there
 be neither narcotism or other general accidents to be apprehended.
A new method,  as it would appear  to me, has  been suggested by the
administration  of  injections  for  the relief of strangulated hernia.
M. O'Beirne, (Dublin Med. and Surg. Journ.,  Sept., 1838—Arch., 
STRANGULATED  HERNIA.
577
 1838, t. HI., p. 329,) by introducing a gum-elastic tube into the large
 intestine, to the distance of fifteen or twenty inches, for  the purpose
 of extracting the gases from it, or for pushing up injections, professes
 to have succeeded in eleven cases out of sixteen, and  M. Grant Wil-
 son, (Gaz. Med., 1839, p. 106,) has  been no less fortunate by inject-
 ing in this manner a solution of common table-salt.  I  can under-
 stand, how in hernias of the  large  intestine, this description of rem-
 edy might possess some utility, but I confess that I cannot comprehend
 its efficacy in the others.   I will add that the facts adduced in its fa-
 vor have not appeared to me to be conclusive.
  f. Topical  applications.—Cataplasms, recommended and made
 use of by a number of practitioners, cannot in reality  be serviceable
 except in a small number of  cases.  If the  tumor is neither heated,
 nor tense, nor painful, nor actually inflamed, their utility is more than
 questionable, unless they should act by their weight; and if the con-
 trary state exists, we are not enabled  to wait long enough  for their
 emollient properties to produce any  effect; as however,  they do  not
 prevent our having recourse, at the  same time, to the bath, bleeding,
 and tobacco  injections, I see but  little inconvenience  in  applying
 them to the hernia in cases of acute strangulation, so long as the ope-
 ration is not urgent.
  g. Experience furnishes nothing in favor of leeches, which many
 persons apply also upon  the  tumor or around its circumference, and
 which would  be injurious in hernias devoid of inflammation.  In in-
 flammatory strangulation itself they could, at best, act only against
 an effect which has occurred, whereas it is the cause which we wish
 to destroy.   The ecchymoses, moreover, which are produced  by
 them, have the inconvenience of increasing  the thickness of the her-
 nial envelopes, of disorganizing them and rendering them more pain-
 ful, and thereby rendering  the operation more difficult.   If they
 could ever be useful they would be,  at the farthest, in cases of stran-
 gulation, of an inflamed  epiplocele, or of some  adipose  or other tu-
 mor which was independent of the intestine.
  h.  Refrigerants.—Compresses  saturated  with cold  water, iced
 water, solution of chloride, or with oxycrat; frictions  with acetic
 ether, and all those  remedies, in fact, which, when applied  upon  the
 tumor, are calculated to  abstract a large quantity  of caloric, may
 favor the reduction of hernia:  1st, as revulsives, by  diminishing  the
 afflux of  the fluids; 2nd, by reducing the quantity of gases in  the
 noose of the  strangulated intestine; and 3d, by encouraging  the
 peristaltic action ofthe alimentary tube.   We thus perceive in what
 cases they may be suitable, and in  which we may reasonably hope
 to derive  any  advantage  from them.  A more active manner of em-
 ploying them  is the one which is adopted by certain old women in
 the  country, and which is related by J. L. Petit.  This author being
 sent  for to  a  young  man, and being accompanied by some of  his
 brother surgeons,  was about to commence with the herniotomy,
 when the grandmother of the patient coming into the chamber,  re-
quested everybody to retire, saying that she herself was going to
cure the boy immediately.  After having  stretched him  naked upon
the floor upon a sheet, she ran to the well to draw a bucket of water,
which she suddenly dashed upon  the hernia.  The result was, says
                               37 
^1
578           NEW ELEMENTS OF OPERATIVE  SURGERY.

J. L. Petit, who had requested permission to remain as a witness to
this experiment, that the intestines almost immediately returned into
the belly, and that the  young  man found himself cured without an
operation.  Any person may understand the action of such remedies,
and which  might be had recourse to with a certain degree of confi-
dence, were it not that  in cases where they do not succeed they are
calculated to favor the development of the various kinds of inflamma-
tions which sometimes succeed to herniotomy.  To leave room, how-
ever, for the  gangrene of congelation, as in the case noticed  by AI. A.
Cooper, to be apprehended, it would have been necessary for the ice,
snow, or any  other refrigerant, even  the most active, to  have been
employed with very little precaution, and I doubt myself if any such
accident is in reality to  be apprehended.
   i.  In these latter times much has been  said of the hyoscyamus and
belladonna for the reduction of hernia.   AI.  Speziani makes of these
substances a  pomade, which he spreads over the tumor; A1AI. Aleale,
Vignes, (These, No. 208, Paris, 1837,) Joffre, Carre, Alorand, Porta,
(Brit, and For. Rev., No. 3, p.  269,) Sorbet, (Bull, de  Therap., t. V.,
p. 96,)  Neuber, (Journ. des Conn., X. IL,  p. 86,) Chanel, (Journ. des
Conn., t. I., p. 94,)  Perone, (Ibid., X. L, p. 60.) Koehler, (Gaz. Med.,
1830, p.  14,) Fuzet,  (Rev.  Med.,  1831, t.  IV., p.  211,) Bouchet,
(Journ. de  Med. de la Loire Infer, &c, t. IX., p. 61.) Pages, Faye
and Magliari have succeeded with the same practice ;  AI. St. Amand
has been no  less fortunate in employing them as cataplasms; and
M. Riberi spreads them upon a bougie, which he introduces into the
urethra,  and  also alleges to have thereby procured  successful re-
sults.   Guerin of Bordeaux long since made use of bougies besmeared
with preparations of opium,  and introduced into the  urethra, as a
remedy in strangulated hernia.   I would  not venture to say that we
ought to place much reliance on such remedies; but as they are as
easy in their application as they are devoid of danger, I  do not see
why they might not be had  recourse to when we are not under the
necessity of immediately resorting  to the operation.   I have made
use of  them  in six instances.  The tumor besmeared  morning  and
evening  with pomade of belladonna, was afterwards covered with
simple  cataplasms.  In two instances I introduced into the anus the
same pomade upon a strong  meche, and I must confess that it has
appeared to do good in a number of patients.  In reference to their
mode of  action we must wait, I should  think, for a greater number
of facts  to be adduced  in their favor before we attempt an expla-
nation.
  j.  Acupuncture.—I shall not treat in this place of astringent cata-
plasms, grinder's dust, &cc, and of wild pomegranates and decoction
of walnut leaves, which Belloste states he has found so useful, since
they have been for a long time universally  proscribed ; but I must
say a few words of acupuncture and electro-puncture.  As early as
at the time of Pare they sometimes ventured to perforate the hernia
one or more  times by means of a long needle or small trochar, with
a view of giving exit to the  gases contained in the strangulated in-
testine.  Pott avers that a practice like this is absurd and unworthy
of refutation, and most of the moderns are of the  same opinion.
Nevertheless it has been put in practice in my presence on a patient 
STRANGULATED  HERNIA.
579
whom I operated upon immediately after.  I allude to a young  stu-
dent of medicine in whom his father had frequently employed it with
benefit.  In my opinion it ought to be rejected ;  it cannot be ration-
ally employed except in enterocele which has been distended by gas-
eous  fluids, and  then one of two things must  happen:  either the
small wound closes up at the same time that the needle is withdrawn,
and then the effect is the same as if nothing had been done; or this
wound remains open, and in  this case it is to be apprehended  that
when the intestine has returned into the belly it may allow of the
escape of some  portions of  the  liquids which it  usually contains.
This last accident however could not occur without great difficulty,
for every traumatic perforation of the alimentary canal, the diameter
of which does not exceed one or two lines, hardly ever fails to be-
come immediately obliterated, either by the approximation of its lips
or by the engorgement of its mucous membrane.
  k.  Electro-puncture,  of which some trials have  been  made on
dogs by  M. Leroy, has not yet been as I am  aware applied to man.
It consists in inserting into the tumor the sharpened extremity of the
wire of an electrical or  galvanic circle, while the other extremity of
the same circle is placed upon the tongue or in the anus, according as
the hernia should appear to have  been formed either by the small or
the large intestine.  Theory would  lead to  the inference that the
currents or discharge  of a  pile  of some  strength directed in  this
manner, were  calculated to give rise among the displaced viscera to
such movements or succussions as to effect, in some instances, the re-
turn of the hernia into the belly.  After all  it is a means which may
easily be made use of, and so much the better inasmuch as we might
confine ourselves in place of the electro-puncture, to the application of
a simple electric circle unaccompanied with needles.
  I. Recapitulation.—Let us now place the operator provided with
these  various  means in  presence of a patient affected with stran-
gulated hernia.  Is the case one of ancient enterocele, but which has
become suddenly irreducible ?  If trials have already  been made, he
will before renewing them place the patient in a bath, or even com-
mence by bleeding him at the arm to a  great extent if he is robust
and s3^mptoms of inflammation are to be apprehended.  If the  taxis
does not then  succeed, the  large intestine  is then to be emptied by
laxative  injections, or a purgative will be administered.   The process
of M. O'Beirne will  come next;  and the infusion  of tobacco in its
turn,  two or three hours later.   We will return again to the bleed-
ing if the strength  permits,   and  to the bath and taxis, or even to
the prolonged  taxis, from which M. Nivet, (Gaz. Med., 1838, p. 481,)
like myself, has obtained very  decided  advantages in cases of ob-
struction ; next will come the cataplasms or frictions  of belladonna,
and the bougies according to the process of M. Riberi or M. Guerin.
If all this proves insufficient and there  is no haste, we  will  have
recourse to embrocations, cold topical applications, compression, and
finally electricity.  In  cases of acute strangulation and recent her-
nia, the taxis, bleeding,  baths, enemata, and cold or  narcotic appli-
cations will have to succeed each other rapidly.  If there should
already be inflammation in  the tumor, the tobacco injections  with
the apparatus of M. Vulpes (Apparech. per Introd. Nell'  int. Ret. il 
580          NEW  ELEMENTS  OF OPERATIVE SURGERY.
Fumo di Tabacco, etc., Napoli, 1838,) or any other, and electricity and
compression are no  longer admissible.  Nor is the taxis then to be
performed but with the greatest degree of precaution.  If the pain and
other signs  of inflammation no longer leave any  doubt  as  to the
condition of the parts, bleeding  and the  bath would be no more in-
dicated except as  preparatives ;  all  topical applications  must  be
banished and we must proceed to the operation as soon as possible.
Leeches in  great  number and emollient cataplasms would not be
applicable unless the  symptoms  should appear to depend upon some
tumor disconnected with the intestine.  When the hernia is formed
of a large intestine or  the  progress of the symptoms is somewhat
slow, we commence with the taxis or baths and then have recourse
to tobacco injections, topical applications with  belladonna or opium,
and to refrigerants and  even electricity ;  but the bleeding might, or
can at least, in most cases be omitted.   AVe should proceed  in the
same manner when the case is  one of obstruction  only, and  it is in
such cases that during the interval between the trials with the taxis,
compression by means  of a suitable bandage may be of some bene-
fit, in the same way as  in cases of epiplocele, which are unattended
with adhesions and inflammation.   Finally, after having made trial
of everything  and  modified the application according to the  nature
of the symptoms, we must  no longer think of attempting to reduce
a hernia of this description,  whether it be that  it is restricted by the
adhesions or that the ring opposes to it an unyielding  resistance.  If
there is still time, the kelotomy, whose chances of success moreover
are so much the greater, and its dangers so much the less  in propor-
tion as the period is earlier  at which we have recourse to it, is to be
no longer deferred.  As the attentions which the patient requires
after the reduction  are at first the  same as after the operation, we
shall not at the present time dwell  any longer upon them.

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

                        § I.—Enterocele.

   The operation for strangulated hernia is only  known  since the
time of Rousset.   Maupasius appears to have been the first who
demonstrated its advantages.  Aymar and Formi  (Bonet, Corps de
Med., t. IV., p. 108, obs. 101 and p.  194) however had had recourse
to it with success in the sixteenth and seventeenth centuries.   Up to
that period kelotomy was not performed  except for  the purpose of
effecting a radical  cure of  the rupture.  It  is composed of several
stages ; incision of the  integuments, division of the tissues placed be-
tween the cutaneous envelope and  the peritoneal layer, opening of
 the sac, and examination and appreciation of the strangulated parts,
 the destruction of the strangulation and the reduction of the displaced
 viscera—such are the various  steps the surgeon proposes  to  take
 after having  arranged his  instruments  and the patient and  the as-
 sistants.
   A. Articles of  Dressing.—A perforated linen besmeared with ce-
 rate and sufficiently large,  small balls and plumasseaux of lint, adhe- 
herniotomy or kelotomy.
581
give plasters, long or square  compresses, a long  band or an  appro-
priate bandage, a straight, a convex bistoury, the concave bistoury
of Pott, or the straight blunt-pointed bistoury, a good pair of dissect-
ing forceps and straight scissors, a canulated sound without any cul
de sac, and  some  ligatures and suture needles, constitute, with the
accessories which are required in every great operation, the different
objects  which we may have  occasion for, and which are to  be ar-
ranged in order upon a large flat board or upon a small table.
  B. Position of the patient and the assistants.—The table covered
with a mattrass or the bed upon which the patient is  to be operated
upon, requires no particular  directions, except that it  is to be fur-
nished in a proper manner with alezes.  Nobody at the  present day
imitates Louis, or seats himself upon a stool between  the legs  of the
patient, who is  supported  on the edge of his bed.   The  operator
stands up or places  himself upon his  knees, or sits down and to the
right.  The patient being placed horizontally and  nearer to this
side  of the  bed  than the other, is  to remain  here in a state  of
complete  relaxation.   An assistant  watches the movements  of his
head and arms, another  does the same in respect to the lower ex-
tremities ; a third places himself in front  of  the operator in order to
stretch the skin, sponge  the wound, &c.; while  the  fourth is to re-
main free, and attends to handing the instruments.
  C. Incision of the Integuments.—The parts are to have been pre-
viously shaved, cleansed, and wiped.  If the skin is tense, thick, and
adherent, the surgeon, armed with a  convex bistoury, divides  it in
the same  way as for making a simple incision, from without inwards,
taking care  at first not to go very  deep.   In the contrary case, he
takes up a fold, one extremity of which he gives to the assistant, and
then immediately divides it either by puncture from within outwards,
or what is better, from its border to  its  base.   This fold possesses
the advantage of exposing  less  to the wounding of the viscera, in
spite of ourselves; but the  incision, which is then less  regular, can
never be  prolonged to a sufficient extent with one cut, if the  hernia
is voluminous; so that all things  being equal, the simple incision is
generally preferable when we are sure of our hand.   The  wound
should  have the direction of the greatest diameter, and an extent
proportioned to the size  of the tumor.  We do not give it the T or
crucial form, except in some  particular cases: I prefer the crescenti-
form (en croissant) incision.  When the wound is at first not suffi-
ciently long, the operator, in place of gliding successively under each
of its angles a grooved sound, to enlarge it with a  cut of the scis-
sors or straight  bistoury, pinches up one  of  its  lips, and  directs the
assistant to pinch up the other, in such manner that the forefinger
rests in the wound and the thumb upon the skin for the lower end,
and  the thumb in the wound  and the forefinger on the integuments,
on the contrary,  for the upper end;  slightly  separating while  revers-
ing them  outwards, the lips ofthe wound thus embraced, he then en-
larges it with a  convex bistoury as much as  he deems necessary.
By the  other  method we  cause much more  pain; the skin slips
upon the sound,  folds up and  does not admit of being  incised but with
difficulty.  The vessels which are opened during this first incision, are
rarely of sufficient size to render it indispensable to apply the liga- 
582           NEW ELEMEJ^p OF OPERATIVE SURGERY.

ture  to them immediately.   It generally suffices to make  slight fric-
tion upon them, or to cause the  finger of the assistant to  be applied
temporarily over their  orifice, to prevent their bleeding: their tor-
sion, moreover, is a very simple affair.
  D.  Incision of the intermediate tissues.—The division of the layers
which come next to the skin, requires the greatest attention, and is
not to be made but with caution.   In fact they are not  sufficiently
distinct from each other, nor always  sufficiently constant  in  respect
to their relative thickness, to remove the apprehension of wounding
parts which it is important to respect, or to enable us to dispense with
proceeding with an extreme degree of reserve, even by  feeling our
way until we reach the sac.  The surest mode is to seize them with
the forceps in  proportion as they present themselves on some salient
point of the tumor, to raise up a small flap which is to be excised with
a bistoury flatwise, and to repeat this operation so long as the sac is
not yet laid bare.   The sound  being then introduced  upwards and
downwards, into this kind  of opening, and glided as far  as  the ex-
tremities of the wound, enables us perfectly well to divide these layers
with security by means of the straight bistoury, or even the scissors.
Nobody at the present day  would venture to tear them with the
pointed sound  of Le Dran, or the fleam which some  persons made
use of in the last century.  It is on our approach to  the sac that the
difficulties commence.  In certain persons or in certain descriptions of
hernia, it is only separated from  the skin by an excessively attenuated
lamella; in others it is found at the depth of some lines, and sometimes
even  several inches.  To reach  it  we  are  sometimes obliged to pass
through various lardaceous layers, lymphatic ganglions in a state of
suppuration, and circumscribed or .diffused purulent collections; final-
ly, it  may be immediately surrounded by a more or less considerable
quantity of dark-colored serosity, as has been seen in  one instance,
by both M.  Travers and M. Richerand, and  which is well calcula-
ted to lead to the belief that we  have entered into  its  interior, or it
may be covered by various  kinds  of adipose  tissues, which might
readily be mistaken for the epiploon.
  E.  Interposed adipose tissues, (Plaques.)—This last anomaly, the
importance of which classic authors have omitted to point out, must
necessarily occur frequently.  Saviard (Saviard, Nouv. Obs. Chirurg.,
p. 105,) relates one instance, and Scarpa (Traite des Hemies, &c,
p. 68,) another.  It  was also met with in a patient operated upon
by M. Lisfranc, (Arch. Gen. de  Med.. X. XIIL, p. 453.)   I possess at
the present time more than fifteen  examples, to which might be ad-
ded those of MM. Heller (Journ. des  Conn. Med.,X. IL, p. 346,) and
A. Andral, (These, No. 293, Paris, 1837.)  Though it be  true that a
mistake may in most cases be avoided, it cannot however be denied
that  we must in some instances pay particular attention to it.  When
the adipose layer envelopes the  sac in the manner of a network,  or
that it is itself surrounded with a lubricated membrane, devoid of ad-
hesions, an arrangement like this must evidently embarrass the most
skilful surgeons.  M. Roux, in my presence, came  near making this
mistake at the Hospital of Perfectionnement.  After having divided
the integuments, and several cellulo-adipose layers, he came down
upon  a brownish membrane, very distinct from the others, and which 
HERNIOTOMY OR  KELOTOMY.
583
he cautiously opened.   Finding it smooth and unctuous in its interior,
he supposed he had arrived into the sac.  Underneath it was found a
yellowish colored, porous, and very  pliant mass, but no intestine.
Fearing that this mass might be a noose of the intestine covered  by
the epiploon, M. Roux decided upon dividing it layer by layer, as he
had  done with the other tissues.  In place ofthe intestine, it was the
legitimate sac which soon presented  itself; after which the hernia
presented nothing remarkable ;  Boyer himself had been deceived by
it.  The abnormal production does  not always surround  the whole
of the sac.
  In 1829,  a  patient who had been inadvertently  placed in the
medical wards of  St. Antoine, was brought down  on the following
day into my department.  The strangulation had existed for several
days.  The membrane which I took for the sac being laid open, we
saw before us  a mass composed of two portions, one globular, black,
smooth, and of the size of a  small  egg, situated posteriorly and  in-
wards ; the other larger, less dark, bosselated, and incasing the anterior
and outer half of the first.   The idea of an entero-epiplocele imme-
diately occurred to me.  But in attempting to isolate the adipose por-
tion, in order to proceed to the reduction, I perceived that the intestine
was not laid bare,  and that a semi-transparent lamella still separated
it from the other tissues.  It was the real sac, whose neck gave attach-
ment on its outer surface to quite a large pedicle of a true adipose
hernia, winch I excised.  A washerwoman to whom I was sent for by
M. Forget, presented  an instance of a no  less remarkable arrange-
ment.  I had also laid open a membrane, which might have led to the
supposition  of its  being the sac.   The tumor that it  contained was
trilobated, and its  three lobes, which  were  of unequal size, were of
a.deep brown color.   We immediately perceived that there still was
another covering to the viscera, which it became necessary to divide.
The inner prominence  only  was connected  with  the intestine ; it
had its own sac.  The two others  also  had a distinct  envelope;
they were pediculated,  of an adipose  character, and attached to the
external surface of the hernial peritoneum.  I excised  them after
having reduced the intestinal noose,  and the patient was perfectly  re-
established.  I operated at La Pitie in October, 1831, on an old wo-
man, who presented an arrangement precisely similar to that ofthe first
case, and have found the same arrangement  since in various  forms
at La Charite, both in men and women.  These adipose vegetations
may also assume a thousand other different varieties.   Tartra came
down upon a hard elongated tumor which he could not reduce,  and
which he took for degenerated intestine, and  excised with the view
of establishing an artificial anus.  The patient died, but the intestine
had not been touched !  There was not even an enterocele, and  the
part that had  been removed proved to be an adipose hernia.
  F. A cyst which might have been formed from an ancient hernia
or other sac, empty like that which was found in the patient operated
on at La Pitie by the method of M. Belmas, or filled with liquid, as
many authors  have observed  it, would lead to mistakes of another
kind, and which  may be readily understood ;  mistakes which  might
occur so much the more easily, inasmuch as the sac itself may, after
having been inflamed and then transformed  into an  abscess, give rise 
584
NEW ELEMENTS OF  OPERATIVE SURGERY.
to most of the symptoms  of strangulation, as has been already said
above.
   G.  State  of the sac.—The experienced surgeon, however, aware
of the possibility of so many  errors, will in almost every case be
enabled to protect himself against them.  The sac  is not opened so
long  as  there  presents  a  woolly,  irregular surface,  and a  me-
lange  of plates or  peletons of  an  adipose, vascular, cellular or
lamellar  character, or  so  long  as  the neck of the tumor is not free,
and does not allow of our passing around the whole  of its periphery-,
as high up as  into  the ring, by means of the  nail or  the extremity of
a  sound.  Cysts, abscesses, &c. will be distinguished by their want
of communication with the abdomen.   The  same remark applies to
all morbid  productions  situated  outside  of the   peritoneum.   In
supposing, however, that an  adipose layer might be  mistaken for the
epiploon, what danger  would there be  in dividing it in order to ascer-
tain what existed beneath it ?  Unless there  were particular difficul-
ties in the way, however, we should restrict ourselves to dividing the
sac in the direction of  the wound  of the integuments.   In endeavor-
ing to separate it from the surrounding tissues, the surgeon protracts
the operation,  augments the amount of pain, and renders mortification
of this prolongation of the peritoneum almost unavoidable if he does
not immediately excise it.
   H.  In  the most simple hernias the opening of the sac is an easy
operation, and without any danger for one who is possessed of accu-
rate  anatomical knowledge and some degree of skill.  The intestine
constantly exhibits a certain inequality,  and is  never as  uniformly
globular  as  its peritoneal envelope, which last, moreover, is usually
separated from it  by a greater or less quantity of serosity  or liquid
matter.  It  would  be  in such cases that we might in some respects,
as Louis has ventured  to assert, divide with one incision the skin and
principal layers which separate it from the sac, and then penetrate
with a second incision  into this last envelope without any further ex-
ploration.   In cases  somewhat complicated,  such a procedure would
approach to  rashness, and  in  reality deserve  the censure  which
has been bestowed  upon it.  When there is only a certain quantity
of liquid in the sac, as  in the cases to which M. Tessier's attention
has been directed, (Arch. Gen. de Med., 2e ser., t.  IV., p.  197,) this
would not prevent us from recognizing the  presence of the intestine
in its interior.   It would be the absence or excess of fluid in this pouch
which might lead us into an  error.  It is readily perceived how easy
it would  be  for us, in the first case, to cut down upon the viscera and
divide them without being conscious that we had  gone beyond the
sac.   It is readily understood that the difficulty would be still greater
if those different parts were found united by adhesions.  In the second
case, the only danger is in the possibility of our confounding the sac
with a large portion  of intestine distended by gases or any other fluid
matter, supposing  in such cases that we have not yet been enabled
to distinguish  the sac.
   I.  Hydropsy of the sac.—The presence of a large quantity of
liquid in  the sac has  been so frequently encountered, that I must ne-
cessarily say a few words on this subject.   Saviard mentions a case
of this kind, and  Mery noticed one in a woman in  which there was 
HERNIOTOMY OR KELOTOMY.
585
more than a pint of liquid.   MM. Liegard and Roux have also each
seen  an  instance of the same kind.   Schumcker and Siebold state
that they were upon the point of being  deceived by it,  and of  sup-
posing that  they had come down  upon a hydrocele.  Monro avers
that he has found  more than six pounds of liquid, and Scarpa more
than three in a single sac.  Pott frequently had recourse to puncture
for a complication of this kind, and  M. Lawrence also appears to
have met with it.  Finally, M. A. E. Marechal has collected numer-
ous examples of this kind noticed by him at La Charite.  For this
result to happen, two conditions are required:  1st.  The neck of the
sac must have been shut  up by the strangulation, or by any other
cause;  2d.  The peritoneal prolongation has become the seat of  an
unnatural exhalation.   The other affections which might possibly, to
a certain extent, similate it, are hernia of the  bladder, or  a hydrocele
which should have an  ancient closed hernial sac for its seat, as has
been noticed  by Bertrandi and  Pelletan, (Clin.  Chir., X. III., p. 25,
111,) or large hydatid cysts developed in a strangulated epiploon, as
mentioned by Lamorier.  I have myself seen an  extraordinary case.
Quite a robust old man was brought into my department at St. An-
toine in the month of October,  1828,  to be treated  for an enormous
hernia which had  been accompanied during  the preceding five  days
with constipation,  vomiting  and other symptoms  of strangulation.
This hernia, which occupied the scrotum, was double the size of an
adult head, heavy,  distended, of a brownish color,  slightly painful, and
covered with veins greatly injected with blood, and without any pro-
jection on its  surface.   Its walls were  so thick that the fluctuation
was obscure, and the light of a candle furnished but little information
as to, its nature.  The patient informed us that he had had this hernia
for fifteen years,  during which it had  not  exceeded the size of the
fist, and that he  had frequently succeeded  in returning it into the
belly.  I did not hesitate to open into-it,  adopting  the same precau-
tions as for  an ordinary hernia, that is  to  say, by dividing its en-
velopes  layer by  layer, and  on one point only.  As soon as it was
perforated a clear liquid like urine escaped from  it  in a jet and  with
considerable force.   I immediately enlarged the opening and drew
from it more than  three litres of serosity, which  was slightly turbid.
Its upper part, moreover, contained an entero-epiplocele which was
as large as the fist, strangulated and presenting  several gangrenous
patches  upon it.  Several analogous  cases  have since  occurred at
La Charite..  M. M'llwain, (Encyclog. des Sc. Med., 1838,  p. 94.—
The  Lancet, 21st July,  1838,) in operating upon  a woman for crural
hernia, found a large cyst filled with serum ;  through a neck he was
enabled to  reach  a projection of the  intestine, which was  liberated,
and the  patient recovered.   Was this  anything else than a hydrocele
of the sac ?  (See article on Hydrocele.)   By calling to mind the  natu-
ral characters of  simple hydrocele and cystocele  in such cases, we
shall experience no difficulties.   The mistake, moreover, would  not
be very serious.  Only it  is necessary to recollect that a complica-
tion of this kind renders the efforts for the taxis nearly useless, seeing
that  they are expended upon the liquid before reaching the  intes-
tine, and that, on the other hand, this liquid must  favor the strangula-
tion by its reaction on the  viscera.   The important point therefore is 
586
NEW ELEMENTS OF OPERATIVE  SURGERY.
here, as in every other case, not to confound the sac, which is in this
manner filled with  liquid, with the intestine.  To prevent the possi-
bility of our succeeding  in this, it would be necessary to suppose an
intimate adhesion between these two parts, a sort of blending of the
visceral with the parietal peritoneum of the tumor, which is an ex-
ceedingly  rare circumstance except in very ancient or in cascal
hernias.
   J.  To distinguish the Intestine.—Unless there should be no sac,
or where even adhesions should  exist, we cannot conceive how it
would ever be  absolutely impossible to  distinguish the intestine if
we proceed with proper caution.   The  sac in its natural state is no-
thing but  a simple lamella, and  cannot be  surrounded except by la-
mella.  Whatever be its thickness, and whether that depends  upon
the cellular tissue  which  covers its exterior, or upon accidental lay-
ers deposited upon  its internal  surface, it  will always present itself
under the form  of concentric laminae irregularly superimposed  upon
each other; while the existence of a fleshy tunic with a double layer
of fibres underneath a completely adherent serous membrane, will
prevent our  mistaking  the  intestine or penetrating  into  its  inte-
rior if we are cautious in avoiding it.  A note of the translator of
Scarpa, in which it is  said  that  a surgeon divided the intestine be-
cause the adhesions which united it to the sac did not allow him to
distinguish those two parts;  also  the accident, which happened  in
1831, in one  of  the great hospitals ofthe capital, to the surgeon who
was at the head of that  institution, and who also opened into the in-
testinal  canal while operating for a hernia; as well as many other
mistakes of the  same kind, appear to militate, it is true, against the
opinion  which I have just expressed; but in examining  into these
different cases more closely, without reference to the operators, and
with  a  desire to ascertain the exact truth, we shall readily perceive
that the error was not unavoidable, and  that it would be much more
proper to  impute it to the inattention of the operators than to the na-
ture of  the circumstances.  For example, the practitioner mentioned
by M. Olivier, states that before reaching the sac he was obliged to
pass through a cyst  filled with brown colored serosity.  Now it ap-
pears to me evident  that this pretended cyst was the sac itself, which
was not suspected.   That being the case,  it is very natural that the
intestine should  have been cut  into under the misapprehension that
the hernial envelope only was being divided.
  K.  Be the case  as it may,  we can proceed in two different modes
in order to open the sac.   The first, and which is generally followed,
consists in seizing with a common forceps the point which appears
to be  most free, in order  to raise  up from it a flap which is excised
by  directing the bistoury horizontally underneath the extremity of
the forceps.   The  liquid, if it  contains  any, immediately runs out
through this opening; if not,  it is the intestine which immediately
protrudes into  it, and  which is  distinguished from the  sac by  its
greater suppleness, by its smoother aspect  and other natural charac-
ters.  A sound inserted  into this aperture then enables us to enlarge
it as much as we desire, by protecting the  viscera against the action
of the probe-pointed bistoury, or blunt-pointed scissors which should
then be used.  The other method is apparently more dangerous, and 
HERNIOTOMY OR  KELOTOMY.
587
on that account  is generally censured by authors.   Nevertheless I
have always found it more simple than the preceding, and I would
not hesitate to give it the preference if wre  could always count with
sufficient  surety  on the  hand  of those persons who  operate  for
strangulated hernias.   While the left hand makes sufficient tension
upon the sac or tumor, the right,  with a straight bistoury held  like a
pen, directs the point gently, and  with small cuts upon the projecting
part, divides them layer by layer, enables us in this manner to distin-
guish  all  the lamellas  which present themselves, or to stop  when
we wish to do so, and to  penetrate with full  as much  certainty as
by the ordinary process.   It is  a rule  to open the  sac  down  to the
lower part of the tumor, in  order that this part may not serve as a
receptacle for pus or other liquids  which might  accumulate  at the
bottom ofthe wound.  Many surgeons advise to do the same for the
upper part;  but others recommend  that we should not incise in this
last direction only to  a certain distance from the ring.   It is alleged
that the patient is thereby less exposed to peritonitis, and the sur-
geon less in danger of making a  mistake when he divides the ring;
but it becomes then almost impossible to insert the bistoury between
the neck of the serous tunic and the aponeurotic opening, as it is said
has sometimes happened.  If names like those of J. L. Petit and A.
Cooper had not   become its defenders, such minute surgery would
not have required to be specified.   Is it in  fact  possible that they
have seriously discussed  the question of ascertaining whether it was
advisable or not to prolong to the  distance of a few lines more or less
the incision of the sac in  one direction or another ?  Those who have
performed the operation for strangulated hernia, will not be able to
understand how the debridement can be made either more or less easy,
or peritonitis be more or less avoided by one than by the other of these
modes of procedure.  All that we have to accomplish is to lay bare
completely the root of the parts  that are to be reduced. As to the
rest, it is a matter of little  importance whether the incision of the
peritoneal prolongation  be extended as high up as  into the ring, or
arrested at some lines this side of it.
   L.  Expansion  and adhesion of the viscera.—The  viscera  being
now free  from every impediment as soon as the sac  is  largely laid
open, frequently  acquire suddenly a size much more considerable
than would have  been at first supposed; so  much so, as to lead  to
the belief, that an additional quantity of intestine has escaped through
the hernial opening.   When the hernia is voluminous, the inflamma-
tion is frequently found to have  glued  the  different duplicatures to
each other or to the sac.   In such cases, slight tractions, or the  fin-
gers glided between  the parts, will  be  found sufficient  to separate
them.  Should ancient  adhesions  prevent  us from  isolating  them
completely, a bistoury or the scissors would soon accomplish the ob-
ject.   Those general adhesions only are to  be respected, which are
so intimate, as to make it impossible for us  any longer to recognize
any line of demarcation between the sac  and the hernia.   In en-
deavoring to destroy them, it would be  a difficult matter not to make
some mistakes in the direction of the intestine ; or if in order  to ob-
viate this  danger, we should direct the instrument  more to the out-
side, the viscera might be left covered with  too thick a layer  of ex- 
588
NEW ELEMENTS OF  OPERATIVE SURGERY.
traneous tissues not to render  their reduction dangerous.  Should
they be found to have been strangulated by a rent in the sac, or with-
in the sac itself  by a rupture, or a bridle of epiploon, or by an acci-
dental  band, or in any other way, we  must also  begin by liberating
them, in order to be enabled to unroll  them, and  to ascertain if they
are not the seat of some degenerescence, or ulcerated, or gangre-
nous, in .a word, if they are in a  perfectly sound  condition.
  M.  To  draw upon the intestine.—After having thus unrolled them
and spread them out, we  are then to proceed  in replacing  the intes-
tines into  the belly, if the constriction of the ring  presents no ob-
stacle to this step.   In fact, in a certain number  of  cases,  the thing
is practicable ;  in the first place,  when the abdominal opening is not
the seat of the strangulation ;  again when the course of the matters
has been interrupted only by too  sudden an inflexion  of the organs
upon the hernial orifice ;  and lastly, when the substances  accumula-
ted in the internal noose, are sufficiently fluid to enable us, by ma-
king use of exact pressure upon  them, to  cause  them  to return be-
hind the  ring.   Before doing this, however,  whatever may be the
condition  of the parts, it is recommended, even after having destroy-
ed the strangulation, to draw out  all  the portion comprehended in
the aponeurotic track.   Without  this precaution,  it is said, we should
incur the risk of returning into  the belly a contracted or  ulcerated
portion of the  intestine.   There results  from this, moreover, as is
generally  considered,  another advantage, which is, that  the noose
being made longer, the matters it contains would be dispersed over
a greater  surface, distend the intestine less, diminish the size of each
of its rings, and in this manner render its reduction  more easy.  At
the present time, I have laid aside this practice.   By following it we
might enlarge a  laceration or ulceration in the  intestine, which lat-
ter, moreover, is  by this means rendered  more difficult of  reduction.
If we omit it, we evidently favor, in place of diminishing the pros-
pect of the cure of lesions which might exist behind the ring.
  N.  The coarctation ofthe intestine  in the ring, is a result admitted
by all authors, and one which the experience  of Ritch had long since
placed beyond dispute.  In a patient operated upon by this surgeon,
the accidents persisted after the reduction, when  the opening of the
dead body explained them ; the portion of the alimentary canal which
had been  strangulated, was found so  much  contracted that  it was
with difficulty that an  ordinary quill could be made to pass through
it.  Other examples of contraction of  the intestine remaining in the
belly, have been related since ; I have myself seen  some, but it ap-
pears to me that we are  deceived as to their nature, as  they have
nothing about them which is organic or permanent.   They are im-
mediately removed by means  of  the fingers, when they present them-
selves  to our notice; a purgative generally removes  them after the
operation, and it would be barbarous treatment to stretch the intes-
tine below, as has  been  proposed, in  order to enable us  to distend
them from the interior to  the exterior before proceeding to reduction.
  O. A more frequent lesion,  and one which  has not been sufficient-
ly noticed, is the ulceration of the intestine upon its external surface.
The solution of continuity in such cases, presents itself under  the
form of a groove, which is from one to two lines broad, situated some- 
HERNIOTOMY OR  KELOTOMY.
589
times on one, sometimes  on various  points, and at other times even
upon the whole extent of the circumference of the intestine, while it
corresponds to the fibrous circle which has produced this disorgani-
zation.   It might be said to have  the appearance of having been
caused by a packthread drawn tightly around the intestine ; so long
as the peritoneal coat alone is affected, the muscular tunic not com-
pletely perforated, or that the mucous coat  preserves its integrity,
we may return the whole into the abdomen without danger; but the
greatest degree of precaution would be necessary under such circum-
stances,  for these different tunics being at the same time softened, the
slightest traction upon them would instantly cause  their rupture, as
I have seen in a woman  operated upon in the presence of M. Roux,
and who died on the following day.   M. Lawrence and M. Roux,
who have more  strongly pointed this out to the attention of practi-
tioners than M.  Boyer, might have added that this groove has some-
times resulted in a perforation of the entire  intestinal canal,  and in
the  production of a fatal  effusion, the origin of which would be very
erroneously explained by a gangrenous ulceration.  In 1824, a wo-
man 55  years of  age was  brought to the Hospital of Perfectionne-
ment.  I operated upon  her immediately for a strangulated  hernia,
which had existed for 40 hours.  After having liberated the intestine,
I reduced it with the exception of its most projecting pbrtion, which
was in a state of gangrene, and the aperture in which I attached to
the  ring.  The patient died on the next day but one.   The  circum-
ference  of the organ, which had  borne the constriction, exhibited
the  ulceration above mentioned, and there existed  near its mesenteric
border,  a perforation through which the matters had passed into the
peritoneal cavity.
  P. To remove the strangulation.—Strangulation at the  neck of
the sac takes place only  in ancient hernias, and in those which have
come down and been reduced a number of times.   In the others, in
fact, it would be difficult to conceive how this  ring should  have be-
come thickened, contracted, and indurated  to  such degree as to in-
terrupt the course of the matters in the  intestine.  When it exists,
we recognize it by the mobility of the peritoneal prolongation, which
permits itself to be pushed  up into  the  belly, drawing the, intestine
with it,  also  by the freedom ofthe ring in spite ofthe  constriction of
the viscera, and by the facility with which we can introduce  the fin-
ger either wholly or in part, between the fibrous circle and the  root
of the sac.   If the strangulation is formed by the external orifice ofthe
hernial canal, the nail directed upon this point will immediately give
evidence of it.   When, on the contrary, it is more deeply situated, the
opening in question is neither tense nor completely filled up.  In this
case we shall know that it is not the entrance into the serous cavity
 which has caused it, but that of the aponeurotic canal, provided  the
incomplete reduction of the intestine is not accompanied by any slip-
 ping of the sac.
  I. Dilatation.—Two different methods have  been  proposed  to
remove strangulation, viz., dilatation and incision.   Dilatation, which
had already been eulogized by Thevenin, and afterwards by Arnaud,
 has  been especially recommended by  Le Blanc.   Various instru-
 ments  have been devised for that  purpose.   The double gorgeret, 
590
NEW ELEMENTS OF  OPERATIVE SURGERY.
the two branches of which open and shut in the manner of a dressing
forceps, would certainly fulfil the object  better than  any kind of
crotchet or dilatator whatever, if the method itself was worthy of
being retained; but the  only advantage it  possesses, that of protect-
ing us from any lesion of the vessels, is of too little value in compari-
son with its inconveniences, to cause it ever to  be  adopted in gen-
eral practice.   The impossibility of applying it when the strangu-
lation  is very deep, its insufficiency in the majority  of  cases, the
contusion of the viscera which is generally produced by it, and the
enlargement instead  of the ultimate contraction of the ring, which
would almost  inevitably result  from it, sufficiently justify, in my
opinion, the oblivion into which it has  fallen, and I doubt if AI. True-
stedt, who, intimidated by the fear of wounding the arteries while
liberating the stricture, has again proposed its employment, will find
many imitators among his  cotemporaries.
   II. Incision, or the debridement, consists in dividing at one or
several points, the free border of the constricting circle. This is the
delicate and dangerous part of the  operation; it incurs the risk of
wounding  the organs contained in the  ring, and especially the vessels
ofthe contour of the hernia.   A multitude of different processes also
have been proposed to effect this object.
   a. The  scissors, curved on their border, employed formerly, are,
as they should be, proscribed  at the  present day.  The same remark
applies to the bistoury  of Bienaise, an instrument which seems to
have suggested the idea of the lithotome of F. Come.  The concave
bistoury of Pott  is the one, at the present day, which  is substituted
for all other kinds of hernial bistouries.  M. A. Cooper has modified it
in  such a  way that its cutting  edge has no more than an extent oi
six to eight lines, and stops at the distance of from two to three lines
from its button-pointed extremity.  According to M. Tesse of Douai,
(communicated by the author,) the  cutting edge of M. A. Cooper's
instrument Would be  made still more commodious if  it were  made
convex upon a straight bistoury.  Constructed in this  manner it in-
curs less risk of wounding the parts which, during  the debridement,
might be interposed in front of its heel.  This slight advantage ought
to be adopted, but we must guard ourselves against exaggerating its
importance.  I would even remark that in certain cases, when the
abdominal opening has very thick borders, and when the saw-like
movements, or those backwards and  forwards become necessary, it
is  less commodious  than  the bistoury of Pott' properly so called.
 The oval plate  which M. Chaumas  has  attached  upon  its convex
 border in order to protect the intestines, is  too troublesome and ot
 too little  utility to be spoken of more in detail.   The  object of Du-
puytren, who has placed  the cutting  edge upon its convexity, and
 which  most  of those who have since spoken of it do  not appear to
 have precisely understood, was to render  the curved bistoury better
 adapted to divide the tissues from before backwards, and from the
 centre to the circumference of the ring. From thence it was adapted
 only to certain cases, and we shall soon  see that even in the cases
 mentioned, the simple straight or common convex  bistoury may be
 advantageously substituted for it.  The button-pointed  bistoury, shar-
 pened that its edge may represent a file, (aiguise a la lime,) invented 
HERNIOTOMY OR  KELOTOMY.
591
by J. L. Petit, and the edge of which, too coarse  to divide the ves-
sels, would be sufficiently sharp to cut through the aponeurotic ring,
is of no value notwithstanding all the eulogies which have been
bestowed  upon it.   As to the  ordinary  blunt-pointed bistoury, in
many cases it is often less convenient than the curved bistoury, inas-
much as we are sometimes compelled to  pass through a track more
or less tortuous to reach and destroy the constriction.
  b.  The  winged sound of Mery which was  supplanted by the  in-
vention of M. Chaumas, and which was intended  to fulfil the same
indication, is no longer found among the instruments of surgery ; so
that  in reality the bistoury of Pott is' the  only special  instrument
which has been retained for the debridement of strangulated hernias.
When  there are no vessels that we are in danger of wounding,  the
concave or even the simple blunt-pointed  bistoury, if the debride-
ment is to be made  upon a ring and not in the canal, will answer
and may  be substituted.   The nail of the  left forefinger is to be first
introduced between the intestine and the  constriction which is to
be divided; the pulp of the finger will  then serve as a guide to  the
instrument, the point of which is to be  made to penetrate  into the
belly before turning its cutting edge upon the resisting  border.   An
assistant  then  attends to the viscera and separates  them from  the
point which is to be divided;  another assistant proceeds in the same
manner in respect to the lips of the wound.  The surgeon combining
the movements of his right hand which holds the  handle of the  bis-
toury with those of the left forefinger which supports its back, then
 presses upon the ring which  he cuts with a saw-like movement until
 it yields  and is thoroughly divided;  which is  made manifest by  a
 sound  similar to that of breaking a piece of tin or unrolling parch-
 ment.  However, as this  bruit  is caused by the  division of fibrous
 tissue, it  would be unnecessary to wait for it when the debridement
 is made only upon the neck of the sac.
   c. On  the supposition that we  should  use a director, it would be
 only as an auxiliary to the forefinger; we should glide upon it  the
 bistoury  which  it is to  support during the debridement.   In such
 cases it is well that it should have a cul de sac and be curved in such
 manner  that the concavity of its extremity  may  sufficiently  well
 adapt  itself to the inner side of the abdominal wall to prevent  any
 portion of the viscera from being interposed in front of it, and there-
 by incurring the risk of being  divided  at the same time with the
 hernial opening.   It is in such cases that the grooved spatula of M.
 Vidal  might be conveniently substituted for  the ordinary director.
 If it were absolutely necessary to make use of a straight bistoury  or
 one without a blunt point, all these precautions doubtless would  be
 of service ; but of what importance can they be where we use the
 bistoury of Pott or any other bistoury  whatever ?  Are  not these
 rules more embarrassing than in reality useful ?
   d. Process of Bell.—A convex bistoury or one with a broad point,
 like most of the English  bistouries, with its  back supported on the
 pulp of the left finger, was directed by Bell in front of the ring, which
 it divided with small cuts, fibre by fibre, from below upwards or  from
 the centre towards the  circumference, and from the cutaneous  to-
 wards the peritoneal side, always taking care that the edge of the 
592           NEW ELEMENTS OF  OPERATIVE SURGERY.
nail went a little beyond the point of the instrument.  By this means
we remove the strangulation before arriving at the fascia propria,
in which the arterial vessels are situated, while no difficulty exists in
giving to the incision all  the extent which is desirable.  This process,
the advantages of which I endeavored to  demonstrate in 1825, and
which M. Colson and afterwards M. Dellouey have since reproduced
as belonging to them, in the first place is applicable only to a stran-
gulation disconnected with the neck ofthe  sac, and that which would
be situated at the anterior orifice of a hernial  canal;  in the next
place it would be impossible or  dangerous to  have recourse to it,
when  the circle to  be divided is deeply situated or imperfectly de-
fined.   However, if we  were desirous of making use of this process,
the most simple kind  of bistoury, whether convex or sharp-pointed,
would answer  full as well as the bistoury of Bell.   There is much
less danger moreover of wounding the vessels than is generally sup-
posed.  These being enveloped  in the cellular layer which lines the
peritoneum and separates it from the fascia transversalis, are always
thrown to the distance of at least two lines to the outside of and upon
posterior  surface of the  ring, and this because the internal opening
of every hernia flares like a funnel, and  that the viscera themselves,
by being introduced into it have  separated  the vessels  from it to a
greater or less extent.   On the other hand, they are sufficiently pli-
ant and generally so movable as to escape in front  of the bistoury
rather than to run the  risk of being divided by  its cutting edge,
should we happen to come in contact with them.  When the stran-
gulation is situated in a canal, we cannot  perceive the necessity of
making the point of the instrument penetrate into the belly, nor con-
sequently what danger there  would  be  of wounding the  blood-
vessels.
  e.  Repeated  Debridements.—In  a case  of necessity, moreover,
there is a mode by which we may escape every inconvenience of
this kind, with almost  absolute  certainty, in cases' where we are
obliged to pass through the entire track  of the hernia.   This mode
consists in making on the border which strangulates the viscera two.
three, four, five, or even ten incisions instead of orre>  In multiplying
them in this manner, we  need not give to any of them more than a
line or  a line and a half of depth; the enlargement of  the opening
would nevertheless be considerable, and the vessels in reality will in-
cur no risk of being wounded.  The first idea of this  process, which,
with M. Vidal, I would call multiplied debridements, and  which is al-
ready found mentioned in Scarpa, and even in Junker, has long since
been applied in vaginal uterotomy.  AI. Mance, of Lyons, had spoken
of it in the year 1826, and it would seem that Dupuytren also adopted
it in some cases. But it is to M. Vidal that we are indebted for having
established it as a precept  in  1827 and  in 1831.   AI. Dellouey has
proposed to associate it with the method of Bell.   For my own part,
I have frequently made use of it in practice, and have every reason
to consider it worthy of  the  serious attention of the operative sur-
geon.   M. Belhomme, (Arch. Gen. de Med., January, 1831, p. 114,)
M. Viguerie, (Vignes, These, No. 208, Paris, 1837,) and M. Cou-
dray, (Bull, de Therap., t. XII., p.  161,)  have also  pointed out its
advantages. 
HERNIOTOMY  OR KELOTOMY.
593
  f. What extent ought to be given to the debridement ?—According
to certain authors, an incision of more than two or three lines in
depth, would, by enlarging  the ring too much, render the return of
the hernia almost  certain, even  though there should be no risk of
wounding the vessels.  There is no  doubt that we should confine
ourselves to a small incision, when the constriction is slight, and that
the reduction does  not require any thing more.  On the contrary,
however little we may feel the necessity of making a larger debride-
ment, the practice of Sharp, Hey, and Dupuytren, and  the  cases  of
AL Sanson, (Journ. Hebd.,  X. V., p. 465;  t. VL, p. 81,)  as well as
those of my own, prove that there is no reason for refraining from it.
The incision of two lines  repeated on many points, or the multiplied
debridements, do not  in  this  respect leave any  excuse for those
who might  be deterred by the fear of coming into the  vicinity of
important vessels.   As to the relaxation of the  hernial opening, we
cannot conceive that it is  a subject of much apprehension, unless it
be in those cases of long slits which are only rendered necessary in
certain rare cases of deep-seated strangulation.  Should  the wound
suppurate, as it almost always does, the inodular tissue which is formed
in front, or even at  the centre of the ring, in such manner as to con-
stitute the cicatrix,  frequently presents a greater degree of resistance
to the viscera, than the natural  tissues would have done.   Under
this point of view the multiplied debridements, moreover,  would still
deserve the preference, because the more numerous the  scarifications
of the ring, the more solid is the  cicatrix  that  will follow, and  the
more are the chances that will exist for the development of the elas-
tic tissue in question.
   g. Without opening the sac.—Some authors also have supposed
that it would be advantageous and practicable to divide the  stricture
without opening the  sac; that we should in this  manner  have an
operation attended  with but little danger, inasmuch as it would  not
incur the risk of peritonitis, so common after the usual operation ;  the
viscera, for  the same reason, would escape all  danger of  being
wounded; while the  opening of the sac, which is usually  attended
with so much fingering, being dispensed with, the  kelotomy could be
performed with confidence and promptitude, and with but little pain.
In such cases, moreover, the debridement in itself is attended with
no more difficulty than in the ordinary process.  The bistoury is in-
serted between the  fibrous ring and the neck of the sac, in  place of
passing between the sac and the  viscera;  the root of the hernia is
isolated with somewhat more caution, in order to  be better enabled
to recognize the external  surface of the serous prolongation  at its
egress from the abdominal opening, and this  constitutes  the  whole
operation.
  J. L.  Petit, who became the advocate  of  this  process, to  which
Franco,  Rousset,  Pare  and some others  had  already  drawn  the
attention of practitioners, ascribes to it, as Garengeot and Ravaton
have since  done,  so  many advantages, that  we  ought  not  at  the
present day  to follow any  other if they had a real existence, and
were  not destroyed   or  counterbalanced  by  its  inconveniences,
which are still greater.   The radical  cure, which it  is  pretended
may be  obtained  by  this  process, is  certainly less probable than
                           38 
594
NEW ELEMENTS OF  OPERATIVE  SURGERY.
by opening the sac.   If we reduce  the  hernia without  diviaing its
peritoneal envelope, it is to be apprehended that the parts contained
in the sac may have become the seat of  alterations which it  is
important  should  not be overlooked.   To what accidents might we
not be  exposed if the intestine were gangrenous, ulcerated, con-
tracted, rolled  upon  itself, strangulated by a bridle, or lodged in  a
rent  of  the epiploon, or  should  many  of these  parts be found
glued together among themselves ?  A patient operated upon under
such  circumstances,  by M. Cooper,  (Gaz. Med., 1837, p. 50,) sunk
rapidly.   In cases of adhesion the reduction would  be  impossible,
and  this description  of debridement would  be  insufficient in every
instance where the constriction was produced by the neck of the
sac.   Let it be added also, that the serum which might be found in
the hernia, as has  been said  above,  could not  be  returned into the
belly without  giving rise  to  some  apprehension.  This  method,
nevertheless, which in a case of necessity might be employed suc-
cessfully in recent hernias, and such  as  were of  small size, does
not deserve  the neglect  into which  it has pissed.  Certain cures
adduced in its favor  by M. Gendron, (Bull,  de la Fac. de Med.,
X. VL, p. 131,) Beauchene,M. Key (Arch. Gen. de Med., 2d ser., t. IV.,
p. 497,) and other modern  practitioners, who have supposed them-
selves the authors of it, satisfactorily show that it might still be applica-
ble.  Having laid bare the sac and divided the ring,  the operation, if
we have succeeded in returning the hernia, is evidently reduced to  a
species  of taxis ;  and no one would  venture  to maintain  that, all
other things  being equal, the  consequences  of  the taxis could be as
formidable as those of the ordinary operation for strangulated hernia.
What I have said, therefore, for  and against the taxis in general, is
applicable to the debridement without opening the sac.
  h. Process of Franco.—Another  kind  of debridement, which  it
would appear goes  back to the time of Franco, is the one which is
recommended by Pigray.   It consists in making an incision into the
parietes  of the  abdomen a little above the strangulation, in such
manner as to be enabled by introducing the fingers into the wound,
to draw back the intestine  and return it into  the  belly.  Rousset,
who wrote a little before  Pigray, says that a process  like this had
been frequently adopted by Duval and  his  son as well as by Maupas.
Heister, who ascribes it to Cheselden, was evidently deceived on this
point.   The  attempt of the English  surgeon appears to have been
that  only of the usual debridement,  except that it was by  a very
large incision.   It is  sufficient I  presume,  to mention the operation
in question,  to  demonstrate  its  dangers  and absurdity.  If, after
having incised the anterior  opening  of the hernial  canal, the reduc-
tion  should be attended with any difficulty, it would be necessary, by
means ofthe finger, to explore the depth of this passage,  and to
ascertain if there did not exist a second strangulation in the direction
of the belly.  If in this case the constriction depended upon the sac,
we might by drawing upon it by means of the  two lips of its exter-
nal division,  bring it into  the  wound and  divide it without  danger,
throughout the whole extent necessary,  by  means of the blunt-
pointed scissors or a bistoury.  When this posterior strangulation, on
the contrary, is caused by a fibrous circle, the traction made on the 
HERNIOTOMY OR  KELOTOMY.
595
neck of the  sac will not be  sufficient; we must then make use  of
the curved bistoury, guided by the finger or the director, and proceed
in the same manner as for an  external strangulation.
   III. Reduction.—The obstacle which existed to the return of the
displaced organs being removed, nothing  more  remains to be done
than  to proceed to the reduction, properly  so called.
   a.  After having dispersed in a uniform manner the matters in the
noose before us, we grasp it near the ring with the thumb and two
first fingers ;  the right hand embraces the portion which has protru-
ded the last, pushes  it back by making it  pass between the fingers
of the left hand, which prevent it  from coming out again,  while  an-
other portion of the intestine  is to be  grasped and  reduced in the
same manner, and so on in succession until the whole  shall have re-
turned  into the belly.  The  forefinger is then introduced into  the
canal, in order to ascertain that  the intestine  has properly resumed
its natural position, that it has not deviated through the tissues of the
abdominal walls, that the sac has not followed it, and that it is actually
free of any bridle or any adhesion that might be calculated to inter
fere any further with its functions.
   b.  When a strangulation remains at the posterior  part of the sac,
and that this  latter has contracted but feeble adhesions with the parts
which surround it, and if the hernia is not of very large size, it may
return in mass, by pushing before it the circle which strangulated
it.  Le Dran is one of the first who pointed out this fact, and which
many surgeons  have since  mentioned.  Under such  circumstances
the intestines slip in between the peritoneum  and the parietes of
the abdomen, and sometimes  remain there and become fixed.   As
the constriction has not been  destroyed, there ultimately takes place
a  laceration and afterwards an effusion into the abdomen.   Arnault,
De La Faye, Leblanc, Bell, and Sabatier, have noticed cases of this
kind, and  Dupuytren also appears to have met with several. It is not
in all cases, in consequence of the  resistance of the sac, that the hernia
returns in this manner without ceasing to be strangulated.
   c.  If the strangulation is situated at the internal opening  of the
canal, and has not been removed, the intestines  may also become
lodged between the fascia transversalis and the muscles, separate those
parts, and remain there equally as well as between the aponeurosis
and peritoneum.  An adult, twenty-eight years of age, whom I ope-
rated upon for an enterocele in 1823, at the hospital of Perfectionne-
ment, presented an  instance of this peculiarity.  After having  di-
vided the external opening  of the canal, I  neglected  to explore the
posterior  ring, and proceeded  to the reduction.  As I  heard no gur-
gling, and as the wall of the belly still projected, I passed  my finger
to the interior  of the peritoneal cavity, where I recognized that the
reduction was incomplete.   The intestines  were brought to the  out-
side,  and  the  left forefinger passed into the bottom of the wound,
soon  showed  me the existence of a second strangulation, and which
was produced by the entrance of the fibrous  canal.   I effected  the
debridement, after which the reduction no longer presented any diffi-
culty.  We must therefore  distinguish  the return of  the  intestines,
between the peritoneum and  the  aponeurosis, from that which takes
place between the aponeurosis and the muscles, or between the dif- 
596           NEW ELEMENTS OF OPERATIVE SURGERY.
 ferent muscular layers  of the abdomen, and  not confound the ob-
 struction which is produced by the neck of the  sac, with that which is
 owing to the  contraction of the posterior ring of the hernial canal.
 When an accident of this  kind has taken place, the first thin" to  be
 done would be to reproduce the hernia.  We effect this, by inducing
 the patient to cough, or to make some exertions, and  even to get up°
 Quite frequently also the viscera come out of themselves.  If wo
 can reach them, however, with the finger, it is a still more certain
 mode to pinch them  up and draw them towards us, doing this with
 all the necessary precautions.  If the difficulty arises from the  neck
 of the sac, tractions  made upon  the portion of this envelope which
 has  remained in the wound, would be frequently an excellent means,
 as Dupuytren moreover has long since shown.  None of these re-
 sources, however, would be  a certain guarantee of success.  Cho-
 part, Lobstein, and  other  experienced practitioners  have seen the
 patient perish, notwithstanding they had been enabled, in this man-
 ner, to reproduce the hernia.
   d.  There is still another circumstance which sometimes prevents
 the organs from being immediately returned into the belly; this is the
 existence of an ancient and large sized hernia.
   J. L. Petit having  succeeded in reducing a  tumor of this descrip-
 tion,  after much difficulty  and  fatigue,  perceived that the symptoms
 continued and did not cease until he had allowed the viscera to come
 out again.  He explains the fact by saying that the abdominal cavity
 had  become habituated to the absence  of the organs, and so con-
 tracted as to  be incapable any longer  of readmitting them, in such
 manner that they had in fact, he says, forfeited the right of domicile.
 When we reflect upon the distensibility of the walls of the belly, and
 that in  the course of the same day they will allow the  stomach and
 rest  of the  bowels to acquire double or treble the dimensions they
had  a moment before, it is difficult to comprehend how their resist-
 ance alone should be  capable of rendering the  reduction of any her-
nia whatever impossible or dangerous.   Is it not more probable that
 in the neighborhood of the  neck of an ancient and voluminous hernia,
 adhesions have  become established between the organs to such ex-
tent as to render its return difficult;  or that these viscera, which have
been  protruded for so  long a time, give rise to accidents, because
after the reduction they continue pressed together, agglomerated and
 united in a mass, and  do not uncoil themselves freely behind the ring?
 This  reflection, which occurred to me a long time since,  and which
 Petit the son  (Mem. de I'Acad. de Chir., X. IL, p. 70, 1819,) had not
overlooked, deserves, in my opinion, to be taken into account.  This
however should not lead us  positively to deny the  explanation of
J. L. Petit, which is applicable in reality to young and vigorous per-
 sons whose abdominal parietes are endowed with a great degree of
elasticity and  a certain  thickness,  and to those who possess a great
embonpoint, and in whom the epiploons are loaded with  fat.  In con-
 clusion, it is better to  leave  the intestines  in the sac,  after having
 freely liberated them, than to bruise and injure  them by persisting in
attempts to  reduce them.   Experience has shown that retained in
this  manner externally,  they ultimately return into the  belly gradu-
ally, either entirely or  at  least a very large portion of them.   The 
HERNIOTOMY OR  KELOTOMY.                 597
horizontal position and  debilitating regimen which  the patient is to
be submitted  to, gradually produces in the belly a species of void
which favors in a remarkable degree in such cases  the effect which
we are desirous of producing.
  e. There are a number of alterations, moreover, in which the  re-
turn into the belly  would unquestionably be the best remedy.   Thus
the concentric ulceration should not deter us if it is limited to the outer
coat, or even if it has reached to the muscular membrane, if, in a word,
it has not perforated the intestine completely.  Nor is  the  coarc-
tation of the displaced organ always  a  counterindication.   If when
recent and not excessive, it allows the  alimentary canal to retain at
least half its natural dimensions, there is reason to  hope that it will
ultimately disappear  in the abdomen.   Gangrene  is  the  accident
which is most seriously obnoxious to every attempt at  reduction;
but  for the  same reason we must not allow ourselves to be imposed
upon by false  appearances.  However  slightly acute the strangula-
tion may be, or however trifling may have been the  inflammation or
the duration of the symptoms, the intestine contained in a hernia will
usually be found to be of a deep red  color.  Frequently it  will be
found to be brown, blackish or violet colored.  Its  peritoneum may
be separated  by small  flaps, and this part may have lost its smooth,
moist aspect,  and  will appear rugous, without however being gan-
grenous.  The fetid odor of fascal matters, which some  persons have
laid down as characteristic, might also lead to a mistake.   The same
remark applies to the slaty, grayish  or ashy tint.  If  its tunics are
not shrunk and flabby,  and as it were folded on themselves, if it re-
sists the tractions made upon it,  and continues to be dense and shin-
ing, if the thickness of its walls appears to have augmented in place
of having diminished, if it retains some degree of heat, and that this
heat is uniform upon all. its points when it has remained some time in
the air, and  if no perforation exists, there is no gangrene; we must,
nevertheless, when intimate adhesions, which it is found impossible to
destroy, are encountered, effect the debridement as in ordinary cases ;
only that it is  advisable to liberate largely, in order that the free por-
tion of the viscera may afterwards be made to return into the belly.
The rest of the gut is left in the sac, which is covered with com-
presses saturated with emollient liquids, as in the case of irreducible
large-sized hernias.  The organs being  relieved of their constriction,
and gradually drawn upon by those of which they are  the continua-
tion, frequently succeed also in  gradually returning of  themselves
into the  belly, or  at least no longer form in the ring anything more
than a slight tumor, which may afterwards be kept up by a concave
pelote.

                       § II.—Epiplocele.

  Epiplocele existing alone rarely strangulates to such degree as to
require debridement, but it is quite common to meet in the same sac
a noose of intestine and a more  or less  considerable portion of epi-
ploon.  In such cases it is advisable before dividing the stricture, to
ascertain if the opening has not contracted adhesion with the neck
of the sac or the  periphery of the intestine.  It is also  proper to 
 598          NEW ELEMENTS  OF OPERATIVE  SURGERY.

 make the debridement upon  a point where there  is no epiploon, in
 order not to incur the risk of wounding any of the vessels, sometimes
 quite large, which are dispersed over this  membrane.  Though it
 usually presents  itself the first on opening into the sac, we  must
 nevertheless commence the reduction with  the intestine as soon as
 the strangulation has been removed.   The reduction ofthe epiploon
 is always attended with more difficulty.  It has almost alwavs under-
 gone some alteration.   If it is  adherent to the sac only by means of
 bridles  or filaments,  nothing  is easier than  their destruction.  But
 whenever the adhesions are close and lamellar, it becomes almost in-
 dispensable to remove the  part.  If it has remained a long time in
 the hernia, it becomes loaded with fat and is transformed into an adi-
 pose mass ; or it doubles upon itself and becomes covered with pelo-
 tons, cylinders and hard, shining tumors, which have been compared
 to scirrhi.   We  meet with those, moreover, of an infinite variety of
 forms, and it would be as impracticable as it would be useless to de-
 scribe them all.   If such masses were reduced with the  viscera, sup-
 posing that  this  could be  done, there are some of them whose reso-
 lution we might  count upon ;  but this could  happen but rarely, and
 should they be ever so  slightly voluminous, their presence in the ab-
 domen would expose to too many dangers to venture upon their re-
 duction.
   I.  Their excision is unattended moreover with danger when they
 are pediculated,  as frequently  happens, and when it is not necessary
 to excise them through a sound portion of the epiploon.  M. Payen
 and myself operated for an entero-epiplocele in which many of these
 productions were developed.   One which was four inches long and
 fifteen to  eighteen lines in thickness, was adherent to the bottom of
 the sac  by means of an epiploic band which was  still recognizable,
 and  was  continuous  in the direction of the belly with the same
 membrane by means of a narrow lamella, which was so slightly  vas-
 cular that its excision was effected without giving rise  to the slightest
 discharge of blood.  Another  which was  of less length  but far more
 dilated in its middle portion, and which had also a broader root, was
 removed in  the same  manner  and without being attended with  any
more inconvenience.   If their root moreover should appear to in-
 clude vessels of  a certain  calibre, nothing would prevent our stran-
gulating them by means of a double thread before completing their
excision.  Should the epiploon have  preserved its natural state, it
 ought to be reduced.  For this purpose  it is to be pushed back by
 degrees, commencing  as in the case of the intestine  by the portion
 which had come  out  last, after  having thoroughly liberated it from
 all its  adhesions  and  from  every kind of duplicature.  When  it is
 irreducible some  persons recommend, as M. Vidal (Pres. Med.,  X. I.,
 p. 216) still prefers, that it should be left in the wound, asserting that
 it will  return  by degrees and  that a concave pelote will afterwards
 keep  up the portion which remains outside.   M. Simonin,  (Decade
 Chir., 1838, p. 45,) by proceeding in this manner, was enabled to
 cure his patient,  though some  accidents had occurred.  Though ex-
 cision is more expeditious  and satisfactory at first sight, it has not
 been  adopted but by a small number of practitioners.  There are
 three modes of performing  it;  1st, in the event of gangrene, to excise 
HERNIOTOMY OR KELOTOMY.
599
between the dead and living parts;  2d, whether there is a gangrene
or not, to divide through the  living parts, to apply no  ligature,  and
then to proceed to the reduction; 3d, to divide through the  living
parts and to ligate separately all the vessels  as  they  successively
appear.
  The first  method is  bad, because  however  small a  quantity of
mortified tissues  may be left, their return  into the abdomen must
necessarily be dangerous,  while  if the  bistoury is carried  through
parts that are  still living, we  should  incur the  risk of causing a
hemorrhage.
  The second has been advocated by Caque de Reims, who enume-
rates nine successful cases  in its favor.  Like this author, I am satis-
fied that the  ligature upon the vessels of the epiploon is not always
indispensable, and that in many cases they  would cease to  bleed of
themselves after the expiration of a certain period of time.  Never-
theless I should not venture  to  sanction his process as a  rule.  I
adopted it in one instance in a patient of M. Florence.  Up to  this
point  the operation presented nothing peculiar.   It  then became
necessary to  remove a portion of the epiploon.  The vessels  scarcely
gave out any blood at first and I proceeded  to the reduction.  In the
evening the blood issued from the wound to a certain extent, when
syncopes and swoonings supervened, accompanied with cold sweats,
and though the vomitings had ceased, and the matters had  resumed
their course in the alimentary canal, the woman died ten hours after
having been operated upon.   This  suffices for me not to incur here-
after an exposure to such dangers.
  The third  method is the  one adopted  by Boyer.  To perform this
the surgeon  begins by  spreading out and unfolding the epiploon, in
order that he may have to divide through one membrane only  ; then
excises with  the scissors or bistoury the portion  he wishes to  remove;
immediately  seizes with  the  forceps each  vessel as  soon as it is
divided  and  forthwith  applies the ligature to it.  This being done,
nothing  more remains than to push back behind the ring the parts
that have been preserved, and to gather the threads on one  of the
sides of the wound.  The  inconveniences of this process are  that it
requires time, and a laborious research for the vessels, and that it may
expose us to  the risk of overlooking some of them which afterwards
might give rise to  unpleasant  consequences: it would  be advisable
to submit it to an important modification.  The threads in fact would
not allow of  our abandoning the epiploon behind  the hernial open-
ing, and  would compel us to arrest it in the ring.   The torsion of the
arteries, which  might be  readily performed in  such  cases,  would
advantageously replace the ligatures and should be substituted  for
them.  1 have used it in two  instances, and am of opinion that but
for this  precaution my operation would have been attended with
more  difficulty.                                             >
  II.  The ligature, which was used a long time since, and which had
already been mentioned by Galen, was in the last  century the object
of numerous  attacks.   J. L. Petit, among others, reproaches it  with
frightful consequences.   A  patient  in whom he had used  it  was
speedily attacked with colics, violent pains in the abdomen, and ner-
vous, symptoms which no one  knew  how to explain.   The surgeon 
600          NEW ELEMENTS OF OPERATIVE SURGERY.

took off the dressing to see if the intestine had not come out  again.
Finding nothing of this kind, he removed the ligature, when all the
symptoms  disappeared, as if by  magic.   From this  fact and some
others, it has been concluded that the constriction of the epiploon was
almost as formidable as that  of the intestine.   Theory,  which is al-
ways ready to be brought in support of opinions which practice has
suggested, has appeared  to furnish an explanation of the phenomenon,
by  indicating the fact that the great sympathetic nerve distributes a
certain number of branches to the whole extent of the epiploic mem-
brane.  Pipelet confined himself to  remarking that the dangers arise
from the  constriction  having rolled up into a cord  a portion of a
membrane which requires to be kept spread out, and  the opinion
of J. L. Petit has in this  manner  become an axiom.  As  the ligature
however is infinitely more easy  of application, and that  it  protects
us from hemorrhage with greater security than all the other methods,
some practitioners have  not  been disposed to renounce  it entirely.
Hey and Scarpa, for example, assert that by means of a very simple
modification  we  may  avoid  its inconveniences without  interfering
with any of its advantages; the first applies the ligature in the same
way that the ancients did, but he  recommends that we should tighten
it only by degrees, and in such manner as  not  to bring about the
mortification  of the organ until after the  expiration of several  days;
the  second leaves the epiploic plug  in  its  place until  it has become
covered with cellular  granulations,  and then strangulates it in the
manner of Hey.
  III. The Author.—The facts related by these authors in favor of
their practice, leave no ambiguity in respect to its innocuousness, and
there is no doubt that it should be adopted by preference  if the liga-
ture in mass were as much to be  dreaded as Petit thinks  it is.   For-
tunately this is not the  case.  In fifteen cases already, I have had oc-
casion to ligate the epiploon,  and  most of the patients have got well
without any accident.  AVhen the tumor to be removed does not ex-
ceed the size of the finger, it would appear  to me that  it might be
embraced without danger by means of a strong ligature and effec-
tually strangulated at a short distance from the ring.  On the contra-
ry,  I divide the root into as many portions as is desirable when it is
larger, in order to pass a thread around each of them, and to be ena-
bled to tie them in this manner separately.   I  found two were suffi-
cient in a woman I operated  on in 1829, at  St. Antoine.   The same
was the  case in a man  operated  upon by M.  Payen.  In a lady
whom I operated on with M. Gresely, I was  obliged to use seven.
We then excise all that portion which is outside of the threads, which
latter are to be collected on one or several'points ofthe ring, and the
operation is then terminated.  M.  Goyrand, (Press. Med., X. L, p. 215,)
who has followed this method, has also had every reason to be satis-
fied with it.   In conclusion,  if the epiploon is  gangrenous, and we
wish to return its sound portion into the  belly, the best plan is to di-
vide it through the living portion, and then  to twist  its  vessels.  If
the surgeon,  on the contrary, deems it advisable not to push it back
beyond the hernial circle, he may confine himself to detaching those
portions of it which are completely mortified, and without making use
either of the  ligature or torsion.   When it is simply irreducible, with- 
HERNIOTOMY OR  KELOTOMY.
601
out having lost its vitality, and when we are obliged to excise it and
then to leave the remainder in the  ring, a ligature which would in-
clude the whole of it, or several  threads, each of which would em-
brace a distinct portion, constitute the  process  which is at once  the
amplest  and the safest to be adopted.
  IV.  Some practitioners have considered that after having return-
ed all the viscera into the belly, the  sac which is  left  in the  wound,
should in its turn engage our attention.  Those who, like Garengeot,
recommended that it should be liberated without  being opened into,
suggested that it should be completely isolated, and then  crowded into
the interior ofthe ring, where it was to  be kept up by means of a pelote
of linen or  lint.  There are others who have advised to apply a liga-
ture upon its neck to strangulate it,  and then excise it.    In cases even
where it has been deemed proper to divide it throughout  its  whole
length, it was  suggested also that it might be reduced and made use
of to plug  up the  hernial  passage.  Louis earnestly proscribed all
such attempts, maintaining that the  reduction of the sac  is impossible,
and that the adhesions upon its external surface do not  admit  of  the
mobility (glissement) which under such circumstances would be  re-
quired.  On this point, Louis has certainly been deceived.  It  is  ex-
ceedingly probable that the  sac, whether  opened or not, if it  were
pushed back in this manner, would  close up the  ring to a sufficient
extent in some cases to prevent  the return of the  disease.   Its exci-
sion and its ligature would not possess the same advantages, though
exposed to the same inconveniences. Should it in fact become neces-
sary, in order  to remove it, to have recourse to the cutting instrument,
there would be evidently danger in certain cases at least, of wound-
ing vessels or other parts which  it  is important should  be respected.
I would  therefore recommend the  reduction of the sac in all  cases
where it is found to be almost entirely  free, or where  its adhesions at
least are so trifling that they may be destroyed without the aid of
the bistoury, or any other cutting instrument.  It has been supposed,
moreover, that when once laid open, and we should not wish, or did
not  find  it practicable  to attempt its reduction, it might be advanta-
geous to exsect its flaps.   I see no objection to a process of this kind,
except that it  is not applicable to hernias surrounded with large sized
arteries and organs of importance.   Nevertheless, if  the borders of
the sac were sufficiently well isolated to enable us to excise them effec-
tually without wounding any important part, the operation could not
but be attended with advantages.   By this means the wound is more
uniform, the suppuration less abundant, and the subsequent treatment
ofthe operation necessarily rendered somewhat more simple.
  Dressing.—The dressing, after the operation for hernia, is reduced
to a trifling affair.   A perforated linen spread with cerate is placed
over the entire bleeding surface, and  over this are immediately ap-
plied the small balls of lint.  Then  come the plumasseaux, and com-
presses,  and  finally a bandage, adapted  to the  kind  of hernia for
which the operation has been performed.   In  place  of a perforated
linen, some persons employ a simple piece of fine linen.  By being
made larger than the  wound, it serves  in some respects as a sort of
chemise  to the lint, and  moreover  performs the same offices as if it
was perforated ; but as it offers no  egress to the discharges, I see no 
602
NEW ELEMENTS OF  OPERATIVE SURGERY.
reason for giving it the preference.   Others confine  themselves to
filling the whole wound with lint without the interposition of linen,
and then to covering it with  plumasseaux, compresses, and the con-
taining bandage, as in  the preceding case.   The principal objection
to this practice is, that  at  the time  of the first dressings it renders
more difficult  the removal of  the deep-seated portions.
   I.  Immediate Reunion.—Franco, who appears  to  have  been the
first that endeavored  to establish as a rule, the necessity of laying
open the hernia, and liberating it at its strangulated portion, recom-
mends that we should afterwards  approximate the borders of the
wound  and make use  of  the suture  to maintain  them in contact.
Most of  the surgeons of that epoch appear  to have acted in confor-
mity to the advice of Franco.  There  were none, not even Rousset,
Pare, Pigray and Thevenin, wTho did not adopt it.  It  had, however,
been laid aside until about  the middle of the last century, when Mer-
trud again endeavored to bring it into repute, by maintaining that the
wound in an operation of this kind was placed in the same conditions
as a simple wound.   In spite of the argument of  Hoin and Le
Blanc, who adduced quite a  number  of facts in  their support, the
process  ultimately fell  into disuse, as  it had done in  the century in
which it had originated.  Union by the first intention, however, ap-
pears to  have been again made trial of by some modern practition-
ers.   M. Serre establishes beyond dispute, that it is in fact possible
by means of the suture, to cure in a few days the wound which re-
sults from an  operation for strangulated hernia.  AI. H. Berard also
informs  me that he has made trial of it at the  Hospital of St. An-
toine, and that his patient was restored at the expiration of  six days.
Up to this point, as it appears to me, we are perfectly agreed on this
question.  If  the point under consideration is only that of the possi-
bility of this result, there is no doubt that the practitioner of Mont-
pellier is perfectly right; but the important point to examine is the
utility of such a procedure.
   II. Secondary Reunion.—When the hernia is  but of small  size
and recent, and its envelopes preserve a certain  degree of thickness,
and almost all their natural characters, and that  the sac neither rolls
nor  leaves fringes or flaps whose mortification at the bottom of the
wound  might be apprehended ;  union by the first intention would
certainly take place  in a large number of cases.   When the tumor
presents a  larger volume, and its coverings  are attenuated and the
seat of  various alterations, and  that  the sac is large and has a ten-
dency to roll  up upon  itself after  the reduction of the viscera, the
chances  of  success  are not  as good.   It is then to be feared that a
suppuration may take place in the midst of  the tissues, and separate
them by extending itself in various directions, and thus give rise to
collections and serious  accidents.  This is what I have seen in those
cases where I had deemed it  prudent to attempt immediate reunion.
The hernia nevertheless was not very large.  The lips of the wound
were brought into accurate coaptation, and were maintained at their
root by an exact and methodical compression.  On the filth day we
thought  we could count on agglutination having been accomplished.
On  the  following day, however, we  were  undeceived.   Swelling,
redness, pain and heat manifested themselves below one of the sides 
HERNIOTOMY OR  KELOTOMY.
603
ofthe wound ; the inflammation increased and was accompanied by
fever and general symptoms, which were not subdued until after the
opening  of  an abscess of considerable size which had insidiously
formed  at the lower angle of the  sac.  This  immediate  reunion,
moreover, appears to me to act in opposition to one of the intentions
of the surgeon, which is  to favor  as  much as  possible the radical
cure of  the hernia.   Without the necessity of  placing the divided
tissues into  perfect contact, we may with facility approximate them
to a certain degree, diminish to a greater or less extent their  bleed-
ing surfaces, and  thus  while favoring  suppuration  obtain  a cure in
from 20  to 30 days.  A patient treated in this manner had his wTound
completely  closed on  the 24th  day.  A  woman whom I operated
upon with M. Forget, (Lancette Franc., X. II., p. 354,) was perfectly
re-established at the  end of  a month.   After an operation of this de-
scription, would a more rapid cure be a matter of such great impor-
tance as some persons appear to have  imagined ?  Finally, there-
fore, except in a  few cases, secondary union is the method which
possesses most advantages, and the one which  in this operation de-
serves the preference.
   III.  When the patient  has been once dressed, he is recommended
to make no effort or movement whatever which can react on the ab-
dominal  organs, or  that  if he is forced  to cough or contract  his
muscles  from any cause whatever,  he  must apply his hand upon the
front part of the  dressing, in order to support it.  Without these
precautions the intestine might escape  a second  time, and reproduce
the accidents.  Lassus  relates the case of a man who, in this state,
had the imprudence  to  leap  out  of bed and walk  some  steps.
The intestines came out in large quantity, and it was with much diffi-
culty that their reduction  could be effected.   We must not, however,
allow ourselves to  be  too much alarmed  by  such  apprehensions.
When the intestine has been once returned into the belly, it does not
very readily come out  again.  A slight attack of  coughing, or  the
moderate exertions made by the  patient in turning himself in bed,
would not be sufficient to reproduce the hernia.  If, in  consequence
of the debridement, the orifice of the abdominal wall should be found
to have  been somewhat  larger  than  usual, the sensitiveness which
has already been established in these parts, or that which the inflam-
mation soon occasions here, forms a kind of barrier  which the viscera
rarely pass.   It would  appear that  a natural, instinct prevents their
passing  in this direction, and that the patient, even when he does not
think of it, is, so to speak, compelled, as often as  he  makes any effort,
to prevent this being extended towards the wound.  These remarks
appear  to me to be  useful in this respect, that if prudence  ought to
recommend repose and immobility of  the patient who has been ope-
rated upon, there  would  also be  an  inconvenience in forbidding him
to venture to move himself either  in one direction or another, or in
considering the  slightest exertion  as dangerous;  they  will show,
moreover, that there is no necessity of making the bandage compress
the front part of the wound, and that a containing dressing methodi-
cally applied, will perfectly fulfil the object in view.
   D.  Subsequent  treatment.—Unless  certain  particular  accidents
should occur, the  wound  should  not be dressed before the  third or 
604          NEW ELEMENTS OF  OPERATIVE SURGERY.

fourth day, as it is not  until then  that the suppuration begins to be
established.   The dressing is  afterwards renewed every morning,
and requires no particular directions.   Should certain portions of the
sac, epiploon, or any other  tissue  have mortified, they are  to be ex-
cised immediately.  Emollient or chloride lotions, even the decoction
of bark when the suppuration becomes fetid or grayish or the tissues
continue pale, or the employment of nitrate of silver when the cellular
granulations  spring up with too much activity, might become neces-
sary ;  but these different resources are  resorted to. under such cir-
cumstances, from  indications which differ in no respect from those
which require  them  in  other kinds of wounds.  AVhen everything
goes on well the symptoms of strangulation cease almost immediately.
Alvine evacuations come on abundantly at the expiration of a few
hours, and afford  corresponding relief to the patient.   The pulse
resumes a  certain degree of force, and  sometimes acquires even so
much  frequency as  to  constitute  a febrile condition, and it is not
until after the expiration of four or five days that this slight reaction
ceases.  Frequently the functions are  not so speedily and completely
re-established.  The inflammation  of  the peritoneum may extend  in
place of being  moderated.  The peristaltic movement having been
disturbed, sometimes experiences difficulty in  resuming its ordinary
functions, and the  matters are  not then pushed forward with suffi-
cient force from above  downwards to arrive without difficulty into
the lower extremity of the  alimentary canal.   This inaction in the
intestines may  arise  from a slight degree of inflammation having
taken place in its several coats in the  vicinity of the hernia.
  I. If then the stools do not take place spontaneously at the expira-
tion of two or three hours, we administer  a simple  enema.  In case
this is not sufficient, we  soon give  another, which is of a  somewhat
more irritating character.   If  after  twelve hours the evacuations
have not yet  taken place, we should have to have  recourse even to
purgative injections, by  means of decoction of senna.   Many prac-
titioners are in the habit of employing at the same time a slight pur-
gative, administered  by the mouth.  Dionis,  who strongly recom-
mends the  advantages  of such a  course, states that it was recom-
mended to him by Moreau, physician  of the Dauphine.  Some  sur-
geons, at the head of whom are to be  placed Dupuytren and AI.
Green, nevertheless censure its employment, asserting that it must
necessarily promote or aggravate an inflammation,  which is already
too much to be dreaded in persons affected with strangulated hernia.
At first sight this reasoning might deceive us, although in reality it is
easily refuted.  In fact the matters accumulated in the intestines are
a powerful source of inflammation.   Now the best  means of sub-
duing  or preventing  this inflammation, is to force these matters  to
escape by the rectum.  In this  respect the purgative injections and
drinks of the same nature possess an efficacy which no one can call
in question.   At the hospital of Tours, I have seen  M. Gouraud ope-
rate in quite a great  number of hernias; he administered to all his
patients  a purgative  dose almost  immediately after, and  no  where,
as far as I know, was there a large proportion of cures.  Boyer, who
was in the  same practice,  was also  deemed exceedingly fortunate
in this description of operations.  As  to the nature  of the purgative, 
HERNIOTOMY OR  KELOTOMY.
605
this may be of different kinds.   Some give one or two ounces of
castor oil in teaspoonsful at a time, and others  employ Epsom salts.
The purgative which I have seen M. Gouraud administer, is com-
posed of an ounce or two of manna dissolved in a glass of infusion of
mint.  There  are those who prefer  dissolving this last mentioned
substance in four ounces of  red wine.  The common prejudices are
opposed to the use of this vehicle, and I have no personal experience
in its favor.  The purgative I prefer is castor oil in infusion of mint,
with syrup of lemons.   I notice  with pleasure  that this  practice, in
favor of which M. Tessier has adduced new facts, counts at the pre-
sent  day a number of advocates.   It  is unnecessary to add, more-
over, that in my opinion the administration of a purgative is not in-
dicated, and is at least  unnecessary when the stools appear spontane-
ously, and  that there is no evidence of any intestinal disturbance.
  II. When instead of a mere  obstruction, there are found to  be
symptoms  of actual inflammation, or manifestations  of peritonitis,
notwithstanding the re-establishment  of the course  of alimentary
matters, we  should  unhesitatingly subject  the  patient to  the most
energetic antiphlogistic treatment.  One or more bleedings by  the
arm, one or several applications  of leeches to the number of 20, 30,
40, and even 60 if the strength of the patient permits,  should be im-
mediately prescribed if, in the space of twenty-four hours, the inflam-
mation should not be reduced, but, on the contrary, have a disposition
to extend and become  general.   Nor can I perceive why the mercu-
rial  treatment  and salivation might not also  be  advantageous,  or
what objection there would be in applying  every two or three hours
friction upon the belly with two or three gros of Neapolitan oint-
ment, together with  the administration internally of two grains  of
calomel every two hours.  The  cases of puerperal, simple and trau-
matic peritonitis, which have evidently yielded  to this treatment, are
a sufficient authority for not omitting  it under  the present circum-
stances, when  the  sanguineous evacuations no longer afford any
prospect of success.
   III. These unfortunately,  however, are not  the only difficulties
after  kelotomy, which may present an obstacle to the re-establish-
ment of the functions.  Besides  the return in mass of the intestine,
which continues to  be strangulated at the neck of the  sac, or which
becomes lodged  between the parietes of the abdomen,  we have to
apprehend moreover that the noose which was outside, may in en-
tering have  passed above  or below an abnormal bridle, which  is
sometimes found in the neighborhood of hernial openings.   It is also
possible that the portion which has been reduced, may form an angle,
and one so acute as  not to allow of the passage of the  matters, as is
proved by a case of Lassus.  The same difficulty may arise from the
intestine having become twisted  upon itself in such manner as to
close up  its passage  completely.  It may moreover have slipped
through a  tear in the epiploon, or in  some  old  false membranes, or
in the mesentery.
   Finally if, after the  reduction of the viscera, the vomitings, pain
and distress continue at the same time with the constipation, without
our being  authorized to impute such symptoms to a violent inflam-
mation of  the peritoneum or some other viscus, and should there be 
606           NEW ELEMENTS OF OPERATIVE SURGERY.

no reason to suppose  that an  infusion of intestinal matter has taken
place, we are justified  in  believing that the strangulation has not
ceased, but from  having been external has now merely become in-
ternal.  The first indication then is to reproduce the hernia; we must
then make the patient cough and move, and exert himself.  In case
this does  not  succeed, the finger is  to  be introduced through the
ring into the abdomen, in order  to ascertain the state  of things as
correctly  as possible.   Should the surgeon clearly recognize the in-
testinal noose, and find it tense, fixed or immovable, he will endeavor
to seize it with the dressing-forceps in order to bring it to the outside.
Should it appear to him that  the constriction has been caused  by a
bridle, ring or any lamella whatever, he should proceed to divide the
same by  means of the  scissors or curved bistoury  guided on the
finger.  If the finger cannot reach the parts, or conveys only con-
fused notions  in regard to their arrangement, we should proceed to
examine carefully the neighborhood of the wound, in  order 10 ascer-
tain if the organs contained  in  the  belly  do not form a projection
there,  or  a sort of tumor  which  is  perceptible through the  skin.
There can be  no  doubt that  under such circumstances it would be
necessary, as a dernier resource, to enlarge the incision at the ring
liberally, and to penetrate to the point where the strangulated organs
are situated, in such manner as  to lay them bare completely, and to
be  enabled  to disentangle them and to give  them full liberty to
spread out in the  abdomen.

                 § III.—Internal Strangulations.

  An internal strangulation co-existing with an external hernia may
be very difficult of recognition.  A woman 42 years of age. affected
with an omphalocele  and laboring under symptoms of strangulation,
was received in the Hospital  of  the Faculty, in the  month of Alarch,
1824, and would have been submitted to the  operation for hernia,
had it  not been perceived that there  was a hard deep-seated tumor,
which was situated in her right iliac fossa.  This tumor opened itself
upon the  outside, and was formed by the caecum,  which was  filled
with a mass of stercoral matter !  Another woman 49 years of age,
received in the same  hospital, in the  month of July,  1N25. had been
vomiting  for  the space of 24 hours, with the impossibility  of ob-
taining any  alvine  evacuations.   The  belly was  distended and
painful, and the pulse small, hard, somewhat frequent, &c. ;  at the
same time there existed a crural hernia.   On opening the dead  body
I found the commencement of the rectum transformed into a larda-
ceous  tissue,  and completely  shut up.  The  hernia had suffered in
no  respect.  In another case, that of a man I  operated for strangu-
lated henna;  the accidents  continued, and  I  was on  the point of
operating for  the hernia, which he  had on the other side.   After
death we  found that  the  intestine, which had  become  twisted upon
itself,  was situated within the  belly in  an  infundibulum  of the
epiploon.   A patient  operated upon  in my presence  by AI. Michon,
presented a  somewhat  similar  case.  Any  polypous, fibrous,  or
cancerous tumor  of the intestine, should it have acquired a  certain
size, would produce the same accidents.  A man  who had  been  a 
HERNIOTOMY OR  KELOTOMY.
607
long time in the Hospital  of Tours, for vomitings and a constipa-
tion which would yield to nothing, finally died.  The small intestine,
which was greatly dilated above, was shut up at its  middle portion
by a cylindrical mass more than  a foot long,  partly free and in part
adherent, and which had been  produced by an ancient degenerate
invagination.  If the  hernia which this  man  had formerly had, had
still existed, the accidents noticed during his life might possibly have
been attributed to it.
  Numerous examples of this kind are found in  scientific works.   A
patient who was sent to me in the month of October, 1831, from the
service of M. Andral, presented to me one of the most remarkable
examples of this description; the memoir of Hevin proves, at  the
same time, that the different descriptions of invagination  may pro-
duce the  same assemblage of symptoms.  It may also happen that
such accidents arise from a spiral  torsion of a noose of the small in-
testine upon the mesentery, or by its becoming  flattened against the
spine, as was proved  by  the death of Chopart;  from a circular con-
traction on a portion of the organ which has  been returned  into the
belly,  after having been for a long time lodged in a  hernial opening,
as in the case related by Ritsch; or from the neck of the sac, after
it  has been  returned into  the belly with the hernia, continuing to
strangulate the intestine, as  is seen  in  the cases  of Le Dran, Ar-
nauld, &c.;  and more frequently still from the noose of the intestine
becoming entangled to such degree as to be strangulated by  passing
through  certain rents or  below certain bridles or appendages of the
abdominal organs.   M. Berard has  seen it in  this manner  become
lodged in the anterior  mediastinum, by detaching the xiphoidean
fibres from those of the diaphragm ; and also  it  has been in many in-
stances seen introduced into one or the other of the thoracic  cavities
through the body of the  diaphragm itself; through a rent of  the epi-
ploon, as has been seen by Arnaud; of one in the mesentery,  as
mentioned by Saucerotte and M. Bouking, (Gaz. Med., 1838, p. 109 ;)
through the hiatus of Winslow, and  a  laceration of the transverse
mesocolon, as noticed by M.  Blandin ; between the bladder  and the
pubis, (H. Cloquet, Bull, de la Fac. de Med. de  Paris, p. 86,) where
an epiploic bridle, adherent to an  inguinal sac retained it  in a state
of strangulation ; under  the  cascal  appendix, which latter  had be-
come  adherent at its point, on some one  or other portion of the cav-
ity of the abdomen ;  under an accidental diverticulurn of the intes-
tine;  under an epiploic arcade, connected with  the spine on the one
hand, and with  the upper  strait of the  pelvis  on  the  other, as has
been seen by M. Bonnet;  under an enormous bridle in the form of a
T, the horizontal branch of  which extended  from  the  liver to the
left side, and the vertical portion to  the right  iliac fossa, as I have
noticed in two instances; finally, under  the  thousand forms of bri-
dles or cords, that diseases or certain  accidents may give rise to the
formation of in the interior of the belly.   Strangulation produced by
these  various causes, differing after all from hernial  strangulation
only in having its seat in the interior of the splanchnic  cavities, may
consequently readily lead  to error in patients who have at the same
time  a visible rupture externally.  It  may, nevertheless, in  the  ma-
 jority of cases  be distinguished  by noticing  the  point from whence 
608           NEW ELEMENTS OF OPERATIVE SURGERY.
the pains  originate and  their direction, and by comparing the con-
dition of the tumor with  that of the belly, and vice versa.  When
this strangulation  exists separately, there is scarcely any room for
deception, but the question then arises to determine its species, and to
ascertain if surgical art can afford any relief.  If the affection has su-
pervened suddenly, in consequence of an effort made, or any kind of
violence;  if the patient has  been  conscious of feeling  a laceration,
accompanied with  a crackling noise, and with a pain, which from one
determinate point has extended over the  rest of the belly; if  from
this moment vomiting of  alimentary, mucous and afterwards sterco-
ral matters, have continued to take place,  at the same time that it has
been impossible to procure alvine evacuations, and  that the ordinary
symptoms of a violent peritonitis  are wanting, it would be difficult
not to believe in the existence of an internal strangulation.
   A. Internal remedies.—Three classes of remedies have been pro-
posed to relieve accidents of this kind.  The ancients, who were
fond of  believing in  the existence of invaginations and the twisting
of the alimentary tubes, had great confidence in quicksilver, balls ol
lead, purgatives, &c.   They  hoped by means of such heavy and ac-
tive substances, to act mechanically on  the intestines, and to compel
them  to disentangle  themselves by means of sudden movements.
AIAI.  Balluci, Bellini, and Ribell,  have also  in our days adduced
examples  in  favor of quicksilver.  In  recent  and simple volvulus,
such means might  in some cases be  followed  by success; a patient
who by the advice of M. Vogel, (Arch. Gen. de Med., X. L, p. 450,)
had swallowed quite  a large quantity of crude mercury, evacuated
twenty-two inches of small  intestine, the  nature of which was es-
tablished by M. de Rapp.  Forty-three cases of this kind have been  •
collected by M. W. Thompson,  (Encyclog. des Sc. Med., 1839, p.
221 ;) but there is no  person who would not dread their employment
in a case of internal strangulation properly so called.   For my  own
part I should not dare to have recourse  to them.
   B. Local and general bleedings, cataplasms and opiates, suitable
for moderating  the inflammation and  assuaging the pain, have no
influence whatever on the kind of constriction in which the intestine
is implicated.   The only advantage they have is that of favoring the
efforts of the system, or the process by means of which it has in certain
cases been so fortunate as to re-establish the continuity of the intes-
tine without destroying its permeability.  The invaginated portion of
the intestine  may  in fact, after a greater or less length of time, and
accidents more or  less severe, become detached by  the rupture of its
neck or root, whether it has been attacked by gangrene, or whether
this separation takes  place by the progress of a simple elim native
ulceration.  In such cases the mortified mass, having become free, is
ultimately  expelled outwardly.   The  whole of the cascum, and a
large portion  of the  sigmoid flexure of the colon have been seen to
be discharged in this  manner, numerous examples of which are con-
tained in the memoir of H6vin.  MM. Rigal and Bounial (Ibid.)  have
seen as much as 30 inches of small intestine evacuated by this process.
Cases that are  nearly similar have  been related  by  MM. Mallet,
Baillie,  Lobstein, La Coste, Boucher, Gaultier de Claubry, &e.
   C. Gastrotomy.—It is  readily understood,  moreover,  that a ter- 
HERNIOTOMY OR KELOTOMY.
609
mination like this can only take place in cases of invagination, and
that for the relief of an actual strangulation we cannot count on the
resources of the system.   Gastrotomy then presents itself as our last
refuge.   Up to the present time but  few persons have ventured to
perform it, and experience, so to speak, is silent on this subject.  We
cannot, in fact, place any confidence in the history of a certain
Baroness de Lanti mentioned by  Bonet, and who, - according to the
authority of an ecclesiastic, had been cured of an iliac passion by an
incision into the lower  belly.  Though the case  in which Nuck re-
commended the belly to  be  opened in order to reach and  untie the
intestines may be  somewhat more authentic,  and that M. Fusch
(Arch. Gen. de Med., X. IX., p. 118,) has published a case of radical
cure by gastrotomy performed for an invagination, we cannot, never-
theless,  but with extreme caution,  place reliance upon so small a
number  of facts.  M. Pring, (S. Cooper,  Diet, of Surg., 7th edit.,
p. 311,)  desirous of affording relief to a lady whose rectum had be-
come obliterated by scirrhosities,  laid open the sigmoid flexure of the
colon, established an artificial anus there, and in this manner pro-
longed the life of the patient six months ; but M. Monod, (Gaz. Med.,
1838, p. 667,)  having performed gastrotomy in a woman twenty-five
years of age for supposed ileus, saw death supervene two. days after,
and found that in place of an ileus the  case was nothing more than a
simple coarctation  above the cascum.  If it should happen that we
had arrived almost to a positive certainty of the existence either of a
recent invagination or of a strangulation, and  that the  locality of the
disease was well ascertained, we should, in my opinion, venture to
perform gastrotomy, which was already in use at  the time of Praxa-
goras, who united the wound of the belly immediately, by means of
the suture.  Dupuytren, who made trial of it in one instance, would
probably have succeeded, he says, if he had been allowed to, incise as
he wished upon the side of the belly where the pain was situated, in
place  of incising on the linea alba as he did,  in conformity to the
advice of the consulting surgeons.  A  case noticed at the hospital of
St. Antoine, and the facts which  I have since collected at La Charite,
prove also that it is in Some cases possible to designate, with sufficient
precision during life, the actual  seat of the strangulation.   The pa-
tient should be laid upon his back, in the same way as for the opera-
tion of ordinary hernia. ..The incision, which should be rather semi-
lunar than straight, should be made very near the strangulation.   If
we are not sure of  the seat of  this  last, the incision should be made
outside of the  recti muscles.   We  should then seek for the diseased
part by means of the fingers.   In case of invagination we should, in
order to remove it, only have to make traction upon the two ends of
the intestine in an  inverse direction,  and then immediately replace
the whole in  the peritoneal  cavity.   If it were  a strangulation the
finger might undoubtedly succeed in reaching and isolating it, in such
manner  as to  divide the constricting  band or circle without danger
by means of a bistoury.   A female patient who  was sent  to me by
M.  Donne, and who  died at the Clinique, might possibly have been
operated upon in this manner.
  D. After the toi's.—Another kind of internal strangulation, viz. :
that which  persists  after the forced  reduction  of a  hernia,  also
                                 39 
610           NEW ELEMENTS OF OPERATIVE SURGERY.

requires to be mentioned.  M. Delmas mentions a case in which the
organs had become  lodged in this  manner in the tissues  of the
muscles themselves.  They may also pass under a bridle or through
a rent, in  the  same manner as when we wish to reduce them after
having opened the sac, and as I have mentioned further back.  It  is
unfortunately  a thing too common  to  see these reductions in mass
under the  influence of the taxis, incapable of preventing the accidents
from marching progressively forward.   There are few authors who
have not  mentioned instances  of this kind, and we  still daily meet
with them in  practice.   The first thing to be done  is to make the
hernia  protrude again.  If nothing  should present itself at the ring,
the surgeon would be censurable if he delayed too long a time and
did not perform the operation immediately.  He knows that a hernial
tumor existed  ; that after having given rise to accidents or remained
a long  time outside, it has disappeared under the influence of extra-
neous efforts; the opening which had  given a passage to it is free,
readily admits the extremity of the  finger,  quite frequently even
exhibits a kind of depression or cul de sac, or seems to be  drawn
towards the interior by  some bridle or  some adherent membrane;
and sometimes also the finger directed into, this depression is enabled
to feel  an  intestinal tumor which has been imperfectly reduced.  In
a case  like this we incise the soft parts in the same way as for stran-
gulated hernia, and we arrive by degrees into its interior.  If the sac
may be reached, it rarely happens that the operator is not enabled to
come down upon the seat of the disease.  Dupuytren, who had been
frequently called  upon to  relieve this species of strangulation, and
who had seen  a great number of these cases at the Hotel Dieu, makes
the remark that after having in vain endeavored to bring the viscera
to the exterior, we have  the resource still left of  largely incising the
ring in the direction in which there  are no vessels, and of arriving by
this means into the belly.

                 § VII.—Hernia with Gangrene.

   A.  When the tumor is entire.—When the gangrene of a hernia is
recognized at  first view,  the division of the tissues does not require
the same  precautions as in the ordinary operation.    The incisions
may in fact penetrate, without any impropriety, into the intestine with
the first cut.   If  the gangrene comprises the whole  tumor, and the
hernia  be of large size, we should, after having made several deep
incisions,  remove  all its mortified portions.   We might nevertheless
confine ourselves  to the  incision of the intestinal noose and wait for
the sloughing  of the tissues.  Quite a number of facts show that the
system, under such circumstances, readily succeeds in effecting  a
complete  cure.   J. L. Petit, travelling on  one  occasion by  post  in
Germany, stopped at an  inn, and was immediately struck by an odor
of gangrene.  They showed him,- in a neighboring room, a man who
was suffering with symptoms of hernia with mortification.  Suppos-
ing the man would die he merely made some incisions into the tumor,
which immediately discharged an abundant quantity  of matters.
Upon  his return, twenty-eight days  after, J. L. Petit learned, not
without astonishment, that his  patient had  recovered perfectly, and 
HERNIOTOMY OR  KELOTOMY.
611
was cured without a stercoral fistula.  Having gone on another occa-
sion to Ferte-sous-Jouarre and lost his way in  the night,  he asked
the road  at a house where he perceived a light.   The woman told
him her husband was at the point of death, and entreated him to come
in.  This also was a strangulated hernia, which J.  L. Petit confined
himself to opening and cleansing, recommending  not to adopt any
other  measures, as he considered that this patient also would not
survive.  The cure however did take place, and  it was the individual
himself who came to inform the surgeon of it some time after.
  B. When the  tumor is  opened.—Nevertheless we cannot dispute
that it is better to liberate the tumor, by means of the scissors or bis-
toury, of everything it may contain that is evidently mortified.  In
other respects there is no reason why we should proceed otherwise
than if the intestine alone was gangrenous, and that we did not recog-
nize the gangrene until after the opening of the sac.   In this last case
the gangrene may occupy only the most projecting  part of the stran-
gulated noose, as it may have its seat in the interior of the ring itself
and upon the parts which  are directly acted upon by the constriction.
  I. To open largely into the intestine.—Many methods have  been
recommended in the event of this  accident.  One  of the  most an-
cient consists in opening largely inio the intestine in order to  make a
free passage for the matters.  In proceeding in this  manner, we have
two things to  apprehend:  1st, that the  constriction may persist to
such degree as to present difficulties to the passage of the substances
contained in the alimentary tube *, 2d, that we  almost unavoidably
establish an artificial anus.  To these objections some persons  have
replied, that the  lower portion of the intestine from no longer receiv-
ing  any matters, shrinks ; that the portion  which corresponds to the
stomach being the one which alone continues to receive the digestive
substances,  ought  to be sufficiently large in the hernial opening to
fulfill in that part without  danger the functions of an abnormal anus.
On the other hand, experience  demonstrates that this mode  of pro-
cedure has  frequently been followed in quite a short time by a  radi-
cal cure.  The two examples just cited are an evidence of it, and J.
L. Petit relates others which are no less remarkable.  This surgeon
being  on his way to Flanders,  was sent for on the road at Douay, in
order  to give  his opinion respecting a hernial tumor which he could
not reduce and which was strangulated.  A charlatan, whose opinion
had been concurred in by the relations of the  patient, maintained
that this tumor was an abscess  and that it was necessary to  open it.
J. L. Petit  informed them that this  might be  followed by serious
accidents, and that there would at  least result from it a stercoral
fistula.  Upon his return he was informed that the  patient had  been
perfectly restored.   He  furthermore  learned  that the  charlatan
opened in this manner all strangulated  hernias, and that in the en-
virons of Douai and Cambrai  he  had thus operated upon a great
number of persons. A student of medicine declared to me  that his
father,  who was a  surgeon  in  one of the  provinces, had  been led
from experience to adopt a similar method, and that he had  already
employed it ten  or twelve times with success, whether the strangu-
lated hernia was or was  not  accompanied with gangrene.  When
we recollect that cases of artificial  anus which have existed a long 
612           NEW ELEMENTS OF  OPERATIVE SURGERY.

time have ultimately disappeared spontaneously, though the two
ends of the intestine had  become adherent to and consolidated in
the ring,  and that a considerable portion of the gut had been re-
moved, such results as those above must soon lose their marvellous
character.  The resiliency (ressort) of the mesentery and the natu-
ral movements of the organs contained in the belly, must necessarily
constantly tend to draw towards  them the portion of gut which has
escaped into the hernia.   Little  by little the two ends of the intes-
tine succeed in reaching the posterior surface of the ring and in ap-
proximating  to each other; their openings ultimately become united
and the matters pass into  the  lower portion of the gut in place of
escaping by the wound,  which latter moreover as it contracts, pre-
sents to them a greater and greater degree of resistance.
   II.  To  divide the  ring.—All authors  however do not  concur in
this mode of considering  the  subject.    Scarpa  recommends that
after having opened the intestine, if there should be much stran-
gulation we should  divide the ring.  Without this precaution  the
matters accumulated  behind it wrould experience, he says, too much
difficulty in escaping, and would give rise to a dangerous inflamma-
tion even in  supposing that they did not keep up the symptoms of
strangulation.  What  danger would there be after all. in proceeding
in this  manner ?  The adhesions which he admits upon the limits of
the gangrene must give entire confidence.  Even though we  should
be obliged to incise the intestine  from within outwards, at the same
time with  the neck of the sac and the fibrous ring which surrounds it,
we should not, according to  him, have any  reason to apprehend an effu-
sion into the peritoneal cavity.   Dupuytren, who has taken ground
against this doctrine, maintains, when the gangrene has reached into
the ring, that the borders ofthe hernial opening are usually mortified,
and that after the intestine  has been once laid open the strangulation
must soon disappear of itself, and  consequently render all kinds of
debridement unnecessary.   He thinks, moreover, that the adhesions
mentioned by Scarpa are far from being constant around the whole
circumference of the intestine, and that if the  incision of the alimen-
tary tube was extended to  behind  the ring, they would not present a
sufficient obstacle to the effusion of the matters.
  It is  certainly incorrect to say that gangrene  is never developed
without being preceded by adhesions between the neighboring serous
surfaces.   The opening  of the dead body in  individuals  who have
died  in consequence of strangulated hernia,  has satisfied me that
Scarpa had singularly exaggerated the  importance  of this  morbid
condition, and that he  was  deceived as  to its frequency and the ra-
pidity with which these adhesions are developed.  That these adhe-
sions, in fine, are sometimes restricted to such narrow limits, that it
would  be  difficult not to  go  beyond them in dividing the  hernial
stricture through  the  intestine.  On the other hand, it  appears  to
me that the mortification of the neck of  the sac, and  of the borders
of the  ring,  is  much less  common than MAI. Corbin and Caillard
represent  Dupuytren to have stated it, and that if we had to count
upon this  in order to put a termination to the  strangulation,  we
should  have frequent  cause to  regret it.   For example, it does  not
take place when it is the free portion of the hernia which is morti- 
HERNIOTOMY  OR KELOTOMY.
613
fied.  I will add, that if we do not divide the stricture, the intestine
which is inflamed behind the portion destroyed, usually becomes the
seat of considerable tumefaction, which reaches its three tunics, and
especially its mucous lining; and that this tumefaction, arrested out-
side by the constricting circle, extends almost exclusively upon the
inner side, in such manner as to produce in some instances  almost an
entire obliteration of the intestinal opening.   This is a  result which I
saw take place in a woman operated upon for a  hernia with gan-
grene at the hospital of Perfectionnement, in 1$24,  and who died on
the following day.   The same result also has happened several times
in other hospitals of Paris.  In conclusion, if, after having opened the
intestine, the  matters which it contains either in the hernia or in the
belly, freely escape, and if the constriction ofthe ring is inconsiderable,
we may dispense with  dividing it.   If, on the contrary, the  finger in-
serted into the strangulated portion penetrates and passes through it
with difficulty, prudence, in my opinion, suggests that an opening of
this description should  be enlarged.  If the instrument can be readi-
ly glided between  the  viscera and the sac without exposing  to  the
risk of destroying  the  adhesions which might possibly exist behind,
the debridement is to be performed as in the usual operation.   If a
contrary state of things exists, the  bistoury is to  be directed into
the interior of the intestine itself, to incise from the  centre to  the
circumference, and in  one or  more directions, the orifice through
which the  matters are to  pass.  In reflecting upon the natural ar-
rangement of the parts, it will  be seen moreover that the incisions in
such cases incur less risk than would be supposed, of producing an
infusion into the peritoneal cavity.  This effusion would  not in fact
have to be dreaded, unless the incision was carried  beyond the pos-
terior orifice of the ring, and consequently beyond the place where
the strangulation is situated, the constriction under such circumstan-
ces being almost constantly somewhat nearer to the external aponeu-
rosis than to the fascia propria, or the  peritoneum.  This fact per-
haps might reconcile the  ideas  of Dupuytren with the practice of
Scarpa.   If we have not divided the stricture; if  at the expiration
of a few hours the colics still continue ;  and if in removing the  dress-
ing we perceive that the matters escape with difficulty, it  is in our
power, moreover, to introduce into the upper end of the intestine a fe-
male catheter, a silver  canula, or what is  better still, a  large gum
elastic tube, and thus procure immediate relief from this difficulty ;
but if in spite of this the engorgement of the tissues and the narrow-
ness of the  ring present impediments to the re-establishment of  the
functions, we must  divide the stricture, as we might  have done at the
moment of the operation.  Since this part of the work was printed,
in 1832, I have frequently,  from many practitioners having carried
the prolonged  taxis to an  abuse, had occasion to  treat in  this man-
ner hernias accompanied with gangrene, and  it is now a practice
which I have definitively adopted.

       § VIIL—Hernias with Perforation of the  Intestine.

  Up to this point we have supposed that the parts were left in their
place; but a great  number of practitioners consider that we should, 
614
NEW ELEMENTS OF  OPERATIVE SURGERY.
in order to satisfy ourselves of the extent  of the gangrene, cause  a
certain portion of the intestine which was not contained in the her-
nia, to be brought through the ring and drawn to the outside; they
recommend also that we should then excise every portion of it which
is mortified, by dividing  through the living part; that we should
reduce the sound parts in such manner as  to leave nothing more in
the  wound than the opening or the openings which have been made,
or that we should  immediately endeavor to unite the two ends ofthe
intestinal  noose by means of the suture;  from  hence arises many
operations applicable to perforations which are caused by gangrene,
as well as to those which result from ulcers, wounds, &c.
  A.  Process of Littre.—After gangrene  Littre  proposed to tie the
inferior end of the intestine, in order to effect its obliteration, then to
attach its upper end into the ring in order to establish,  in this man-
ner, an artificial anus,  which the patient was to retain the rest of his
life.  Louis, who was  disposed to adopt the advice of Littre. finds it,
however, attended with a difficulty, viz., to know how to distinguish
the  upper from the  lower portion of the  alimentary tube, to avoid
which he recommends that we should  administer to the patient  a
small quantity of syrup of chicory, which, being evacuated at the
expiration  of a few hours, indicates  by  its green color in which
direction lies the stomach and in which the rectum.   This is an in-
genious suggestion, but we are rarely obliged to  have recourse to it.
After the division of the intestine its  inferior end almost always be-
comes contracted, and in a short time reduced to the  size of a large
cord; while the other  usually preserves its primitive dimensions, and
moreover, continues to give egress to  the matters.   As the process
of Littre  has the effect of establishing  a disgusting infirmity, it has
necessarily been proscribed, and at the present day is  not worthy of
the  slightest attention.
  B.  Lapeyronie .has  proposed one which is more simple and more
rational.   This surgeon  passes behind the division  a double thread
through a fold of  the  mesentery,  and after having  pushed back the
two ends of the intestine into the ring, makes use of this thread to
prevent their entering the belly  completely, by attaching it at the
outside upon  the  dressing by any mode whatever.   We obtain by
this means, it is true, an artificial  anus, but one which may possibly
close up  spontaneously, or by the aid of art.  Scarpa, who censures
the  process of Lapeyronie, recommends, after we have once removed
the gangrenous portions, that we should  leave the two ends of the
intestine  in the wound.  The adhesions they have contracted during
the time  the mortification has been  going on, are always sufficient,
he says,  to prevent  them  returning too speedily into the belly, and
to constitute a certain obstacle to any kind of effusion into the peri-
toneal cavity.  According to him the thread through the mesentery
would be injurious in more respects than  one;  in  the first place, by
presenting an impediment to the  gradual retraction of the 'parts, and
to the formation  of the membranous funnel; secondly, because this
thread, which must soon cut through  the mesentery,  may, at the
same time, divide certain vessels whose hemorrhage  would be a
source of apprehension; and in  the last  place,  because this thread,
from resting against  the deep-seated  surface of the intestines, may 
HERNIOTOMY OR  KELOTOMY.
615
possibly cause there an ulceration or perforation, in the same manner
as  a  precautionary ligature may divide  the artery around which it
has been placed.  As the apprehensions of Scarpa, however, have not
been  concurred in by all surgeons, there are some who have imitated
Layperonie, and who allege that they have had no reason to be dissa-
tisfied with it.  M. Hervez de  Chegoin, (Revue Med., 1829, t. III.,
p. 517,) among others, published, in 1829, a case of cure in support of
this process.   There would be no difficulty, moreover, in leaving the
thread for the space only of one  or two days, if we  really had any
apprehension about its presence ; we would have nothing more to do
than  to keep the two halves apart by attaching  them separately to
the outside, and  after the expiration of a certain time nothing would
be more easy than to remove the thread  by drawing  upon it on one
of its extremities.
  C. Suture.—In following the course which has  been traced out,
the immediate result produced would be a  stercoral fistula or arti-
ficial anus.   The suture has been proposed with a view of prevent-
ing this infirmity, and  to re-establish immediately the continuity of
the divided  tube.  This is an  indication which numerous  authors
have endeavored to effect by  various means, which  M. Steinmetz
(Bull, de Fer., X. XVIL, p. 395,) asserts  he has employed in two in-
stances with  success, and  which, after having been  frequently for-
gotten, has again strongly attracted attention in these latter times.
  I.  Suture upon a foreign body.—The  first  idea of approximating
the two ends of the intestines, and of sewing them together, is attri-
buted to the four masters who united themselves together for com-
mon purposes of charity in relieving the  sick poor of Paris.
  a.  The four masters.—These surgeons commenced, it is said, by pro-
curing the windpipe of an animal.  Introducing one extremity of this
tube into the upper end of the divided gut, they inserted the other into
the lower end, and tjien approximated the ends ofthe two bleeding cir-
cles, in order to adjust them and keep them in contact by means of seve-
ral points of suture.  Guy de Salicet, who lived before the time of G.
de Chauliac, does not make  mention of the animal trachea;  but he was
acquainted with the process ofthe four masters, and openly censures
it. " Do nof; listen," says he, " to those who tell you before sewing up
gut, that we  must place inside of it a canula of sambouc wood  (sam-
buc.) or something else, and then sew up the  wounded gut upon this,
for," &c.  And  further  on : '• It would be much better to use a por-
tion of gut from any animal, .... but we must use neither this or
anything else."  Is it, however, quite certain that the ancients on this
subject entertained opinions similar to those held at the present day ?
Guillaume mentions  it only for incomplete divisions of the intestinal
tube, and expressly states that the others are necessarily mortal.
  b.  There is nothing moreover to show that Guy entertained  a dif-
ferent opinion. " And if there should be  necessity of a suture (of the
parts contained in the belly,) and  that  it would  be  advantageous in
the manner that it is at  the bottom of the belly, and in the large guts,
they  may be sewed together by the glover's  suture.   Some persons,
like Rogier, Gamier and Theodore, place in the gut a  canula of elder,
in order to prevent the  cleft from mortifying the  suture, others, as
Guillaume  has mentioned, introduce  there  a portion of the gut of 
616          NEW ELEMENTS OF  OPERATIVE SURGERY.

some beast, or a portion of the trachea, as the four masters do." The
above are Guy's own words.
  c. Watson has since recommended a canula  of fish glue.   Some
with Scarpa, make mention of a cylinder of tallow.   Sabatier, Ritch
Desault, and Chopart,  speak of  a piece of playing  card besmeared
with essence of turpentine, or oil  of St. Johnswort, or varnished in
any manner whatever.
  d., The process  of the ancients, however, had attracted so little at-
tention, that Duverger, who revived it at the  beginning of the last
century, considered himself its author.  It would not appear, more-
over, that it had been frequently made trial of, or that up to the pre-
sent time it has obtained more than two or three cures.   Should it be
decided upon to make  trial of it, it would be, I  suppose, a matter of
indifference almost whether we  used a very pliant portion of the tra-
chea of an  animal, a  cylinder of glue, playing card, or  paper, or a
canula of gum-elastic.   After having besmeared with some oily var-
nish this species of tube or ring, which necessarily should be  some-
what less in size than the intestine, we should pass through its middle
portion three or four nooses of thread or silk at a few lines' distance
from each other, armed at each extremity with a needle, and destined
to form as many points of suture.  Its  introduction into the upper end
of the alimentary canal can be  attended  with very little difficulty;
but in order to introduce it into the lower end, this latter should be
seized with two forceps, which can make traction  upon  it in an oppo-
site direction in order to enlarge its opening. This being effected, the
extremities of each thread are to be passed in succession from within
outwards through the corresponding end  of the intestine, and at the
distance of two or three lines from the wound.   After having knotted
and divided them very near the knot, the whole is to be returned into
the  belly; a slight aperient is to  be  administered, and the  patient
treated as after the ordinary operation for strangulated hernia.
  e. While  the reunion is being accomplished, the threads cut through
the  tissues which they embrace,  and as soon as  this process is  effect-
ed} the foreign body, now become free, descends  with  the intestinal
matters, and is soon expelled.  In place of four threads,  Duverger re-
commends two only, one in front, the other behind.  Those of Ritch,
as they were composed of one string, had the inconvenience of form-
ing  a kind of septum in the interior of the card.   Desault had no other
design than  that of getting rid of this difficulty when he proposed the
modification which is imputed to  him, and which is not of sufficient
importance  to be described in detail.   A suture of this  description is
in the first place very difficult to accomplish;  afterwards we should
have reason to fear that the reunion would not be effected in the in-
terval between the points of suture;  that the  threads  in becoming
liberated, might leave ulcerations, and  allow the effusion of some ol
the  fluids.   Finally, its dangers are so formidable that unless there
had been conclusive experiments and numerous facts, which science
does not at the present day possess, we should  not decide on having
recourse to  it, but  in despair of any other means.
  II.  Suture  with invagination.—a.  Randhor.—Itandhor having
under  treatment  a  soldier  in  whom the  continuity  of the intes-
tinal  tube  had  been  destroyed,  proposed  to  introduce the upper 
HERNIOTOMY OR  KELOTOMY.
617
 into the lower  end, to  attach them  together  in  this position  by
 means of two points  of suture,  then to reduce  them  and leave
 them in the  belly.  His patient recovered  perfectly.  As he died
 some years after of another affection, Randhor being thus enabled
 to examine the  condition of the parts, removed the portion  which
 had been formerly divided, and sent it to Moebius, who took occa-
 sion to show  it  to Heister, which latter, upon the strength  of this,
 made experiments  of  the  same  operation upon dogs, but without
 success.  The method of Randhor, which  has been eulogized  by
 some, rejected as impossible  or dangerous  by others, admitted as
 very ingenious by Louis, and made trial  of  in  a great number of
 instances since it has been known, does not appear to have succeed-
 ed  but in a very small number of cases.  Boyer performed it in one
 instance and his patient died.   In  another case he was not enabled to
 complete the operation.  I have seen it attempted at the hospital of
 St. Louis, in a  patient, who also died on the  following day.   M.
 Lavielle (Journ.  Gen.  de Med.,X.  XLV., p. 176,) and MM. Chemery-
 Have, Schmidt  and  some others  have, however,  each   related
 an  instance  of  cure in its  favor.   The  first difficulty is  to over-
 come the contraction of  the lower end of the intestine. One of the
 best means to effect this, would be to seize at the same time its two
 principal diameters at  their four extremities, with the same number
 of forceps or  hooks.   In order to prevent the upper end from filling
 up  or becoming  swollen, the assistant would  have  nothing more to
 do  than to grasp it at  the distance  of  four or five  inches from  the
 division, and  to  hold it  properly compressed, while the surgeon is
 endeavoring to draw it  and adjust it  into the opening of the rectal
 portion.  But there is  another  obstacle which M.  Richerand, I
 believe, was the  first to point out in a clear and unequivocal manner.
 The researches  of Bichat have shown that  mucous membranes do
 not contract adhesions  with each  other; and that adhesive inflamma-
 tion does not  usually take place  except between cellular surfaces.
 Now, in the invagination, after  the manner  of Randhor,. it is  the
 peritoneal covering of  the upper end of the intestine, which is placed
 in contact with  the mucous membrane ofthe other.  If the law
 established by Bichat is true, and the remark  of M.  Richerand well
 founded, the agglutination of the two  ends of the  intestine by this
 method would be impossible.  Therefore it had been almost entirely
 proscribed when M. Raybard (Mem. sur les Anus Artific, 1827,")
 undertook to bring it again into repute, and  to show that it  is pre-
 ferable to the  one which  it has recently been  proposed to substitute
 in its place.
  b. Process  of  M. Raybard.—In support  of  his  assertions, this
 surgeon relates a number of his experiments upon living animals and
 facts in pathological anatomy collected on man.  M. Raybard, like
 Randhor, recommends  that we should first incise the mesentery in a
 direction parallel  to the concavity of the intestine, and  to the extent
of a few lines.  Afterwards he  passes a little  above the wound a
thread, one end of which remains within the  canal, while the other
hangs outside.  According to him, two nooses thus  adjusted will  be
found sufficient, that is, one on each extremity ofthe antero-posterior
diameter of the diseased  gut.  By the aid also of a needle, we  are 
618           NEW  ELEMENTS OF OPERATIVE  SURGERY.
 enabled to pass the inner extremity of each thread from within out-
 wards, and through the lower end of the intestine, in order to inva-
 ginate the two portions methodically, and  to terminate, hy fastening
 each point of suture by means of a knot.  M. Raybard" maintains
 that his process is  at once more certain, more  easy, and infinitely
 less dangerous than that which has been proposed by AI.. Jobert; I
 have not, however, learned that it has yet been applied to man.
   III. Suture with contact of serous surfaces.—Experiments which
 were already ancient, might have been adduced in support of the
 ideas of M. Richerand.    MM. Schmidt,  Thompson, and Travers,
 had remarked the singular phenomenon, viz. that if we apply a thread
 around a small perforation  of the intestine, it soon sinks into it as
 into a depression,  in such manner as to be approximated gradually
 to the interior of the canal, and to become entirely free there, at the
 same time that the serous membrane or surface is approximated pos-
 teriorly, and blended with a layer of plastic lymph as if intended to fill
 up the opening which but for that  would have been left.   Still more,
 M. Travers has found that if we strangulate the entire calibre of the
 alimentary canal,  the peritoneum of the upper  portion adheres so
 rapidly to that of the lower, that the septum  formed by this stran-
 gulation soon becomes gangrenous, and is detached and drawn in the
 direction  of the rectum  in such manner that the tube ultimately be-
 comes perfectly re-established.  In France the labors of Dupuytren
 on  the  subject of artificial anus, had also already corroborated the
 same facts, and shown with what facility and promptitude two  por-
 tions of the external surface of the intestine will agglutinate when
 they are kept in contact.
  a. Process of M. Jobert.—From these various facts M. Jobert con-
 structed a method which appeared at first to promise important results.
 This surgeon commences by turning in the orifice of the lower end of
 the intestine ; he then employs the suture in the manner of Randhor,
 and by this mode succeeds in bringing the two ends ofthe intestine into
 contact upon their serous surface only.   Two threads wrere found by
 him to  be sufficient ;< he does not knot them, but attaches them out-
 side, in  order to remove them after the expiration of a few days.  In
 his experiments made upon cats and dogs he has, he says,  succeeded
perfectly.  But  this mode of invagination, which would not appear
to be attended with much less difficulty than that of Randhor,  pre-
 sents, at first sight, the advantage only of placing  in contact two  por-
 tions  of the peritoneum, instead of applying the peritoneum upon a
mucous membrane, as in the ancient process.   It has not  yet, more-
over, been made trial of upon living man.
  b. Process of M. Denans.—M. Denans, a surgeon of Marseilles,
proposed  about  the  same  time another mode of invagination.   For
this purpose he  required three.small hollow metallic  cylinders.  He
 placed one in each end of the intestine, which latter he turned or in-
 vaginated within them.   The third  cylinder,  which was  somewhat
 smaller than the two others, was to be introduced into the one above
 and then  into that below, in such  manner as to act as  a rod, axis or
support to both.  A noose of thread embraces them and  secures all
 the three on two different points of the  intestinal circle.  The  ends
 of the suture  are  divided  very near the peritoneum, and the whole 
HERNIOTOMY OR  KELOTOMY.
619
returned and left in the belly.   The  agglutination of the  parts is
soon accomplished.   Everything which is pressed between the three
cylinders soon becomes gangrenous and is detatched, and these foreign
bodies have then only to descend and pass out with the evacuations.
M. P. Guersent has corroborated the assertions of M.  Denans by
exhibiting an intestinal  noose, the ends  of which had been brought
into contact  by the process with  the  cylinders, and had perfectly
cicatrized.   M. Denans, (Note a I'Acad. de Med., 1838,) by simplify-
ing his process still more, uses only at the present day the three cy-
linders, which incase themselves so accurately that he does not find
it necessary to make use of the suture.
  c. Process of M.  Lembert.—M. Lembert in 1825 proposed another
mode of bringing the serous surfaces into contact.   He  passes with
an ordinary needle as many nooses of thread as he wishes to make
points of suture, first through the thickness of the walls of the upper
end of the intestine and afterwards through those of the lower end.
The point of this needle is introduced upon the  external surface  of
the gut at  the distance  of two or three  lines from  the  wound ;  he
causes it to make its way through the tissues as far down as to the
mucous membrane ;  brings it out at one or two lines' distance from its
place of entrance, and succeeds in this manner in adjusting his noose
of thread ;  applies  his  needle with the same precautions upon  the
external surface and into the tissue,of the rectal end of the intestine  ;
introduces  successively and  in  the same manner  the  number  of
threads which he judges advisable, and afterwards has nothing further
to do than to knot them in order to complete the suture.   In making
traction upon nooses of this kind we compel the lips of the wound to
become reversed upon  their  internal  surface, to form  a valve  or
projecting border in the interior, and to produce  at the same time an
exact  approximation and direct  contact  of the outer surface of the
two ends ofthe intestines whose continuity we wish to re-establish.
  d. These three processes have the same object  in view, viz: that
of the adossement of the two  serous surfaces.   That of M. Denans
appears to  promise more  certainty and to  be attended with less
danger than the two others, in  this respect, that it cannot be dis-
arranged.  Who, however, would venture to leave  the' intestine in
this  manner in the belly ?  Who  will guarantee that these  metallic
tubes will not perforate  the intestine ? In operating after the manner
of M. Jobert we incur the risk of the threads becoming relaxed, and
some  points  in  the circumference  of the  intestine may continue
ununited and allow of an effusion.  The modification of M. Lembert is
apparently more simple  and easy; it does not require either  the pre-
vious inversion nor the invagination, but  it appears to incur  to a still
greater degree than the preceding, the risk of leaving between the
points  of suture some interval through which the  matters might possi-
bly escape.
  e. The Author.—If however I was disposed to  make use  of it,  I
should prefer employing the whip suture ;  that is to say, that I would
pass the needle obliquely  from above downwards, from the upper
end to the  outer surface of the lower end ; return afterwards above
to the first end at a line or two from the point where I left it, then
come back on the second and  return again to the first, and  so on in 
620           NEW ELEMENTS OF  OPERATIVE SURGERY.
succession until I had passed around the whole circumference of the
intestine.   To complete the operation  there would be nothing more
to do than to make traction  in an  inverse direction upon  the two
ends of the thread, one of which would be at the origin and the other
at the termination of the suture.  If these simple tractions would not
suffice to cause the reversion  of the lips of the wound and to briti"
the peritoneum in contact with itself, the extremity of a sound would
effect this purpose.  After making a double knot the operation would
be immediately completed.  The  two extremities of the thread, or
either one of them moreover,  would serve for attaching the intestine
behind  the ring, upon the supposition that we  did not wish to return
it into the belly;  and no knot  in that case would be required.
  f.  Upon a rigid  examination, would prudence  authorize us in
depending  upon  such resources, which  would necessarily result in
death if they failed in effecting their object?  Would we be justifiable
in exposing in this manner the life of a patient, when by establishing
an artificial anus we are  almost  certain of being enabled to effect a
cure at a later period ?   I have used upon  dogs the  process of M.
Jobert and that of M. Lembert, modified in the manner I have just
described.   Whether it be that I did not take all the precautions
necessary, or that I  did  not  possess all the experience required in
such experiments, I am compelled to confess that in two cases out of
six the matters  were effused into the  peritoneal  cavity,  caus:ng
thereby the death ofthe animals. I will also add that in the four others
two only were  perfectly cured, while in the third and fourth there
remained  an aperture through which mucosities made their escape,
and  around which there were  no  adhesions or  false membranes,
which cases would not  have been very encouraging  for the result.
I was also desirous of repeating the experiments of M. Travers, and
the result was that in  two dogs, which  were the only instances in
which  I made  trial  of this process, the strangulated intestine was
ruptured, and was found  completely divided  after the death of the
animal,  which took place on the next day but  one.
  g. M. Choisy,  (These, No. 322, Paris, 1837,) making  trial of the
trachea of  an animal, after having  introduced it into the upper end
and attached it there by means of a whip suture, brought the thread
from within outwards through the lower end, which he brought up
by this means before strangulating it circularly, upon the tube intro-
duced.  Though these experiments of the author may have succeed-
ed upon animals, they do not  appear to be in  my opinion sufficiently
conclusive to justify the  application of his process, which has more-
over been still farther modified  by MM. A. Thomson, Amussat  and
Philippe, upon living man.
  h. Priority.—There still remains another question to be decided,
which is that of priority.   M. Jobert (Arch. Gen.  de Med., X. I\ ., p.
73 or 71)  has claimed  this honor ; but M. Faure  (Arch.  Gin. de
Med.,&Lc.,X. X.,p. 474) alleges that when he was a pupil ofthe Hos-
pital of St. Louis, he had proposed before the  year 1820, the adosse-
ment of serous surfaces in intestinal wounds. M. Denans (Ibid., X. XII.,
p. 618; Soc Med. de Marseilles, 1826 ; Journ. des Prog., X. III., p.
250 ; Bull, de Fer., t. X., p. 90)  also mentions that the suggestion of
his process is disconnected with the researches of M. Jobert, and M. 
HERNIOTOMY OR  KELOTOMY.
621
Lembert, (Ibid., X.  X., p. 318 ; Bull, de Fer., t. IX., p. 325,) on his
side maintains that he published his in the year 1825.  To determine
who is completely right or entirely in the  wrong in the midst of all
these pretensions, would doubtless be a difficult matter.  The follow-
ing is what appears to me to be probable.
  AI. Denans began  his experiments in 1823, but they were not an-
nounced  until March, 1824, and  the Archives for January of the
same year, contain a description of the process of M. Jobert.  The
idea of placing the peritoneum  in  contact with itself in order to
bring about the reunion of intestinal  wounds  is derived from the
labors of Bichat, the assertions of M. Richerand, the observations of
Dupuytren, and the experiments which were made  at the same time
in England and in America.  M.  Jobert,  transforming this sugges-
tion into a principle, has, like M. Denans, a little  sooner or a little
later, or at the same time with M. Denans, invented a peculiar pro-
cess to test its application.  Setting out also from, this point, M. Lem-
bert, who did not  communicate  his memoir to the Academy until
1825, has proposed another  mode of effecting the same object,  and
this is the one that M. J. Cloquet appears to have made trial of a
short time after, upon the man in whom he had the misfortune to cut
into the intestine while  operating  for a strangulated hernia.   Such,
if I am not deceived, is a true statement of the  case.
  i. Appreciation.—The important  point to be ascertained at the
present time would be, to what extent  it should be  retained in prac-
tice.  In my  view  the most rational  process is that of M. Lembert,
and this is the one to which we must necessarily ultimately give the
preference, should  experience ever confirm the  theoretical principles
which have suggested it.  M. Dieffenbach, (Arch. Gen. de Med., 3e
serie, t. L, p. 314,) who operated by this process,  after having ex-
cised a gangrened  noose  of the intestine, supposed  that he had suc-
ceeded, but the  patient  died at the expiration of a few weeks.  Two
points of the  suture were still suppurating.  We must moreover not
forget that pure and  simple invagination, in the  manner proposed by
Randhor or as modified by M. Raybard, has to  be submitted to new
experiments upon living animals, before being definitively  proscribed
or yielding its place to  the process  either of M. Jobert, M. Denans
or M. Lembert.
  D. If the mortification were limited to the peritoneal tunic, or had
not  reached  the mucous  membrane, we  might, as Desault recom-
mends, effect  the reduction of the  parts and await the result from the
resources of the organism.   But  of two  things one  must happen:
either the gangrene is evident, and in this  case the surgeon not hav-
ing the means of ascertaining with certainty whether it will extend
or not throughout the whole thickness of the intestinal parietes, can-
not venture upon attempting reduction; or its existence is question-
able, and in that Case prudence suggests that the intestine should be
returned  into the belly.  If the gangrene occupies only a small space
we must remove the portion of the  intestine which is the seat of it,
by incising upon the living part in such manner as to make an ellipti-
cal wound lengthwise  or transversely, according as the same shall
present a greater or less facility of being brought into harmony either
with one or the other of these two directions.  On the contrary, should 
622          NEW  ELEMENTS OF OPERATIVE SURGERY.

it extend  over a large portion of the periphery of the intestine, it
would be better to remove an entire segment of this cylinder, in
order to  make  trial  of one of the operative processes mentioned
above.  When  the gangrenous portions have  been once removed
the solution  of continuity is reduced to the condition of a simple
wound and is to be treated  like that.
  E.  Wounds  of the  intestines.—Modern labors have demonstrated
that the perforation of an intestine by a pointed or cutting instru-
ment, may be left without danger in  the abdomen, provided  it has
less than two or three lines of diameter.  The muscular fibres soon
pucker up its edges, in such manner as to compel the mucous mem-
brane to become entangled in it, so  as to close it up.  Nor does an
incision of somewhat greater extent, as one of three or four lines for
example, always give rise to an effusion; its borders sometimes be-
come agglutinated to the  corresponding surface of another intestinal
convolution,  or it may come in contact with a  fold of the epiploon,
which frequently becomes lodged in  it, and closes it up in the man-
ner of a plug.   I have in two instances reduced an intestine, per-
forated in this manner, without  any unpleasant consequences result-
ing.   M. Vidal has communicated to me a similar fact, and these re-
sults are calculated to diminish to a  great degree the importance of
sutures, and of the operative processes above mentioned.  I shall re-
cur to them again in  treating of artificial anus.   It would, neverthe-
less, be imprudent, when  such lesions are exposed to view, to aban-
don them to the efforts of nature.  Though it be true that the great
majority of them will succeed  in healing up without producing any
accidents, it is also very probable that others might be attended with
a fatal effusion.
  I.  In  hernias, these wounds present themselves under two distinct
forms ;  1st, in the condition of a simple division, when they have been
made by the cutting  instruments used by the  operator; 2nd, under
the aspect of an ulcer, or  solution with a loss of substance, where the
constriction  of the ring has been the cause.   In this  last  case we
can scarcely hope that they will close  up without assistance, and
should we decide upon treating them  by the  suture, it would be ad-
visable  that  their borders  should  be previously regularized.  We
have here the choice  of the glover's, the noose, and  the interrupted
suture.   The glover's suture has the advantage of being prompt and
easy,  and of closing up the wound accurately ; only that it is difficult
to withdraw  the thread when we suppose the  reunion to have been
accomplished.   The noose suture, or that of Le Dran, besides being
less prompt, possesses the disadvantage of puckering up and contract-
ing the intestine, in consequence of the  breadth of the wound; but
the threads having been  passed only once through the  tissues are
easily removed and withdrawn through the opening in the abdomi-
nal walls.  This suture,  slightly modified  by AI. Jobert, (Bull, de
VAcad.  Roy. de Med., X. L, p. 332,) who  had' opened into the intes-
tine, while operating for  a crural  hernia, succeeded perfectly; but
death was the  result  of it in two other cases which were published
by M. Fleury,  (Arch. Gen. de Med., 3e ser., t. L, p. 297.)  The  in-
terrupted suture possesses nearly the same advantages as the glover s,
and if it should be modified as was proposed  by Beclard, there will 
HERNIOTOMY OR KELOTOMY.
623
be less risk when removing it, of lacerating the adhesions and  the
forming cicatrix, than there would be with  the  simple whip suture.
It is nevertheless the spiroidal suture, combined with the principles
of M. Lembert, which would appear to deserve the preference oyer
all.  Whether the wound be longitudinal or transverse, the operation,
notwithstanding, is to be performed after the same rules.   When the
adossement is completed, we may proceed in two different manners.
First, by knotting the suture  and  dividing  it close to  the intestine,
then reducing this last, and leaving the suture free in the cavity of the
abdomen;  or second, we may retain the thread on  the contrary, and
attach it to the  dressing outside, in order to  prevent the wounded or-
gan from escaping to any distance, and  to compel it to attract adhe-
sions behind the ring. If it were certain, as is averred, that ligatures
inserted into  the tissues  of the intestinal coats, would always fall into
the interior of the canal, the first method ought evidently to  be  pre-
ferred, since the other must necessarily present more or less obstruc-
tion to the progress of the matters; but the majority  of surgeons
have not yet  adopted this mode of proceeding.   The  two cases of
M. Gloquet and M.  Liegard, both of* whom followed  the process of
M. Lembert, are in fact the only instances, which up to  the present
time can be cited in its  favor.
  II. M. Raybard  even considers, under such  circumstances,  that
the principal intention of enteroraphy is to attach the two lips of the
wound separately, behind the opening, into the walls of the belly, in
order  that when they have once become agglutinated to the perito-
neum, we may withdraw their threads, and  cure with one operation
the wound of the belly and that  of the  intestine.  If the wound is
longitudinal  this practitioner  proceeds in the following  manner: a
small thin oiled piece of light  wood twelve to fifteen lines in length,
and four to six in breadth, is first introduced into the interior of the
intestine.   A noose of thread attached upon the middle of this piece
of wood, and the two extremities of which  thread are  each armed
with a needle, is then passed  from one side to  the other, and from
the interior to  the exterior, and through  the entire thickness of the
walls of the  abdomen, in such  manner that the small plate of wood
presses at the same time the two lips of the  intestine against the two
sides of the abdominal wound, which latter  it also at the same  time
keeps  hermetically  closed.  When the  adhesion of these different
tissues appears to have been sufficiently consolidated M. Raybard
withdraws his thread; the little plate of wood comes away with the
stools, and from that time we have nothing more  to attend to  than
the cicatrization of  the wound of the belly, if, in fact, that  has not
already been accomplished.   If we may object  to this process, that
it produces designedly  adhesions which  necessarily prevent the in-
testine from  reacquiring its primitive mobility, it  is  proper to add
that in the other sutures the same thing  is  almost as  certain to  take
place,  if not  to as great an extent, also whenever we retain the ex-
tremities of  the thread at  the outside.   It  may be also said  with
truth, that  when we abandon  the intestine  behind the  wound,  after
having divided the thread close  to the peritoneum, we do not even
then any more escape this result.  The adhesive  inflammation essen-
tial to cicatrization  scarcely ever fails to unite the periphery of the 
624           NEW ELEMENTS OF OPERATIVE SURGERY.
 visceral wound to the tissues which cover and surround, or are in
 immediate contact with it.   Another objection is  that the employ-
 ment of the plate of wood, though applicable to longitudinal divisions
 from penetrating wounds into the abdomen, are no longer so in cases'
 where  the parts have escaped through a  hernial opening.   There
 would also, moreover, be danger that the extremities and edges of
 this foreign  body  might perforate by ulceration  or gangrene  the
 coats ofthe wounded intestine.
   III.  In  conclusion, therefore, whether  we retain the intestinal
 noose or leave it in the abdomen, it cannot cicatrize without becom-
 ing adherent to some extent  with the neighboring parts; so that
 under this  point of view, everybody should be left to act according to
 his own particular ideas.  Nor can I seriously blame M. Guillaume
 for using the suture to the exterior wound, in a patient in whom he had
 employed,  for a division of the intestine, the glover's suture.  Finally,
 if the walls of the  organic cylinder should  not have been divided or
 perforated  but to the extent of one or two lines, we should have
 acted still more promptly by seizing its two  lips at once with the for-
 ceps, and'closing them by passing a  ligature  around them, in the same
 way  as in tying the extremity of an  artery.  M. A. Cooper and
 another surgeon, I believe, have each succeeded in a case  in the hos-
 pitals of London by acting in this manner.

               § IX.—Accidental or Artificial Anus.

   The operations, by means  of which art  has sometimes succeeded
in the cure of artificial anus, are quite few.  For a long time even
no attempt was made  to devise any, and  it was scarcely until  the
middle of the last century that operative surgery seriously occupied
itself with  this disgusting infirmity, which, in the case of a woman
mentioned  by Wedemeyer, (Journ. des Prog., X. IV., p. 234—Bull.
de Fer., X. XII., p. 64,) was cured  by her becoming pregnant, and
which I have myself seen in two instances, and as has been related
in many others, frequently disappears also of itself.
  A.  Suture.—One of the earliest processes which here suggested
itself to  the mind  under the character of an operation, was the suture.
It would naturally appear that  by  approximating the lips  of  the
wound previously abraded, and by  maintainmg them  in contact,  we
should compel the matters to  resume their natural course, and to pass
into the lower end of the intestine.   Lecat, who was the  first to  de-
clare his intention of putting this method into execution, had admitted
into his  hospital, in the year 1739, with  the  object above indicated, a
woman  who had been affected with artificial anus for several months;
but various circumstances, over which he  had no  control, led to a
failure of his essay.  Lebrun  was more fortunate, and carried out into
practical operation the idea of Lecat.  A suture in the form of a cross
appeared to him to answer the purpose in the patient who fell  under
his treatment.  For the purpose of abrading the lips ofthe wound, he
made use of a caustic.  For two days every thing appeared to promise
a successful issue ; there were no accidents,  and the cicatrization had
already advanced very far, when on the third day it became necessary
to remove the threads and to give issue to the matters.  Lebrun wait- 
HERNIOTOMY OR  KELOTOMY.
625
ed with the intention of renewing the operation at a somewhat later
period, but the patient would not listen to any such proposal.  This
attempt, which few surgeons have ventured to repeat, has been gen-
erally condemned.  It however has been made trial of by M. Judey,
(Arch. Gen. de Med., X.  L, p. 291,) for an accidental anus which had
existed for four months.   The success was  complete, according to M.
Richerand. M.  Blandin appears to  have been less fortunate, as  ac-
cidents soon obliged him to reopen the wound.
  B. Anaplasty.—It was natural that a modification  of  this  process
should be suggested, and such  in fact has  been the  case.   The in-
teguments in general are so  indurated and so blended with the  sub-
jacent tissues  at the periphery of the wound, that it  would be diffi-
cult to approximate its lips or to bring them into  contact.   M. Col-
lier has suggested that a portion of skin detached from the neighbor-
hood, and brought forward and  attached by threads  or  pins on  the
accidental anus,  according to the principles of anaplasty, would  ob-
viate this inconvenience.  A patient  treated by him  in this  manner
was perfectly  restored, and it is a mode of proceeding which I shall
recur to again farther on.
  C.  Compression.—Compression is a method which  has been made
use of with advantage in more than one instance, and is still frequent-
ly employed at the present day.  It  is moreover in many cases  in-
dispensable as a preparatory or subsequent auxiliary means, to  re-
move certain  complications which would  render the  application of
the other  processes altogether impossible.
  I.  Strangulation ofthe invaginated intestine.—The intestine may
become invaginated through the artificial  anus, protrude to the out-
side, and ultimately, in certain cases, form  a tumor which  has been
seen to acquire the size  of six inches, and even a  foot and more in
length, assuming the form  of a cylinder, through the extremity of
which the  alimentary matters made their escape.   It  is evident  that
an invagination  of this  kind constitutes of itself  a serious disease.
Thus, as  Hebrcard (Bull,  de  la  Fac^ de  Med.  de Paris, X. L, 2d
year) saw in  a  patient who had been  affected in this  manner  for
twenty-four years, and as many other surgeons have also had an op-
portunity  of remarking, its root is liable to  become strangulated  like
any  other species of hernia.  Patients  have died in consequence
thereof.   1 have  no need of remarking, that when this strangulation
exists, we  ought, if the  reduction cannot  be effected in any othei
manner, to lay bare the  ring and incise it from within outwards,  in a
word, divide the  stricture as in ordinary hernia.  The  case of a child
mentioned by Hippocrates, the young man cited by F.  de  Hilden, and
the cases of Albinus, Lecat, Puy, Leblanc, Schmucker. Bidault, Saba-
tier, Desault, Scarpa, and Howship, collected by M. Arronshon, (Mem.
de Chir., 1836, p. 26,) who also saw  one himself, show what the  sur-
geon has grounds for apprehending from these eversions of the intes-
tine through an accidental opening of the walls of the abdomen. The
debridement performed  by M. Veiel, (Arch. Gen. de Med.,  2d ser.,
t. VII., p. 542,) in a case of this kind, did not prevent  a fatal issue.
  II. Compression of the invaginated intestine.—Even in the absence
of any constriction, the intestinal cylinder, with its mucous membrane
thus everted and  outside ofthe ring, does not remain long in this position
                               40 
626
NEW ELEMENTS OF OPERATIVE SURGERY.
without undergoing various alterations.  Thus there is danger that
the peritoneum of its invaginated portion may soon contract close ad-
hesions with that of the containing portion, and that the other tunics
may become thickened and indurated to such degree as to render its
replacement difficult or even altogether impossible. It is for the purpose
of remedying  accidents of this character that compression has been
recommended.  Desault, Sabatier and Noel, were the first to point
out its efficacy, since which it has become a  resource which to some
extent is in common use.  If the tumor is long, it is to be enveloped
with  fine compresses  after having  cleansed it,  and we then apply
over  it a bandage  in the same way  as in adjusting a roller bandage
on the limbs.   During the first days, the diminution of a mass of this
description  being very rapid, the bandage  should be renewed fre-
quently.  At a later period it is only to be reapplied at longer intervals.
If the serous surfaces of the organ do not present an insuperable ob-
stacle to this course, we shall soon have it in  our  power to return the
intestine into the  belly.
  III.  Compression ofthe spur, (Veperon.)—It is evident, moreover,
that after this reduction the artificial anus will nevertheless continue
to remain, and that something else is required to effect the removal of
this.  As the projection, or species  of spur, or prominent border which
separates the upper  from the lower end of the intestine, is the principal
obstacle to the passage of the matters from the first into the second, it
was natural to  hope that by pushing back this projection we  should,
in some instances, succeed in effecting a cure.   Compression, there-
fore, was  suggested for this also.  It is in the school of Desault that
it has received the greatest number of partisans and useful improve-
ments.  Desault expected by means of tents,  first introduced into the
lower  and then into the upper end,  and fastened at the outside by a
thread which embraced the middle portion, to clear out in this man-
ner for. the matters a  passage which they would soon take.   After
having inserted his  meche, he applied a pyramidal tampon on the epe-
ron to support its convexity and to push it as far  as possible towards
the belly.   By this means  he  gradually depressed the eperon, and
finally succeeded in obliterating a great portion of it.   After these
meches could be introduced of a large size, and that the stools had
become almost perfectly free, he confined himself to compressing the
exterior division  in order to prevent by this  means any kind of exu-
dation.  It  cannot  be denied that a treatment  so judiciously con-
ceived has  in  more  than one  instance been followed  by success.
Nevertheless the presence  of  a tent filling  up the two ends of the
intestine, and of the pyramid of lint or of compresses which hermeti-
cally close the wound, is not always supported by the patient without
some inconvenience.   Some under  such circumstances are attacked
with  colics and  pains so acute that  the method has to be laid aside.
Another means of effecting the same result has been sometimes em-
ployed at the Hotel Dieu.  This is a species of crescent of ebony or
ivory, six to eight  lines in length, having a handle five or six inches
long, and fitted with a sponge or compress.  This being introduced to
the bottom of the accidental anus, embraces by its concavity the in-
testinal projection, which is pushed back by making pressure upon its
handle, which is likewise wrapped  in  linen,  and which may  be 
HERNIOTOMY OR  KELOTOMY.
627
easily kept  immovable  by means of a  truss or any other suitable
bandage.
  D. Enterotomy.—The labors of Scarpa in elucidating the mechan-
ism of this affection, have shown that what this author calls a.promon~
tory is caused by the adossement of the two ends  of the intestine,
wHich present themselves behind the ring in the manner of the bores
of a double barrelled gun.  Such being the fact, they naturally sought
means not only to push back this eperon, but in fact  to destroy it.
  I. Schmakhalden  appears to have been the first to have conceived
this idea, which he made public in his inaugural dissertation in the year
1798.  He recommends that we should traverse, by means of a curved
needle,  the  base  of the eperon, and that we should thus introduce
through it a strong  ligature, in order, by making traction upon this
thread,  to cut through  it by degrees in a longitudinal direction, or
that we should proceed  after the manner of treating  fistula in ano by
apolinosis.
  II. According  to J. S. Dorsey, (Elem. of Surg.,  vol. IL, p.  96,)
Physick made trial of  a  similar process in January, 1809, and  suc-
ceeded perfectly.
  III. The proposition of the German surgeon received no attention
in his own country,  and that of the American author would also  pro-
bably have passed unnoticed, had it  not been that Dupuytren, about
the same epoch, viz., in  1813, made an effort on his part to bring it
into repute in France.  Like Physick, the surgeon of the Hotel Dieu
limited  himself, in  his  first trials,  to the introduction of a thread
through the eperon, in order to cut through it from behind  forwards.
The adhesions which the peritoneal surfaces would  contract around
the adossement, were calculated to prevent any kind of effusion into
the belly.   The matters being no longer  pushed towards  the  ring,
and finding an outlet in  the  lower end  of the  gut, would  naturally
take that route and  resume their course towards the rectum. Though
several trials had  confirmed these anticipations, Dupuytren soon  per-
ceived,  however,  that the needle  might  go beyond the  protecting
adhesions, and perforate a point of the alimentary tube, communica-
ting with the interior of the peritoneal cavity.  Intimidated by this
danger, he devised  an enterotome, the inner face of whose branches
was undulated, in order that it might more accurately embrace the
parts, and that these latter might not slip upon each other.  Being ar-
ticulated in the manner of a forceps, its  extremities in the direction
of the intestines,  were shut and approximated by means of a screw
passed through its handles.  One of the branches of this instrument
was to be applied upon  each portion of  the intestine, in such manner
as to include its  eperon to  the extent of an inch  or an inch and a
half.  The pressure necessarily brought about the  mortification of
the tissues, and an immediate  interruption  to  the circulation.  It is
easy to understand the character  of a process of  this  description.
The peritoneum is placed in contact with itself upon the  periphery
ofthe enterotome.  The eliminative  inflammation dev elopes itself by
degrees, and is transmitted to the distance of some lines upon the
outside.  Solid adhesions are the necessary consequence, and no per-
foration therefore is to be apprehended  in  the direction  of the peri-
toneum.  In proportion as the eschar detaches itself, the instrument 
628
NEW ELEMENTS OF OPERATIVE SURGERY.
becomes more and more movable, and comes away entirely, as soon
as the former is  completely isolated.   Should the compression not
have been sufficiently powerful at first, the blood might still continue
to circulate between the branches of the forceps.  In that case the
gangrene would not take place, and the  exterior peritoneum mi^ht
not be inflamed to a sufficient extent to bring about the adhesions
required.  We would have to apprehend  a perforation in the direc-
tion of the belly,  and the failure of the  division of the morbid sep-
tum.   And even  admitting that it should  have taken place, the pain
notwithstanding will be more acute, and the cure much more tardy.
This method, which  was employed  in more than twenty instances by
Dupuytren, and afterwards by MM. Hery de  Bonneval, Lallemand,
Delpech, Simonin,  (Decade Chir.,  1838,  p. 75,) and  other practi-
tioners, has up to the present time occasioned  serious accidents only
in a small number of cases. As soon as the perforation is effected, the
matters pass into  the lower intestine and the stools are re-established.
Each day less and less passes through the  wound, which latter speed-
ily contracts, and is soon reduced to the character of a simple fistula,
if it is before the cicatrization has been entirely accomplished.  Fever
rarely follows, and some symptoms of  colic or of  inflammation, ex-
tending to a slight distance towards the  intestine and peritoneum, are
the only accidents that  have been  noticed, while in most cases the
patients rarely experience any inconvenience from its  employment.
A patient, however, operated upon by M. Lesauvage, (Arch. Gen.
de Med., 2e ser., t. XII., p. 351,) died after the expiration of a few
months, though there was a decided contraction of  the perforation.
I have seen a woman die on the tenth day from this  process, in con-
sequence of peritonitis.   The  eschar, which had detached itself on
the sixth day, had not yet become surrounded with adhesions, and I
know that similar results have been noticed in other hospitals.
   IV.  Some  persons, however, have endeavored to make an addi-
tional improvement  of this process by modifying  the enterotome
forceps.  Thus, M. Liotard has suggested an  instrument or species
of punch, which is made use of by M. Blandin, and which cuts out a
circular flap from the morbid septum without  touching its  free bor-
der,  in  such  manner that an  opening is thereby  made,  which is
modelled in some respects after that  of a natural  intestine.  This
process would possess the disadvantage of not being adapted to all
cases, that of incurring  the risk of pinching up some sound portions
of a free noose of the intestine, which  might happen to get behind
or between the two branches of that portion of which we were de-
sirous of perforating the septum of adossement, and finally, the dis-
advantage of being difficult of execution, for the plates of AI. Liotard
are too large to be easily introduced through any artificial anus
whatever, or  through the ends  of  the  intestines themselves, which
latter, in such cases, are  usually contracted  to a  very considerable
degree.
   V.  Delpech has used  an instrument which acts nearly on the same
principle as that of  M. Liotard.   This enterotome, revived as some-
thing new, and used in one instance with  success by M. Lotz, (Gaz.
Med., 1836, p. 746,)  is  a long  forceps, terminated by two concave
hemispheres (coques,) slightly elongated,  and very nearly similar to 
HERNIOTOMY OR  KELOTOMY.
629
the shells of a walnut, and  the circumference of which is slightly
concave  in  the direction  of their  length.   They are introduced
separately; as they do not make compression at first, except at their
beak, the septum is  divided only by degrees, and from behind for-
wards, while with the enterotome of Dupuytren, the  compression
being generally so much  the greater in proportion as we approach
nearer to the heel of the instrument, the gangrenous division is ac-
complished from before backwards.  Delpech, moreover, was fully
conscious that his  forceps, though useful perhaps in some particular
cases, could not in general be substituted for that of Dupuytren or
that of M. Raybard.  It might, I should imagine, possess some ad-
vantages when the septum is exceedingly long and situated at a great
depth, or when, in order  to reach  it, we are obliged to  pass through
an irregular and more or less sinuous passage ; but these are  details
which can never be subjected to the rules of a systematic description,
and which must be left to the judgment of the surgeons to  whose
notice the cases present themselves.
  E. In this method, moreover, as in every other two  things are to
be distinguished, the object in view, and the means by which  it is to
be attained.   It is upon these last only, as it appears to me, that there
can be any difference of  opinion at the  present day, and there is no
reason why we should not make still further attemps to simplify them.
Since by depressing the eperon in artificial anus, we make a passage
for the matters, why not effect this depression by means of a canula,
which would at the same time allow of the cicatrization of the ex-
terior division ? This advice has been given by M. Colombe, (Bibliot.
Med., 1827, t. L, p. 389,) and M. Forget informs me that he advan-
ced a similar opinion in  the year 1824.  M. Colombe  recommends
that we should insert the extremities  of a large gum-elastic  canula
two to three inches long, into the two  ends  of the intestine, which
canula being  slightly curved, would rest at its concavity upon the
free border of the septum, and would have attached to the middle of
its convex side a thread, for the purpose of retaining it. until the
wound should have almost entirely closed up, or  that the course of
the  matters had been sufficiently well re-established to lead  to no
farther apprehension of  their  escape externally.  At  first sight a
process of this kind seems  to  be worthy of consideration, and ap-
pears to be specially applicable to those cases  in which the  enter-
ing  (rentrant) angle formed  by the mesenteric wall of the intestinal
noose is very open, and where  the  eperon  is not very projecting,
and to those cases more particularly,, in which the intestine has not
been destroyed  throughout  the whole extent of its circumference;
but  in the others it is to be apprehended that it would prove  insuffi-
cient, and that it would  have to give place at  least to  the process
of Dupuytren.   I would  remark,  that in order to have a decided
prospect of success, it would be necessary to make  use of a lar,ge
sized canula, the introduction of which should necessarily be attend-
ed at first with a considerable degree of difficulty.   I used it at La
Pitie, in the month of August, 1831, and the patient succumbed three
days after, under symptoms of an intense peritonitis.   The intestine
was perforated behind, and  the canula had perforated into the open-
ing.  Whether this  perforation was the effect of  the  canula  or  a 
630
NEW ELEMENTS OF  OPERATIVE SURGERY.
 simple coincidence, certain it is that a result  of this character does
 not speak much in favor of the method.
   F.  Excision.—It is proper to remark also that the process of Du-
 puytren is not the only one which  might be attended with success.
 M.  Raye  (Bull. Med. de Gand.; Gaz. Med., 1838, p.  145) seizing the
 eperon with a good pair of polypus forceps, afterwards excised a V
 flap from  it with the scissors, and his patient was promptly cured.
   G.  Complications  to be  encountered.—When  the surgeon has
 decided upon undertaking the cure  of artificial anus he must reflect
 at first upon the difficulties which in certain cases present themselves,
 to the introduction of the enterotome.  If the  integuments  have not
 been largely laid open, or if  from any cause whatever there should
 have been developed  in the neighborhood sinuous  passages or ster-
 coral fistulas, or if a tumor or openings or an erysipelatous inflamma-
 tion exist in front of the gut which  it is our intention to enter, there
 can be no doubt that we ought to  begin by combatting and getting
 rid  of these various  impediments,  either  by  means of the proper
 incisions  or excisions, or  by  sanguineous evacuations, general and
 local,  topical emollients or laxatives, baths, lotions, &c.  It was in
 this manner I saw formed in a patient whose strangulated hernia had
 never been operated upon, five or six openings and a tumor as large
 as the fist  in front of the  ring,  a  tumor which was occasioned by
 the  thickening  and habitual  chronic inflamed  state  of the  skin, the
 cellular  and adipose  tissue and various  lamellae  contained in the
 inguinal  canal.   I was thus obliged to circumscribe this mass by two
 semilunar  incisions, and  in order to remove   it was compelled to
 cut  down  to  the root of the spermatic cord,  that  I might lay bare
 the  intestinal opening.  In such cases moreover  it is to be recol-
 lected that the operation is to be performed in two stages; that is,
 before proceeding to the use of the enterotome we  must wait for the
 cure of the wound which has been made.  In  other cases we are
 obliged to  dilate for a  week or two the artificial anus itself.   In cer-
 tain others the cutaneous orifice is  so remote from the intestine that
 we  meet with  considerable difficulty in  penetrating into this last.
 The perforated  noose  of intestine may also be tortuous or twisted,
 either in the interior of the canal itself or behind the ring, or it may
 have formed  duplicatures  which  have contracted  adhesions with
 each other, and thus  give rise to difficulties which it is important to
 overcome  before proceeding  farther.  The lower  end  also of the
 intestine, which is always contracted to a great degree, may be situ-
 ated  above  the upper  end,  around  which it may  have  become
 twisted in  the manner mentioned in the case which is found in the
 memoir of Delpech.   Though the obliteration  of this portion of the
 alimentary tube, however ancient the disease may be, is unfrequent,
 it  is however possible.  A case  noticed at  the Val-de-Grace in an
 old man who had  had an inguinal artificial anus  for forty years,
 places this fact  beyond dispute;  so  that it is as well to think of this
 fact  before applying the forceps  upon the septum we are about to
 destroy.   At however slight  a depth therefore the wound may be
 situated, or however little doubt may exist upon the character of the
relations  between the orifices of the abnormal anus, we ought  to
endeavor to dilate gradually  the passage which conducts  into the 
HERNIOTOMY AND KELOTOMY.
631
upper intestine, and do the same for the lower also, by means of long
meches, bougies, sounds and gum-elas"tic  canulas, or by portions of
prepared sponge, and never have recourse to the enterotome before
having been enabled, by means of the finger, to recognize the posi-
tion of the  parts and the  relative situation of the septum with both
ends of the  intestinal tube.
  H.  The  Operative Process for Enterotomy.—When we  have
reached this point the  operation, properly so called,  may be per-
formed.  The patient  is  to be  placed  in the same  manner as for
kelotomy.   The forefinger of  the left hand serves as a  guide to one
of the  branches of the forceps, which  it  conducts under the lower
surface of the eperon  to  be destroyed.   An assistant is directed to
keep it in its place, while the operator introduces the  other in the
same  manner into the  upper end of the diseased tube.   He now
grasps both the branches; turns  them  upon their axis  in such man-
ner as to be enabled to unite them together; passes his finger almost
as far as their extremity,  in order to ascertain to what extent they
embrace the eperon and to what distance he may insert them with-
out danger up to the point where he wishes to effect the mortification.
The quick screw or any other suitable  means for shutting  them, is
immediately applied upon the extremity of their handle, and  com-
pression made to  the  degree required  for  suspending, as we  have
said, the circulation or vitality in the septum which they embrace.
Nothing more remains to be done than to surround them with lint
and compresses, and secure the whole by means of a bandage, which
terminates  the operation.   The  patient being carried  back to his
bed, is subjected to the regimen used in  serious operations.  The lint
and other portions of the dressing  are to be renewed as often as
the exudation of the matters  require, taking care however that the
requisite precautions are observed to prevent the forceps from being
disturbed in their position.  Should  accidents be developed they are
to be met by such means as each one of them may require; as soon
as any gurgling sounds are heard or the least tenesmus manifests
itself,  irritating injections become absolutely necessary, especially
when the instrument begins  to  be loosened? and when the  separa-
tion of the  eschar should appear to  have  already taken place.  The
subsequent  treatment has nothing further of a particular character;
the patient should  maintain the horizontal  position, take  from  time to
time an aperient, have recourse  frequently to enemata, and take all
kinds of nourishment.
  I. In respect to those kinds of artificial anus  whose cure cannot
or ought not to be attempted, the best means to  be employed is the
species of box contrived by Juville.   Any other description of vessel
constructed on the same principles, and those kinds of vessels or in-
struments which  are found at most  bandage-makers or manufactu-
rers of surgical instruments, would moreover fulfil the same intention.
  J.  Additional remarks  upon artificial anus.—It would be  readily
supposed, from what has preceded,  that  artificial anus is a disease
which can require no farther investigation.  One important step was
to have established in a precise manner the influence of the infundibu-
liform contraction of the peritoneum upon the progress of the matters
towards the neighborhood of the  fistula.   Another was that of show- 
632
NEW ELEMENTS OF  OPERATIVE SURGERY.
ing that if the contents of the alimentary tube  escape by the acci-
dental opening, rather than continue to pass ffom the upper into the
lower end of the  intestine, it was to  be imputed to the  septum or
species of promontory or mesenteric eperon situated between them.
A third point gained finally, and unquestionably the most important
of all, was the knowledge how to destroy this eperon, since the cure
of the disease  depended  upon  that  result.  The knowledge in fact
that we could  obtain this result  has, in some measure, thrown the
other acquisitions, made into oblivion.    The minds of surgeons, ex-
hausted as it were by such successful  results, have from that time
fallen  back again almost into  a state  of perfect indifference.   In
this respect  however, as in  many others, surgery is  still far  from
having reached perfection.   The adhesion of  the  intestine to the
root of the sac is frequently less intimate than Scarpa alleges.  The.
membranous funnel  is frequently  wanting.  The  adhesive inflam-
mation does  not  always take place at the periphery of the entero-
tome, even after it has been  applied in the most judicious manner.
In  some cases it  is  almost impossible  not to include between the
branches of. the instrument a portion of some important organ at
the same time  with the abnormal septum.  Finally, many cases of
artificial anus and of stercoral  fistulas will persist  to an indefinite
period of time, in spite of the  destruction or absence of every kind
of eperon.
  Georget, a farmer,  39 years of age,  entered into my department
of the hospital of  La Pitie, on the 28th October, 1834.  I examined
him at my visit on the 29th and  perceived at the outer angle of the
right  pubis, a red colored border formed by the everted intestine.
Below this was found a fistula which allowed of the introduction of
a probe into  the perforated  intestine.   The patient was anxious
and desired to be operated upon immediately.  On the 2d Novem-
ber an acute erysipelas made its  appearance around the wound and
death  took place  on  the  9th.
  Morbid Appearances.—1. The upper portion of the ileum is attach-
ed to  the inner and  lower portion of the inguinal  ring,  where it is
slightly adherent, and  in  such manner as  to be continuous with the
fistulous ulcerations noticed  during life.  2. The lower  end of the
same  intestine ascending from the  pelvic cavity into the iliac fossa
turns  round upon the  outside of the other, in order  to  enter into the
hernial canal, and to reach down to the groin, where  it formed the
actual orifice of the artificial anus.   3.  By raising these two portions
posteriorly, they were so easily separated  from  the neck of the sac,
that the slightest effort would have been sufficient to produce an effu-
sion into the  peritoneal cavity.   4. It  would  have  been  impossible
during life, to have strangulated the eperon by means of the  entero-
tome, without causing this effusion.  5.  There was not the slightest
appearance  of infundibulum, and the sac was closely adherent to
the inguinal canal.  6. The two portions ofthe intestine were in con-
tact at their side, and not at their mesenteric border.   7. At  differ-
ent intervals this  adossement was merely that of contiguity, and in
such manner as to allow it to be  destroyed without the slightest rup-
ture.   In this case, therefore, the total absence of  infundibulum, or
of a  membranous funnel, would have constituted an insuperable ob- 
                  HERNIOTOMY OR  KELOTOMY.                 633

Btacle to the spontaneous cure of the artificial anus,  which however
had existed for the space of seven months ;  while the feeble character
and extent ofthe adhesions would have almost unavoidably occasion-
ed a fatal  effusion into the belly, had the slightest operation  been at-
tempted.  Upon the supposition that wre could have succeeded in de-
stroying the intestinal septum, the  matters  nevertheless would  have
doubtless continued to pass through  the  wound, since even in  that
case the contortion of the intestine would have rendered their trans-
mission from the upper into the lower gut next to impossible.
  The following is a fact of another character, though not dissimilar
to the preceding.  Martigny, a day laborer, 56 years of age, had been
laboring under a crural hernia on the  left  side,  for  the space of 18
years.   On the 17th April, 1835, there came on vomitings, and a few
days afterwards symptoms of inflammation.   The patient entered La
Charite on the 26th of the same month.  The fold of the left groin
presented a  red irregular tumor, which exceeded the size of an egg.
Repeated  efforts of  the taxis were unavailing.   Gases of a gangre-
nous odor were disengaged, and the mortified parts were  excised.
Two incisions were now made at the seat of the strangulation.  On
the 30th April the dressings were saturated with faecal matters, but on
the 6th May the pain had almost subsided.   On  the  10th, compres-
sion was applied by means of small balls of lint, and  on the 14th the
forceps of Dupuytren were introduced and tightened upon the eperon.
On the 18th, the patient experienced only some slight attacks of colics
at intervals,  when the forceps were gently tightened again.   On the
19th the colics were more violent, with pain on pressure in the hypo-
gastric region.  Nauseas  with  vomiting succeeded, and on  the 20th
the symptoms became more  aggravated, and the  belly exceedingly
sensitive.  On the 21st,  we removed the forceps, which were found
to include between its  branches a portion of gangrened intestine.
The belly was tympanitic, and  the face shrunk, and death took place
on the afternoon of the 22d.  A part of the epiploon was found ad-
herent in front of the strangulated intestine, and shutting up its cavity
on the left.  On turning back  this  epiploon, we  found  the two  ends
ofthe intestine with their  lips  detached.  Upon  the  inside, the epe-
ron was destroyed to the extent of two inches ; but there was no ad-
hesion except on one ofthe sides ofthe division.   The other border
was cut perfectly smooth, and it was evident that  a certain  portion
ofthe stercoral liquids had made their escape through here.   The pus
in the neighborhood \vas tinged with them, and the entire peritoneal
cavity was filled with sero-purulent matters.   The  entero-mesenteric
septum had prolonged itself into the groin.   The remains of the sac
exhibited no disposition  to become  displaced, or  to be  drawn in the
direction of the belly.   There are  no  reasons for supposing that it
would  have been possible  to have established in that place a membra-
nous funnel.   In this case, the adhesion which the enterotome usually
causes around the portion  of tissues it strangulates,  had been but im-
perfectly accomplished; it is  also to be added that  in front, where
alone this  adhesion  existed, it would have  been  impossible for it to
have retained the matters without the expansion of the epiploon which
covered it.  Aloreover,  inasmuch as from the first to the fourth  day,
no accident  supervened, we may affirm I  think, that  the peritonitis 
634           NEW ELEMENTS OF  OPERATIVE SURGERY.

was the result of the mortification of the eperon, and not  of the her-
nial strangulation.
  A woman whom I operated upon in 1833, with Dr. Bonis, for an
enormous strangulated gangrenous umbilical hernia, died two months
afterwards with an artificial anus, in my department at the hospital
of La Pitie.   The particulars in relation to the operation  were com-
municated at the time to the Royal Academy of Medicine, (Arch.
Gen.  de Med., 2e ser., t. IL, p. 285.)  I wish to recur at the present
time  only to the portion which relates to the condition of the parts
in the belly.  It was the small intestine which had escaped through
the umbilicus, and the convex border of its upper end  was the only
portion which remained partially  adherent behind the ring.  The
other end was more  than an inch  distant  from it; nevertheless no
effusion had taken place into  the abdomen.  The epiploon on one
side,  a sound noose of the intestine on the other hand, and thirdly, a
false  membrane, had  become agglutinated all around, as if  for the
purpose of forming the canal or funnel down to the umbilicus.  The
matters thus, which had never absolutely ceased to pass into the cas-
cum,  must, before issuing from the wound or entering into the lower
end of the perforated intestine, have fallen or glided down upon this
species of accidental plane.   The sinus, or cul de sac, corresponding to
the mesenteric side, was occupied moreover  by another portion of the
small intestine, bent into an acute angle, and agglutinated in  a solid
manner upon the points upon which the enterotome would have had
to have been applied,  had it been judged advisable to undertake the
operation.  We perceive, therefore, that it not only would have been
difficult to have reached the eperon, but moreover that in compress-
ing this septum, we should have inevitably strangulated another noose
ofthe alimentary canal, and caused the death of the patient.
  K.  An  anus without eperon.—Artificial anus and intestinal fistu-
las unaccompanied with an eperon, may be established in three ways
that are quite different: 1st.  If after the reduction of a hernia which
has been previously operated on or not, an opening shall have formed
upon  the  convexity of the  intestinal noose, it may happen that the
matters issue in the direction towards the skin,  and that an artificial
anus will be the  consequence.  2d.  An ulcer commencing in the mu-
cous membrane may cause an adhesion  of the intestine to the corres-
ponding part of the abdomen. Continuing its progress outwardly, and
having perforated all  the  tunics, this  ulcer will cause a stercoral
abscess and may terminate in a fistula.  As the intestine is not dis-
placed, it may neither be bent into an angle nor contracted.  Hence
in such cases the artificial anus or the intestinal fistula must in most
instances  be without an eperon.   3d. Frequently, after the destruc-
tion  of the  eperon by the method of Dupuytren, the artificial anus
persists under the form of a fistula which cannot be closed up by any
means applied.
  a. An anus without an  eperon  and resulting from hernia or a
wound.—The first  description of anus  without an eperon comprises
several varieties.  Thus, in some instances, it originates from a gan-
grenous portion of the intestine which has been pushed  back into the
belly  before being perforated.   In other  cases, on  the contrary, it
depends on a rent or laceration  of the hernia itself, which has taken 
HERNIOTOMY OR  KELOTOMY.
635
place during the efforts at the taxis, or even at the moment of reduc-
tion.   Again, it arises, after having laid bare the hernia and effected
the debridement, from our having pushed back into the belly,  de-
signedly, or contrary to our intentions, or through mistake, the gan-
grened intestine, with or without perforation, and ulcerated through
and through from the peritoneum to the mucous membrane, or vice
versa.  In other cases, finally, it results from  the intestine which has
been wounded  by an instrument penetrating into  the abdomen, or
from the operation of hernia, or in any other way, having been left,
or been returned in its place into the peritoneal  cavity.   1st.  These
four varieties are  divided  into two very distinct orders, according
as there exists or not at  the  same time  a division of the external
parts.  In the first case, that is to say, where the walls of the belly are
laid open, as after  the operation for  hernia, or from a penetrating
wound, the artificial anus or fistula is established immediately, and
without being necessarily preceded by suppuration or an abscess in
the neighborhood.   In the second case, that is to say, where no solu-
tion of continuity has been made in the belly, as for example, in con-
sequence of the taxis, a stercoral abscess, on  the contrary, is  almost
the  inevitable precursor of an artificial anus.  Nature  here  makes
use of a process which comprises two elements.  It is necessary, in
the first place, that adhesion should have taken place between the peri-
phery ofthe intestinal perforation and the corresponding part of  the
walls  of the abdomen.   In the second place, there must be an exit
established between the ulcer and the exterior.  Now it is immedi-
ately perceived that this last stage of the morbid process is infinitely
more complicated and difficult in the one case than in the other; that
with the  previous opening of the  hernia or through the abdominal
walls, nothing is more simple; while,  in the other case,  the abscess
which is developed may extend to a considerable distance, gangrene
the parts over a large surface, and ulcerate the skin in a great num-
ber of places.  The intestinal lesions also under consideration,  are
far from always terminating in the same manner, and their treatment
must be varied  according to certain  circumstances.  2d. Wounds
and perforations without gangrene, as in a hernia, for example, may
be reduced and heal up in most instances, without the  intervention
of any description of suture.   The intestine being returned into  the
belly, remains behind the ring and becomes agglutinated to it.  The
parietal peritoneum agglutinates to the peritoneum  on  the borders
of the intestinal opening, while the  mucous membrane becoming
swollen and reversed outwardly, shuts up the wound, and  presents"
a complete obstacle  to the effusion of the matters.  After the cica-
trization the patient recovers, with the exception only of some slight
colics or tractions in the neighborhood of the  wound.   To the facts
which may be adduced in support of these assertions, I might add two
others which belong to myself.
  A woman  55 years of age  had a crural hernia which had been
strangulated for the space of four days ; she was brought into my di-
vision at the hospital of La Pitie in 1833.  I proceeded immediately
to the operation, which at first presented nothing peculiar.  A noose
of small intestine which was seen at the bottom of the sac, with a
livid tint of a very suspicious character, nevertheless preserved  suf- 
636           NEW ELEMENTS OF  OPERATIVE SURGERY.
ficient firmness to banish all idea of gangrene.   After having divided
the stricture, I drew the noose out in order to have a better opportu-
nity of examining it.  We then  ascertained that it was ulcerated in
three  places.   Pressure caused  the intestinal  matters to issue  out
through the three openings, which  were reversed in the manner of
a chicken's rump, (en cul de poule,) distant from two to three lines
apart, and  situated upon the convex portion  of the  intestine.   A
probe introduced into one  of them entered freely into  the intestinal
canal.  After having  hesitated  a  long time and noticed that these
openings had sensibly diminished in diameter by emptying the intes-
tine,  I  decided upon returning  the latter  into  the abdomen.  The
wound was kept open, and the patient maintained in  a state of com-
plete immobility.   My fears, I  confess, were extreme, but no acci-
dent supervened, and  this patient  recovered as rapidly and as per-
fectly as if it had been  a case of hernia without alteration of the  in-
testine.  Not the slightest  particle of stercoral matters ever escaped
from  the wound, which cicatrized at the expiration of a month, (Arch.
Gen.  de Med., 2nd ser., t. I., p. 595.)
  Another woman  operated upon in the same hospital, in the  spring
of 1834, furnished me  another instance.   This patient, who was  47
years of age, stout, of an ordinary embonpoint,  and in robust health,
had had for a  long time  an imperfectly reducible hernia.  When I
saw her the symptoms  of strangulation had existed for  the space  of
24 hours.   Having in vain made another effort with the taxis,  which
had already been made trial  of under every variety of shapes,  I pro-
posed the operation, which was accepted and performed immediately.
Before  arriving at the sac, it became necessary to push  aside or
make an incision into several degenerate ganglions.   An adipose lar-
daceous layer then presented itself; a cyst filled with blackish-colored
liquid was  the next that appeared, and exhibited before us a surface
slightly rugose, bosselated and resisting, which possibly  might be the
indurated sac, and which I proceeded to divide layer  by layer, under
the apprehension that it might possibly be the intestine, when a sudden
and unexpected movement in the patient caused me to make a com-
plete incision into it to the extent of eight lines.  Mucous dark-colored
matters, and afterwards yellow  and frothy, immediately made their
escape through the wound.  The mucous membrane  being laid bare
was easily  recognized ; my ability to  pass  the  finger into the belly
through the cylinder I had opened, together with all the other attending
circumstances, satisfactorily proved that the instrument had entered
into the intestine.  Emboldened  by the preceding case, which was
still present in my mind,  I  ventured  immediately  to reduce the
wounded intestine.  The wound had  at least  eight lines in extent.
Its direction, moreover, was  parallel to that of the intestine,  and it
was situated  upon  its  convex portion.  The most  absolute repose
was prescribed.  I placed a linen besmeared with cerate  intr the
crural ring.  The division Of the external parts was kept open  by
small balls  of lint, and the rest of the dressing supported merely by a
containing  bandage, and  without  any actual compression.   I h<;
course of the matters was  re-established through the  anus on the fol-
lowing day, when the vomitings as well as the other symptoms imme-
diately ceased.   None of the contents of the alimentary canal  came 
HERNIOTOMY OR KELOTOMY.
637
out by the groin, and the patient left the hospital in a state of perfect
health on the 35th day.  I have seen  her twice since ; she wears a
precautionary bandage, and suffers only some slight colics when she
has walked much, or eaten more than usual.
  M. Castara, (communicated by the author, 26th Nov., 1838,) found
six sharp-edged nuts,  in a  strangulated  and perforated intestine,
which he had cut into, in order  to extract  from  it  these foreign
bodies; his patient recovered like the preceding, without any artificial
anus.  It may moreover be readily  conceived, that the result might
not in every case be so satisfactory.  The intestinal wound, either on
account of its extent, direction, or  form, or owing to the constitution
of the patient, may, should it not close, continue to give  exit exter-
nals, to the matters which pass through the alimentary tube,  and be
in this manner transformed into an artificial anus.  3d.  If,  as happens
quite frequently, the intestine should be ulcerated, or divided trans-
versely on one of its points, in the ring for example,  the reduction
would present but a slight prospect of cure, and would scarcely ena-
ble us to hope for the  spontaneous formation of a simple artificial
anus.  As the reduced  organ continues almost always, in  such cases,
to maintain behind the ring the same relations as in hernia, that is to
say, in such  manner that the  portion -which was free  in  the  sac, is
precisely the same which remains  opposite to  the  canal in the belly,
the following are the  results which  may happen :   1. The periphery
of the perforation, contracting adhesions with  the corresponding part
of the contour of the ring, causes  the course  ofthe matters to  be
immediately re-established through their natural route, and the  cure
to take place as in the  preceding case.  2. However slightly  retard-
ed or incomplete the adhesions may  be, a  certain quantity of  matter
will  effuse itself into  the neighborhood.   This effusion  sometimes
spreads into the peritoneal cavity,  and  speedily causes  death.   In
most cases, it is moderated, confined, and  circumscribed  in the  iliac
fossa, by means of the adhesive  inflammation  of the surrounding
peritoneum.  In such cases, it is nothing  more than a stercoral ab-
scess, which in some instances opens at the ring, where it afterwards
terminates in an anus or fistula ; while in  other cases it forms  in an-
other place, and in such manner as to  make its way into the  perito-
neal  cavity, into some hollow organ, or  into the  substance  of the
walls of the abdomen.   In a patient whom I operated  upon in 1831,
in company with Dr. Florence, a collection of this  kind had formed
internally near the bladder, and between the peritoneum and muscles.
Its size was at first so considerable, that we attributed it at first to a
retention of urine ;  finally, it made  its way into the ring, but death
did not take place until the twenty-seventh day.   In a man whom I
operated upon in 1836, in the department  of M. L'Herminier, at the
hospital of La Charite, and who died twelve  hours after from  peri-
tonitis, the  adhesions,  though recent and slight, had  however  been
sufficient to  retain the  matters in the iliac  fossa, and to force them to
take  a direction, in part, towards  the   ring, though the ulcer in
the  intestine was very large, and situated  outside  of  and above
the crural canal.  I met with a similar case  in a patient of  M. La-
croze in 1834, and two others since at La Charite.   A  woman whose
hernia had become gangrenous at  her residence, entered into the 
638           NEW ELEMENTS  OF OPERATIVE SURGERY.
clinical wards  ten days  after, with an artificial  anus.  The course
of the matters  was  partially re-established, but the iliac region  be-
came swollen and painful.  The finger, introduced into the fistula,
made slight traction upon its outer angle, when more than a litre of
purulent serum, mingled with stercoral and albuminous flocculi, imme-
diately escaped from it; an abscess had been formed there. 4th. When
instead of a solution of continuity without previous mortification, the
intestine is the  seat of wounds, or of some gangrenous  perforation,
its reduction no longer presents the same prospect of cure.  If it is
complete, and peritonitis has not destroyed the patient beforehand,
the accidents will not supervene  until at the expiration  of a few
days, an eliminative process being required to detach the eschar.  If
on the contrary the  perforation  already exists, at the moment of ma-
king the reduction, we shall know what to expect in  regard to  the
progress of the symptoms.  In both cases, an adhesive inflammation
agglutinates  the  sound parts, around  those  that are diseased.  In
both cases, also, an artificial anus is formed without any difficulty, if
the perforation, whether it be primitive or consecutive, corresponds
to the ring.   But if  the gangrene is situated on another  point of  the
intestine, we shall have, in the first case only,  some chances of a cure
without an artificial anus, and in the second, or where both exist  to-
gether, an effusion or stercoral abscess, with  all its consequences, as
in the preceding case.  Whatever may be the nature of the disease,
the loss of substance is too decided in  a case of gangrene, to allow
us to  count upon  the immediate closure of a  wound of  this descrip-
tion.   It is, nevertheless, remarkable that even in such cases, the  or-
ganism hastens, so to speak, to confine  the disease behind  the ring,
by causing, almost immediately, the production of protecting adhe-
sions  all around it.   5th. AVhat is here said of hernias that have been
operated upon, is applicable in every particular to  the intestines that
have  been wounded at the same time with the parietes  of the abdo-
men.   6th. An intestine which has  become gangrenous or perforated
in any manner whatever,  and been reduced by the taxis, and without
incision of the  envelopes  of the hernia, is also placed  in the  same
condition as in the preceding case, with this difference, that the anus
or fistula cannot  be  established at first, that an abscess  must precede
its formation, and that the cure, without effusion or by first intention,
is .next to  impossible.  The cause of this  peculiarity is sufficiently
evident from the  details I  have given,  to allow me to dispense with
their  repetition. In a woman who had a crural hernia, which had been
strangulated for the space of  three days,  and who was dying from
an extensive peritonitis, when an attempt for  the first time was made,
and succeeded  in effecting its reduction, the intestine, which was
gangrened and largely perforated, nevertheless continued  to be  ag-
glutinated to the  peritoneum, around the whole periphery ofthe ring
in the iliac fossa.  In a young man, on  the contrary, who had been
treated in the same  manner, an enormous abscess formed, which  had
to be opened upon the  inguinal ring, and in the iliac region, where
the artificial  anus was subsequently established.  7th. Thus, in what-
ever  manner the  artificial anus may be formed in these various mod-
ifications, it  is  destitute of an  eperon, because the intestine  being
placed back in  the belly is, so to speak, repaired in the portion of it 
HERNIOTOMY OR KELOTOMY.
639
which has been destroyed, by means of the corresponding tissues of
the other organs.
  b. An anus without an eperon, and caused by an ulcer, or internal
perforations in the intestine.—The intestines are liable  to two sorts
of internal perforations.   In some cases, they ulcerate in fact under
the action of a foreign body which has become lodged  or retained
at some point in their interior ;  in  other cases, on the contrary, there
is a true  ulceration which ultimately perforates through the whole
thickness of the intestine.   To the first class belong, the  perforations
caused by the passage of fragments of metal, glass, wood, balls, bone,
kernels of fruit, &c.  To the second belong ulcerations of all descrip-
tions, especially those from phthisis, scrofula, and dothenenteritis. 1st.
When the case is one of pure ulceration, produced by a foreign body,
in a patient who is in other respects in good health, and where  the
loss of substance is not considerable, such fistulas generally heal up
with sufficient promptitude without an operation ; but under opposite
conditions, it is not unfrequent to see them resist every kind of rem-
edy, and obstinately continue for an indefinite length of time.
   The annals  of science furnish numerous examples in support of
these statements.  The blade of a knife, a  fork, fragments of bone,
&c, have been expelled or extracted through the walls of the  belly
without any fistula being thereby produced. A woman  was admit-
ted into the hospital  of the Faculty, in the department of M. Bougon,
in 1825, for a pain which she experienced  in the right iliac  region.
This pain was accompanied with a fever, and had existed for  the
space  of  15 days.   The  stools though rare were always obtained,
nor were there any colics. The whole  iliac  fossa  appeared to  be
affected, and the  abscess made its way   outward  at  the  expira-
tion of three days.   There was  discharged  a large quantity  of fetid
pus, gas,  intestinal mucosities and stercoral matters, afterwards an
angular fragment of bone, which was seven lines in  its small diame-
ter, and which  apparently belonged to the  head of a fish.  The  ac-
cidents afterwards gradually diminished, and in a short time nothing
remained but a stercoral fistula, which was  reduced  to the diameter
of three  or four  lines in the space of 20 days.  The dressing with
cataplasms was continued, and the alimentary matters passed in part
from that period through the natural  anus.   Nevertheless, an injec-
tion given on the 29th  day, again made its way through the fistula,
which however had entirely closed up on  the 43rd. - A permanent
cure was perfectly established.   I saw the patient four months after-
wards and there was no return  of the disease.  2nd.  When the ul-
ceration arises  from  the influence of a constitutional malady, or spon-
taneous inflammation, the fistula will evidently have  less tendency to
cicatrize.   Eugenie  Denis, 17 years of age. without the  eatamenia,
was admitted into the Hospital of La Pitie, on the 18th October,
1833.  From the age of 7 or 8 years this patient had been subject to
colic and  vomitings.   After renewed attacks  of colic, a painful tu-
mor made its appearance at the umbilicus.  An incision was made,
when  there was  discharged a dark-colored and exceedingly fetid
liquid.   A month subsequently a natural opening was formed* below
and to the right, and about the  beginning  of December four others
were established around the first.   At the autopsy,  both lungs were 
640
NEW ELEMENTS OF  OPERATIVE SURGERY.
found filled with tubercles, and  some patches on the intestinal peri-
toneum also contained them.  Besides ancient cicatrices, there were
found also four ulcers in the small intestine.  One  of them situated
in the ileum opened into an ancient false membrane, transformed into
a canal more than an inch long, and  in this manner reached the ab-
dominal parietes a  little above  the  left inguinal ring.  It was by
this route that the matters  had become effused from below upwards
and from .the left to  the right, in order to reach the umbilical region,
where they resulted in the  stercoral abscess.   In this girl, the species
of accidental funnel, which had formed between the intestine and the
wall of the belly, would very probably have rendered the cicatriza-
tion of  the passage impossible, even though there had been no other
complication.   Nor  was there moreover the slightest appearance of
eperon  opposite to the abscess.   Also, she had continued to have her
stools from time to time.  I  had at the  same time at the hospital, a boy
named Castin, 17 years of age, who had a fistulous ulcer on the right
side and a little below the umbilicus, and from which  there was a daily
discharge  of a certain quantity of the contents  of the intestines to-
gether with gas. This ulcer had already existed three months and had
been preceded by an enormous abscess.   The patient, who although
meagre and puny, had a good deal of vivacity, and was never with-
out more or less regularity in his stools.   No other  organ was found
in a state of disease  either  by M. Louis or myself.   The probe took
the course  towards  the  iliac fossa at three  inches below, and to
the right of the  external  fistula.  I laid  open the whole of this
track in order to establish  a complete parallelism, between the per-
foration ofthe intestine and the external wound.   This wound  being
dilated  at  a subsequent  period by means  of a  cone of  prepared
sponge, enabled me to penetrate with  the finger  into the interior,
and to recognize there all  the  characters of the cascum and of the
ascending colon.
  Quite a  remarkable phenomenon, moreover, and which  we have
frequently  seen, was this, that  at the  same time that  we  could
readily  make the injections pass  through the artificial anus, we also
saw the ingesta by  the  mouth  reach there almost with the  same
promptitude.  However this may be, this fistula, which allowed the
patient to have a natural evacuation whenever it was kept closed up
by means of a  plug  of linen, lint, sponge, or even  cork, was trans-
formed  into an actual artificial anus as soon as the plug was removed.
There  was no  eperon behind.   To  effect  its cure I  made use of
every description of remedy ;  and the simple and quilled suture, and
anaplasty repeated three times all completely failed.  A small  valve
which  I recognized  at the bottom of the cavity, was removed by
means of the enterotome of Dupuytren, without any advantage  being
thereby produced.  Finally, this young man, who left the hospital in
March,  1834, and in other respects enjoyed sufficiently good health
by his habit of shutting, up  his fistula  with a plug, and whom I  again
saw at  La Charite on the  15th July,  1836, died  of phthisis in 1837.
The perforation communicated with the large intestine, and the speedy
discharge of the  alimentary matters  was explained by a  noose of
small  intestine  adherent to the cascum or colon, and which opened
there, on its side, by means of an ulceration.  In whatever manner 
HERNIOTOMY OR KELOTOMY.
641
we  consider this fact,  it must, however, be  nevertheless  ranked
among cases of artificial anus which persist notwithstanding  the ab-
sence of an eperon.
  c. Artificial anus in which the eperon has been destroyed.—Many
persons would suppose from the writings of Scarpa and most modern
surgeons, that after having removed the eperon of any artificial anus
the  cure is  almost certain.   Nothing, however, is more incorrect,
and the following is  what Dupuytren  himself  thinks of it.   From
eight to ten days only,  he remarks, are required for the enterotome
to produce  its effects.  "The stools generally become regular in
about the same time, but weeks, and even sometimes several  months
are required to effect a complete obliteration of the abnormal open-
ing.  Sometimes, even, it has been found  impossible to accomplish
this effectually, eVen though when reduced  to the smallest dimensions
this had become unnecessary, as it could be kept closed for a long
space of time without allowing the egress of the slightest quantity of
stercoral matters.  To this obstinate resistance of an opening, which
thus exists without  any apparent  cause, we have successively op-
posed, and it must be confessed without much  benefit, colophane in
powder introduced into its cavity, cauterization of its borders with
nitrate  of silver, and their approximation effected and  maintained  by
means of adhesive palsters, finally the excision of these same borders
which were formed by the skin and  mucous  membrane, and after-
wards  their accurate coaptation by means  of the quilled suture."
When we reflect that an  artificial anus whose  eperon has been de-
stroyed is placed in nearly the same conditions as  an anus or fistulas
from ulceration, or without displacement  of the intestine, we  soon
cease to participate in the surprise of Dupuytten.   We soon, on the
contrary, ask ourselves  the question, why a cure  should be so fre-
quently accomplished in the  first case while it  is so rare in the  se-
cond.   This is a difference which I have endeavored to discover the
cause of, and which I explain in the following  manner:  if the fistula
or artificial anus is established without  an  angular displacement  of
the intestine, there is no membranous funnel formed.  But experience
shows  that  an artificial anus without this funnel  is cicatrized with
extreme difficulty.    Scarpa even  goes much  farther: "Artificial
anus is always  incurable," he says,  " when it  is formed  in conse-
quence of a wound penetrating into the  abdomen, attended with pro-
trusion of the intestine, whether a  part of this  canal has  been de-
stroyed by  gangrene, or whether  it has  been partially or totally
divided by the wounding instrument."   He afterwards adds : " Um-
bilical and ventral hernias almost  always  give  rise to an incurable
artificial anus when  they pass  into gangrene."  This, in fact, is be-
cause there  is then no hernial sac which admits of being drawn into
the belly by the adhesions of the intestine, in such manner as  to con-
stitute the membranous funnel so well described by the Italian author.
It now remains  to ascertain if an anus  which persists, after  the de-
struction of  the eperon, might not be ranged  under the same head.
Those cases of artificial  anus which  are produced by hernia attended
with gangrene, do not always necessarily lead to the  formation of a
membranous funnel.   I am even  disposed to believe that this funnel
is quite  frequently wanting.   The  adhesions of  the sac in  the track
                              41 
642
NEW ELEMENTS OF OPERATIVE  SURGERY.
 or upon the periphery of the hernial  openings are sufficiently solid
 in a great number of cases, especially when the hernia is congenital'
 to resist the  tractions made  by the mesentery and to prevent the
 intestine from being carried to any great distance posteriorly.  The
 destruction of the eperon, therefore, evidently places the intestine in
 the same conditions as if the  anus had  been formed by an internal
 perforation, or without previous displacement.  It is very natural
 therefore, that in other respects the cure should be as difficult in one
 case as in the other.  It is even probable, under such circumstances,
 that after  the exsection of the eperon, an artificial anus, in the con-
 dition of a fistula, will  not heal up unless it  is by a species of perito-
 neal duct  or  membranous funnel which  has become established be-
 tween  the perforation of the intestine and the external opening.  To
 those who would object that an  artificial anus, without displacement
 or pre-existing hernia, will sometimes close  up spontaneously, though
 there may have been  no membranous funnel there, I would answer,
 that upon  this point Scarpa has again gone too far.  The third case!
 in a  memoir  inserted elsewhere, (Journ. Hebd., 1836,) shows us, in
 fact, that this funnel is possible after umbilical hernias;  and we see
 by the tenth case, that the same may take place after intestinal ulcer-
 ations,  proceeding from within outwards, (excentrique;) only that it
 is to -be remarked, in  such cases, that it is a false membrane which
 has become organized and transformed into a canal, and not the
 peritoneum, which  yields or  is elongated  into a funnel; but it is
 easily perceived  that this difference is altogether to the advantage
 of the  accidental funnel.   Thus,  on one  hand, the artificial anus
 without displacement  of the peritoneum, appears to require for its
 cure an accidental membranous canal, which approximates it in char-
 acter to the artificial  anus, properly so called; while  on the other
 hand  an artificial anus with a hernial sac would, if it persisted after
 the destruction of the  eperon, resemble  the  anus without displace-
 ment, by the absence of a membranous  funnel.  Considered in this
 point of view, the  question  appears to me to be very simple.  It
 enables us  to range  every kind of artificial anus that have no eperon
 into two classes,  those that  are  accompanied with a canal or mem-
 branous funnel, and  those  that are destitute of this complication.
   d. Treatment of  artificial anus  destitute of an  eperon.—Those
 cases of artificial  anus that belong  to the first class generally cica-
 trize very well when they are not kept up by a vitiated  state of the
 constitution, nor by an organic  lesion or  any local  complication,
such as sinuosities or separations of the skin, or folding or contortion
of  the  intestines, abnormal adhesions, &c.  On  the  contrary, it
rarely happens that  those of the second class do  not obstinately resist
the means usually  employed against them.  Now it  is especially
to the treatment of  these  last that the following remarks are appli-
cable.
   I. Cauterization and styptics  are evidently only auxiliary means,
which are  incapable of succeeding by themselves except in cases
of very small  fistulas or where the  anus has a tendency to close up
of its own  accord.
  IL  Anaplasty, at  first sight, appears to offer a better  prospect of
success. I have made trial of it in three different ways. 
HERNIOTOMY OR KELOTOMY.
643
  a. In one instance I detached the integuments to the extent of an
inch all around the wound, in order to be  enabled  to abrade and
approximate its borders  with greater facility and to reunite them by
means of the suture.  The stercoral matters soon extravasated be-
tween the detached integuments  and  the  other tissues,  notwith-
standing the compression which  I  had  thought I could use as a
precaution against  this  accident.   It became  necessary to remove
the points of suture on the third day, and the wound was now found
larger after the operation than it was before.
  b. In another instance I  cut out  above  the  ulcer a  flap which I
attached in form of an operculum  by means  of the  suture  to the
periphery of the  fistula, which had been  previously abraded.  On
the second day we  noticed a yellowish  exudation and bubbles of air
escaping from  between  the  points of the suture, followed by gan-
grene, which invaded the flap, progressing from its  borders  to the
pedicle.   M. Blandin, however, (Acad.  Roy. de Med., 1838,) in ope-
rating since upon a patient by this process  appears to have obtained
from it complete success.
  c.  The species of plug  (bouchon) which I  had successfully em-
ployed for shutting up laryngeal fistulas, still presented itself to me
as a last resource.  I borrowed  it from the flank, and after having
turned it back and  doubled  it upon  its  epidermic surface, 1 inserted
it in the ulcer and retained it there by means of four points of suture.
An exudation of  stercoral liquids took  place on the  following day.
The suture had cut through the borders of the fistula and mortifica-
tion of the flap took place as  in the preceding  case.  The quilled
suture, morover,  without any previous dissection of the integuments,
had been the beginning of all these  difficulties.
  d.  I thought I could perceive in fact in these cases  that there were
two difficulties to overcome, one which was imputable to the acrid
or putrescent character of the intestinal matters, and the other which
was caused  by the induration of the neighboring tissues.  Though
saliva, tears, serosity, synovia or even urine may pass through or be-
come temporarily lodged between two points  of suture, the cicatri-
zation nevertheless will take place, provided the contact of the  lips
of the wound has  been correctly maintained.  This is  because  a
solution of continuity touched, en passant,  by any of these matters is
not on that account rendered  much  less incapable of the process of
agglutination.  The stercoral matters cause an entirely opposite con-
dition of things ;  even the slightest particle of these, if it has become
lodged between  the borders  of the wound, will prove sufficient to
destroy the tendency to adhesion, and will expose the surfaces which
have been lubricated by it to the risk of mortification.  The different
kinds of sutures will always find from these difficulties a serious im-
pediment  to their  success.
  e.  Fistulas in  general,  and especially  a stercoral  fistula, rarely
continue  for the  space  of a few months without becoming callous.
Its periphery is transformed  into a hard inodular tissue, which ulti-
mately resembles a sort of inorganic ring which is but little  favora-
ble  to cicatrization, either by first or  second intention.   A flap of
pliant tissue borrowed elsewhere and  dissimilar in texture will .not
agglutinate to it.   To maintain  its  borders in  contact it is necessary 
644
NEW ELEMENTS OF  OPERATIVE SURGERY.
to make the suture exercise such powerful and  continued tractions
that it  must  soon cut  through  a  tissue  so  dense and so  easily
divided.  Finally, it is  almost  impossible by the ordinary processes
that the approximation  upon the  intestinal side  can be made suffi-
ciently  exact to escape  from the danger of every kind of infiltration
of stercoral matters.
  III. New Method.—I had arrived at this stage in the above diffi-
culties  when  there came to La Charite a young  man whom  M.
Auzoux had  sent to me from Normandy.   This boy was nearly in
the same condition as the young Castin.  Before proceeding in' his
case to  any kind  of anaplasty, I resolved upon making trial of the
simple suture by the process of M. Raybard, that  is to say, to include
in the nooses of the thread a  piece of caoutchouc or pliant wood
inserted in the intestine behind the  wound, in  order to prevent all
communication of the  interior  with  the exterior, or  to proceed to a
relaxation of the  abdominal  walls  by means of two lateral incisions.
I commenced with this last process, with the intention of having
recourse promptly to the other in case of its not succeeding.  The
operation was performed on the 15th November, 1835.  The cele-
brated Dr. Mott was kind enough to aid me as an assistant.   I em-
braced  the entire fistula in an ellipse, in order to excise  it' by a
double  semilunar incision, but  one  which was to divide obliquely
from the sides to  the centre, and in such manner  as not to include in
it the intestine or at least not its mucous membrane.   I then inserted
four points of suture at a distance of two lines from each other, taking
care that their middle portion did not reach as deep as the abdominal
cavity or the intestine.  It was at this  point of the operation that I
made on each side, at the distance of twelve to fifteen lines external
to the wound, an  incision two inches  long,  comprising the skin, sub-
cutaneous  tissue  and aponeurosis of the  obliquus  externus.  The
parts being all washed and perfectly cleansed, I now knotted  the
threads  and placed a cylinder  of lint in the lateral wounds in  order
to keep their  lips apart before proceeding to  apply the containing
dressing.  On the 18th  the matters had accumulated to such extent
that it became necessary to cut the threads.   The  operation there-
fore appeared to  have failed ; the borders of the wound were washed
and  the patient recommended  to keep them in as clean a condition
as possible, while he was kept upon  a nourishing diet, but restrained
as to quantity.   On the 30th December the wound was no longer
attended with any discharge except  a very small quantity of puru-
lent  matters;  on  the 4th January,  1836, there was no longer any
discharge of fasces, and the  patient was in  a very satisfactory condi-
tion.  He was kept sometime  longer at the hospital in order to  be
certain  of his cure.  As nothing presented itself that gave rise to any
apprehensions, and as the patient walked with ease  and was without
any pain whatever, he was discharged on the 8th February.  It is dif-
ficult to form an  idea of the relaxation which is obtained from lateral
incisions under such circumstances.   The abraded lips of the  fistula
will then almost come in contact of  themselves.  There is no longer
any necessity of tightening the  suture but in the most gentle manner;
buj it is requisite  that the incisions should be long and deep in order
to attain this double object.  The fistula abraded in the manner I 
HERNIOTOMY  OR KELOTOMY.
645
have mentioned, is transformed into a species of cup, the bottom of
which is perceptibly of less breadth than its mouth.  It  results  from
this, that we do not put its cutaneous portion in contact without
forcing   also  its intestinal  portion to  close  up  completely.   The
threads not penetrating as deep as the intestine, prevent  on  the other
hand the intestinal matters from  having any  opportunity  of insin-
uating themselves into the track of the sutures.   It is probable more-
over, that so far from compressing the belly and the wound in the
manner I have done, it would  be better to leave them entirely free.
A rigid  diet  with  repose, with a  laxative injection  every  evening,
during the first eight days, would  also certainly be -more  advan-
tageous. I am induced to believe that the accidents which came on
on the third day would not have taken  place if I had paid  attention
to these  circumstances.   Thus  in  artificial anus without an eperon:
to remove the inodular tissue while respecting the deep-seated or in-
testinal periphery of the fistula ; to insert the threads without going
as deep as the intestine ;  make  a long incision the distance of an inch
or  two  on each side;  dress without compressing the  belly: and
administer a laxative every evening and restrict the patient  to a diet;
such, in a few words, is the method which I propose, one which is in
reality worthy of being made trial of whether by itself or in  combi-
nation with  it the  various descriptions of anaplasty which I have
already employed.
  [Enterotomy to establish an artificial anus in cases of obliteration
or destruction of the small intestines,  as first recommended  by Louis
in 1757, and  first successfully performed by Renault of Joinville, in
1787, was also recently performed with entire success by M. J. G. Mai-
sonneuve of  Paris, (see this case, Arch.  Gen. de Med., Dec. 1844, 4e
ser., t. VI., p. 174.)   In a subsequent memoir,  (Arch. Gen., 4e ser.,
t. VII., April, 1845, pp. 448-466,) this surgeon returns to the subject
and boldly advocates the propriety of recurring to this  operation in
cases where the effectual interruption to the progress of the  intesti-
nal  matters  and a complete state of strangulation  is clearly estab-
lished, whether from a foreign body, formation of fibro-cellular bri-
dles or  other abnormal  growth in the tube, or by invagination, or
from contraction of its  calibre, (sometimes the result of adhesions
and cicatrices following ulcerations of the gut after its return  in ope-
ration for hernia,) or its entire obliteration, whatever the cause may be;
provided enteritis has not taken place or  that the alarming symptoms,
tympanitis, stercoral vomitings, &c,  have not  resulted in gangrene.
M. Maisonneuve does not recommend the operation but in extreme
cases, and as the only chance to save life.   He is aware of its dan-
gers and difficulties, and  of the  comparatively half-digested  condition
of the aliments which afterwards have to be expelled from the artifi-
cial  opening  before  they ean  have possibly supplied essential  and
proper nutriment to  the blood.   This he would  endeavor to remedy
by generous  food,  and where there is proof that  the interruption in
the tube is  removed he  advises the anus to be closed:  for, strange
as it may seem, his experiments on animals establish the  fact that the
continuity ofthe alimentary canal, after having been completely ob-
literated by  one or more ligatures,  has by means  of  an  artificial
anus kept open during the time the threads were cutting their way 
646           NEW ELEMENTS OF OPERATIVE SURGERY.
through the intestinal coats, been again reestablished so that the food
has resumed its natural course, thereby enabling the surgeon to close
up the artificial opening.   This gradual affrontation and ag'dutina- ■
tion of the divided circular edges of the tube, in proportion as the
ligatures are ulcerating their  way through it, is a remarkable fact in
physiology,  and  goes  to justify  the  performance  of an operation
which might  in some measure  imitate the process of nature.  This
has  been but  feebly carried  out, however,  in the few and fatal at-
tempts hitherto made in what the French call adossement of the intes-
tines, that  is, a complete  exsection transversely of the strangulated
portion ofthe gut and afterwards the restoration ofthe continuity of
the canal by invaginating the  end  of the upper over that of the lower
portion ofthe gut, &c.   [See the text of M. Velpeau above.]  This
process M. Maisonneuve also approves of as it would seem, but inclines,
we should judge, to the only one he has described, viz: the construc-
tion of an artificial anus externally. If the fact he states of ligatures
upon the gut in dogs be exact, the reparative process here resorted
to by nature should  be as exactly imitated by art as possible. But
how to do this ?  How to institute this gradual, slow, certain and
sure process of successive, minute ulcerations, granulations and ag-
glutinations ?   The author considers that the  tympanitic, distended,
small intestine  above the  strangulated part may be diagnosed and
distinctly recognized in its form and course, as M. Laugier had sug-
gested, provided  peritonitis has not taken  place, the evidence of
which latter will be contradistinguished by the general tense condi-
tion of the abdomen, rendering it impossible any longer to detect or
even to reach with the touch the convolutions  of the gut underneath
the  inflation.   M. Maisonneuve says truly  that the  artificial anus
should be  as  far from the stomach as  possible; and that in most
cases,  avoiding meanwhile too much  fingering  and  searching, (so
often a source of fatal mischief,) we may, after the  operation, know
by the more  frequent recurrence of the valvulas  conniventes, felt
through the coats of the intestine, that we are approaching the pylo-
rus, whereas when they are farther apart we are on the ileum.  He
considers this an important point in the diagnosis for fixing a locality
to the  new anus to be opened  by a slit into the gut.
   Gastrotomy  and establishment of an artificial anus,  successfully
performed for constipation ; also gastrotomy successfully performed
for  constipation from intussusception.—Gastrotomy was  success-
fully performed by Dr. J.  C. Manlove, (Northern Journal of Medi-
cine, January,  1846;  Boston  Medical Journal,  July  23,  1845;
Proceedings  of the  Tennessee State Medical  Society,) on a co-
lored boy 17 years of age.  When Dr. Manlove first saw him, (July
7, 1844,) he was suffering under some general uneasiness of the ab-
domen and fever, and had been  constipated for twelve or fifteen
days.   Bleeding ad deliquium, and every kind of purgative and in-
jection almost had been  employed without effect.   On the 10th of
July, the abdomen becoming enormously distended, with difficulty
of breathing, cold extremities, feeble, quick  pulse, anxious counte-
nance, and no evacuation, the surgeon decided upon gastrotomy, and
the operation was performed  by an incision on the median line from
two inches below the umbilicus to the distance of four or five .nches 
HERNIOTOMY OR  KELOTOMY.
647
towards the pubis.  The peritoneum  and bowels along the lower
half of the incision were found in  an intimate state of adhesion, and
in cutting through the former, an  opening of about one fourth of an
inch was made into the latter.  This opening, which appears to have
resulted from a want of proper care in the dissection, proved a for-
tunate accident.    Large quantities of flatus and liquid fasces, and
some oil of turpentine, which the patient had taken, were  immedi-
ately discharged from it.  On further examination, it was found that
the intestines were united to  the  peritoneum by extensive adhesions
at various points within  reach of the finger and probe.   The wound
was closed by sutures and  adhesive straps, except the opening into
the intestine.  The amendment of all the symptoms in the course of
an hour was astonishing; the  extremities  became warm, the pulse
slower and fuller,  and, during the morning, the patient was enabled
to fan himself, the weather being excessively warm.  On the  next
day the appetite was good, and he  continued  to  discharge the  con-
tents of the alimentary canal through  the artificial  anus, until the
seventeenth day after the operation, when  the bowels acted natural-
ly, as the opening had  nearly closed.   The patient, it appears, had
received an injury to  the abdomen six months before, by the falling
of a piece of timber.   The boy was well nine months after the ope-
ration, and exhibited to  the society.  The  reporter, in adverting  to
the operation under similar circumstances, quotes a case of Dr.  Wil-
son, (also of Tennessee,) viz., that of a negro man supposed  to be la-
boring under intussusception, with obstinate constipation, which had
resisted every remedy used.  Dr. Wilson then performed the operation
of gastrotomy, and drew the  intestines out  of the abdominal cavity,
until he came to the point where the obstruction existed.   About one
inch of the ileum was found to be invaginated and  closely united by
adhesions to the receiving  portion.   These were  dissected loose, and
the  bowels returned.  Natural passages immediately took place, and
the  patient was rapidly restored to perfect health.   It is curious  in
the  above cases, especially in the first, to note the salutary efforts of
nature in forming protecting adhesions.  In  the first, the way was
thus completely prepared for an artificial anus, and all danger of in-
filtration of fascal matter into the  abdomen or its parietes avoided.
  M. H. Nunciante is alleged to have succeeded with intestinal su-
ture in three instances, (M. Jobert, Arch. Gen. de  Med., Paris,  4e
ser., t. IX., Oct., 1845, p. 346,) by a sort of spiral or whip  (i. e., the
glover's) suture, which  by drawing on the two ends of the thread in
opposite directions, brought the intercepted portions of the stitches in
such manner as to place the serous surfaces ofthe intestine in contact,
a point of great importance, and perhaps the only principle upon which
we can reasonably hope for  agglutination.   [See text above.]
  The Editors of the Archives  Generales  de Paris, (4e ser., t. X.,
March, 1846, p. 337,) remarking upon  a case of contracted  colon in
an adult man aged  23, in which  Dr.  Evans, (London Med. Chir.
Trans., vol. XXVIII, 1845,)  in  consequence of obstinate  constipa-
tion, stercoraceous vomiting,  and  various enteritic symptoms, deci-
ded upon making an artificial anus, by opening into the colon through
the  right lumbar  region;  assert, that this is the eleventh  time, as they
think, in which Callisen's  process, as  modified by M. Amussat, has 
648
NEW ELEMENTS OF OPERATIVE SURGERY.
been performed. Although the digestive functions were in this instance
partially ameliorated, death  ensued at the expiration  of two months
from  a violent enteritis,  showing  that this operation (as the  other
cases corroborate) does not  cure the patient, or at least establishes a
disgusting infirmity in place of the original disease, and is not there-
fore justifiable, but in an extreme case of dangerous obstruction, as
in the patient under consideration,  and where death  must otherwise
have inevitably ensued ; the  operation under such circumstances pre-
senting the only chance, which,  at best, is but  a bad one.
  Enterotomy for Cancer of the Colon—Exsection of a portion of
the Colon, and cure!—A cancerous tumor occupying the two poste-
rior thirds of the sigmoid flexure of the  colon, occurring in a man
aged  28, and accompanied with lancinating pains, colics, and much
distension, was, according to  a  statement  transmitted by M.  Rey-
bard of Lyon, to the Paris  Royal Academy  of  Medicine, but not
considered by them sufficiently detailed, (see Arch. Gen., Aout,  1844,
4e ser., t. V., pp. 516,  517,)  successfully removed  by him by cutting
down to the tumor, and exsecting it, together with a transverse seg-
ment of three inches of the  colon,  and then uniting the two ends of
the gut by the whip suture.   The cure he says was complete on the
thirtieth day;  if so, it was almost the first, if not the  only case of
cure by enterotomy and adossement.   But in  six months the cahcer
returned and the patient died!
  Voluntary Enterotomy and Exsection of seventeen inches of Intes-
tine !—The  case related by  Dr. Brigham, physician of the New York
State  Lunatic Asylum, in which it  is  stated, (American Jour.  Med.
Sc, April, 1845,) that a female lunatic, who  was a married woman,
and had had five children, during the previous two years, suddenly
made, in June, 1843, two wounds in her abdomen  near the umbilicus,
with a large scissors, and tore out and cut off,  that is, exsected a por-
tion or segment of intestine, seventeen inches  in length, which was
laid aside and preserved, while  the remaining ends  were  returned
into the belly, and produced  no  pain or uneasiness or  inflammation
afterwards, but united and healed  up internally and externally, fol-
lowed by the restoration  of the canal and  natural discharges, and
complete recovery of health, were  it not for  the  high  character
of Dr. Brigham, would on its very face be  too marvellous  to notice
in this  work.   All that we can say is, that it is one of those narra-
tions which defy all comment.   [See text of M.  Velpeau, supra.]
  The Colon opening into the Stomach.—A remarkable case is given,
(London Med. Gaz.,  May 2,  1845,) of a woman aged 64, who, after
the continuance of a protrusion at  the umbilicus  for five years, had
an abscess formed there, which ultimately caused a perforation and
adhesion of the left part of the arch of the colon at  its median line
with the stomach, whereby  fascal matters were vomited up from the
latter, and ultimately caused death.
  Perforation  of the  Ileum—Adhesion  of  the  Omentum,  fyc.—
A remarkable case  is related by  Dr. W. O. Mackenzie,  Dragoon
Guards, Canterbury, Eng.,  of a soldier,  aged twenty-six, who had
been intemperate, and who  had no other symptoms than moderate
pain in the lower part  of the abdomen, chiefly on the left side, and
obstinate diarrhea, without  tenesmus, and more  or less  tympanitis, 
HERNIOTOMY OR  KELOTOMY.
649
ending in exhaustion  and death.   He found on dissection that the
great omentum  was  of a  bright  pink color,  and  lower on the
right than on the left  side, notwithstanding the  seat  of the pain
was on the latter.  The  omentum on the right side, which seemed to
be gathered into a knot above the small  intestines, was found closely
adherent to the  ileum,  two  and a  half inches  above  its entrance
into the cascum; and  in  the absence of the three coats  of the
former intestine ulcerated at this point, it formed the  only imped-
iment to the  entrance of the fasces  into the cavity of the abdomen.
This perforation  was of the size of a fourpenny piece.   At the same
point, firmly adherent in its whole Length, was a large  gland of the
exact shape,  but  rather larger than an ordinary kidney.  It was  of
cartilaginous  consistence, resisting the edge of the  knife;  it was in
the centre of a purple color, but yellowish white in  the other parts,
and it weighed nearly four ounces.   The stomach wTas so much con-
tracted as to be concealed behind  the  liver.  Peyer's  glands were
found unusually  numerous  and distinct in the ileum, and  about six-
teen or eighteen inches from its termination were marks of subacute
inflammation.  At its junction with the omentum it was enlarged and
very much ulcerated, and diseased until  its entrance into the cascum.
Here the appendix vermiformis  presented a singular  appearance,
being of the ordinary size of the duodenum, from the great thickness
of its parietes; it was nine inches  long, pervious  throughout, filled
with fasces, and  had a  similar appearance to that described in the
ileum.  Along the whole of the colon, traces  of inflammatory action
were well marked, but  least so towards the  sigmoid flexure.   The
kidneys were of the usual size, but  of darker color; the mesentery
very thick, no where less than a quarter of  an  inch, besides  being
incapable of being separated into different layers.   Imbedded  in it
were many enlarged glands, varying from  the size of a nut to that
of a pigeon's  egg.
   The disease, Dr. Mackenzie properly thinks, must have been  of
some years' standing.   The seat of the pain, as compared with the
morbid appearances, shows how perfectly misled one may be in the
diagnosis, and thus makes the case, in this respect as well as in others,
of much value.  Howr nature, secretly at work within, makes her own
anaplastic reparations by these  omental adhesions,  recalls what is
seen in some hernias, and also in the cases above.   These cases  of
pathological  anatomy in regions  with which surgery has so much to
do, especially at  this present epoch of the ovariotomy mania for cut-
ting into the abdomen, as well as into the scalp, &c, without rhyme
or reason, become exceedingly interesting, and show with  the thou-
sand other proofs how absolutely essential for correct and profitable
post-mortem examinations are ample bedside details ofthe phenomena
before death,  and how necessary a previous history ofthe symptoms
during life, are to the establishment  of a sound and legitimate thera-
peutic.   The  enlargement of the appendix  vermiformis  in  this case,
says Dr. Mackenzie, was much greater than anything  I have  ever
seen before.   I   believe the  use  of this  structure  has  not  been
ascertained.   When I found, he adds, the cascum quite  loaded with
thin lasces,  and  the  appendix  vermiformis  immensely  enlarged,
lengthened, and  also distended with  feculent  matter, the idea struck 
650           NEW ELEMENTS OF  OPERATIVE SURGERY.

me that it acted as a sort of reservoir, to prevent too great pressure
against  the  ileo-cascal valve, whose use is to prevent regurgitation
into the ileum.   Is such a supposition irrational ?  We should answer
not, but that it is undoubtedly a true one as to the uses of this singu-
lar appendage.
   We should wish to correct one remark however, which we think
must  be an  error in Mr.  Irving, who  first attended  the patient, and
who,  mentioning that his tongue was red, says it was very similar to
what  he had seen in dysenteric patients in the West Indies.  Now
Mr. Irving  probably alludes  to  all cases of continued exhausting
diarrhea like  that of the above case, and which diarrhea without
tenesmus, as in  the case above, and  totally distinct from dysentery
and from all its complications, is marked not only in the West Indies
but elsewhere, by that pecular vermilion redness of the tongue (from
the erythema of its papillae) and in fact of the whole mucous lining
of the mucous  passages, which is seen also  in  the  last stage of
yellow (not remittent or intermittent) fever, and in  the last stage of
phthisis, &c. T.]
                         CHAPTER  II.

                    HERNIA  IN PARTICULAR.

                  Article  I.—Inguinal Hernia.

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

          § I.—The various forms of Inguinal Hernia.

  The external fossa is evidently the point which presents  the  least
obstacle to the viscera; it is by this therefore that hernias must take
place with  the most facility;  so also are they  the only kind to 
INGUINAL hernia.
651
which the attention of surgeons was directed up to the beginning of
the present century.   They are known at the present day under the
name of external inguinal hernia,  a name which Heister formerly
applied  to crural hernia.  When the intestines become lodged in the
middle fossa, the hernia takes the name of internal inguinal hernia,
as given to it by Hesselbach.   If they make their escape through the
internal fossa, an example of which has been seen, as it wopld appear,
by Wilmer, M. A. Cooper and M. Goyrand, (Lancette Franc, X. V.,
p. 478,) the name which would be proper to apply to them would be
supra-pubic  These various kinds of hernia, presenting characters
and anatomical  relations differing from each other,  require each of
them a  separate examination.
  A. External Inguinal Hernia.—The arrangement in external in-
guinal hernia is in general easily understood ; the viscera pushing the
peritoneum before them,  become  lodged in the inguinal canal at its
posterior opening, then pass through its entire length, and then make
their escape finally through the ring of the externus obliquus abdo-
minis muscle, in order to descend  subsequently into  the  scrotum.
When  arrived at this condition, the hernia is complete, but it may
present itself under other forms.
  I.  Supra-inguinal eventration, (eventration.)—-Thus we find, in
many persons, that the external inguinal fossa allows itself to be re-
laxed and distended to so great a degree that the abdominal organs,
in pressing upon it from within outwards, protrude it  above Poupart's
ligament, under the form of a large border, which sometimes assumes
several of the characters of a true hernia.   In these cases, no organ
having yet in fact entered into the inguinal canal, and the posterior
opening of which has not yet given way, the hernia is incapable of
strangulation;  it occasions only a  degree of uneasiness and weight
which are annoying  to the patient,  and which we may find it neces-
sary to relieve by means of a bandage.
  II. Incomplete Inguinal Hernia.—In  other persons the displaced
organs reach as far as to the external orifice, but do not escape from
it, and continue there in the form of a species of cylinder  or mass in the
interior of the canal.  This is a description of hernia which has spe-
cially occupied  the attention of surgeons  in our  epoch, but which
nevertheless had been noticed by several authors in the last  century.
J. L. Petit, Lecat, Murray and Callisen, appear to have clearly de-
scribed it.   Scarpa cites a case in which it was strangulated.  Boyer,
who calls it intra-inguinal, does not consider it as very uncommon.
M. A. Cooper and M. Key, carefully describe  several instances of
this hernia.  M. Dance also gives three cases,  and M. Goyrand has
made it the subject of a special memoir.  It has  also been designated
by the name of  intra-parietal and inguino-interstitial, but it seems
to me that that of incomplete inguinal hernia is more suitable to it
than any other; it  moreover  presents itself under various forms
which must not  be neglected.
  First variety.—In some cases it occupies exclusively the inguinal
canal in the shape of an elastic cylinder, which in the manner of a
border  extends from the neighborhood of the pubis as far as into the
iliac fossa and  towards the  corresponding spine.   I  have seen an
example of this kind. 
 652           NEW ELEMENTS  OF OPERATIVE  SURCl'.KY.

   Second  variety.—In  other  cases  the  tumor acquires so hr<re  a
 volume in  the canal, that it is obliged to ascend into the substance of
 the walls of the belly under the form of a globular mass, or of a plate
 more  or less flattened.  It is  to this description of hernia that M.
 Dance has given the name of intra-parietal, under the impression that
 he was the first who had noticed it, and with the  intention of making
 it a new species.
   Third variety.—In other cases again, a portion of the displaced
 organs escape through  the external ring, while the other portion re-
 mains in the canal.   The parts were in this condition in a case men-
 tioned by M. Key, and also in another noticed by M. Lawrence.  In
 such cases the hernia is  generally an entero-epiplocele; the epiploon
 is prolonged  externally, while  the intestine remains within.   This
 was the arrangement in the case of an adult man whom I operated
 upon with  Dr. Nicault in 1837.
   Fourth  variety.—In certain  cases the hernia  I am describing is
 caused by the imperfect reduction of an oscheocele or bubonocele,
 either  during the usual  taxis  or in the operation for  strangulated
 hernia.
   III.  Hernias through abnormal openings.—It is  also possible, in
 external inguinal hernia, that the intestine, whether situated outside
 of the posterior ring or in  the interior of the canal itself, may make
 its escape through a rent in the aponeurosis ofthe  external oblique, in
 place of passing through the external ring, properly so  called.  This
 modification of hernia, the  possibility of  which is even contested by
 many authors,  is at the present day, in my opinion, a fact which has
 been completely demonstrated.  It is even surprising  that its exist-
 ence should have been called in question, when we reflect upon the
 facts  and observations which have been  related,  and upon the  man-
 ner in which it takes place.  An attentive examination of the inguinal
 region will  soon make it evident that  both in the  fascia transversalis
 and in the  aponeurosis of the obliquus externus, there  exist two or-
 ders of fibres which,  by  intercussating each other,  form  actual
 diagonal apertures, (losanges,)  so much so, that the external inguinal
 ring itself is no other than the largest of these apertures.  It is there-
 fore  very  natural,  that  if from some anamoly the  ring should be
 found more contracted  than usual, or  if some other of these aper-
 tures  of intercussation should  be found wider,  the viscera would
rather  make their escape through this than  through  the  ordinary
track.   I would also remark that inguinal hernia, through a rent in
the aponeuroses, presents several varieties. It may in fact take place
 through the external inguinal fossa and outside of the posterior ring.
or through the  anterior  wall  of the  inguinal canal itself.  I have
 seen two instances of the first of these varieties.  A student of med-
icine noticed in his groin a globular tumor of the  size of a large nut.
It was situated half an inch outside of the ring ;  the fibrous opening
 was found  immediately  above  Poupart's ligament, and upon a line
with the crural arch.   The extremity of the little finger  could be
readily introduced into it, and  it was  easy to  follow the  spermatic
cord as far as the interior of the inguinal  canal, and in this manner to
ascertain that the two orifices were  perfectly  independent of  each
other.   The second case occurred at the beginning ofthe year 1837, 
INGUINAL  HERNIA.
653
at the hospital of La Charite.  The tumor, which was of the size of a
small pullet's egg,  was  situated  above Poupart's  ligament,  at  an
equal distance from the antero-superior spinous process  of the ilium,
and from the ring  of the  obliquus  externus, in  which  last I could
easilv introduce my finger, while I held my thumh on the abnor-
mal orifice.
  M. Blandin  relates an instance which is  still  more conclusive,
since it was demonstrated in the opening of the dead body; a fibrous
bridle two lines in breadth separated the neck of  the hernia from the
posterior ring of the inguinal canal.   When the organs have already
entered into the canal they may make their exit in the same manner.
J. L. Petit relates that he saw a hernia which escaped in  this manner,
through  a rent in the external border of the ring, (pilier  externe.)
Arnault mentions a  patient  who had at the  same  time  two hernias,
one crural, and  the other a little higher upon the  side of the ring, and
both  of which  were  only  separated by a small fibrous bridle.  A
case of the same kind has been more recently met with by M. Roux.
It is well to add, that in a  case which  M. Laugier  showed  me, the
intestine, after  having made  its  escape through Gimbernat's  liga-
ment also took the character of a hernia of this description.   It is
also to be remarked, that according  to  certain facts related, hernia,
by means of a rent  may also take place through  the inner border  of
the ring (pilier interne), either directly through  the middle inguinal
fossa, or through  the  interior  of the canal itself.   J. L.  Petit relates
an example of this kind, and another is found in  the treatise on ban-
dages by Juville; but a sufficient number of details are not given  to
make these facts conclusive.  Whatever, however, may  be the form
of external inguinal  hernia  which shall present   itself, it will always
have the epigastric vessels on  its inner side; whether it  be complete
or incomplete  it  will, nevertheless,  be, found accompanied by the
close proximity of these vessels at its lower and  inner semi-circum-
ference, provided it  has  entered by the posterior  opening  of the
canal; but it is  readily perceived that in  hernias which  protrude  at
the outer half of the external  inguinal fossa, there may exist a  con-
siderable space  between the epigastric vessels and  the  neck of the
hernia.   When any organ  whatever protrudes  from  the belly into
the interior  of the inguinal  canal, it will almost  inevitably be found
situated above,  and  to the outside of the spermatic cord,  so long as it
has not yet made its escape through the external ring.   Up to that
point the relations of the  hernia with the canal which it  traverses,
are altogether of a  peculiar character, whereas  afterwards they are
nearly the same as in the varieties of hernia which remain to be de-
scribed.
  B.  Internal Inguinal Hernia.—The  viscera, instead of following
the inguinal canal, and of taking  a direction obliquely from without
inwards, or from the iliac  fossa towards the  pubis  and scrotum, be-
come in internal hernia lodged in the  middle inguinal  fossa.   This
form of hernia, obscurely mentioned by Camper, and described  by
Lhne in his public lectures about the middle of the last century, and
which, notwithstanding, has only been recognized in the character of
a distinct species of hernia, since the  labors  of  Hesselbach, is still
designated under the epithet of direct inguinal hernia, or of ventre- 
~^
654           NEW ELEMENTS  OF OPERATIVE SURGERY.

inguinal hernia.  Pushing before it the fascia transversalis, which it
sometimes lacerates between the epigastric artery on its outside, and
the cord of the umbilical  artery on its inside, it has a tendency from
the beginning to force directly in front of it, and through the external
ring, the posterior wall  of the  inguinal canal.  In this  hernia the
spermatic cord is situated  to  the  outside, afterwards posteriorly, or
rather it does not contract any absolute relations  with the hernia un-
til at the moment  when the latter has become  lodged in  the rin<r of
the external oblique muscle.  Without being  very uncommon, this
species of hernia, however, is less frequent than some modern authors
seem to imagine.  Up to the present time no special varieties of this
form  have been pointed out; and  in  fact,  unless we admit hernia
which protrudes through  a rent in the inner  border of the ring to be
one of its modifications, we can  see no advantage that could be de-
rived in investigating various forms of direct  inguinal hernia.   It is
sufficient that it protrudes through the external ring itself, after having
become lodged in the  middle  fossa, to entitle it  to  the  designation
under which it is generally  known at the present day.  As to a her-
nia which might  be formed between  the  pubic  extremity  of the
rectus muscle and the umbilical artery, it has  not been studied with
sufficient care even in  the example related by M.  Goyrand, to render
it possible at the present time to  furnish a detailed description of it.
Anatomy only instructs us that the organ which is displaced, lacera-
ting the fascia transversalis or  pushing this latter before it, would not
arrive at the external ring, except by taking the  direction  of a line
which would extend obliquely from within outwards, and from behind
forwards, that is, a direction  opposite  to that of external inguinal
hernia.   These  general  relations, moreover, would  differ but  little
from those of inguinal hernia which takes place at the middle  fossa.
There would be no difference  between them in this respect, except
that the epigastric artery, which  runs  on the  outer  side of internal
inguinal hernia, would probably  be  found at the distance of a few
lines from supra-pubic hernia.
  C. Hernia of the  Tunica  Vaginalis.—Inguinal hernia, leaving out
of consideration the aponeurotic  canal that it traverses, presents still
another variety, which it  is  important should not be confounded with
those above;  this is the hernia which is called congenital, because
some infants have it at  birth,  and especially because it  is lodged  in
that  prolongation of the  peritoneum which  naturally envelopes the
testicle, that  is to say, in  the tunica vaginalis.   To comprehend cor-
rectly  the difference which exists between this species  of hernia,
which had already  been recognized  by Mery,  and other inguinal
hernias, we must recall to mind the displacements which the testicle
undergoes, in the  latter periods of intra-uterine life.
  I.  In the foetus, in fact,  the testicle is at first situated near the
kidneys, in the  lumbar  region, and  covered, like all the other ab-
dominal organs, by  the peritoneum.   But a  bundle of fibres belong-
ing to  the obliquus internus  abdominis muscle,  and not a cellular
cord, as has been supposed since  the time of Hunter, who designated
it under the name of gubernaculum testis, insensibly draws the semi-
nal gland  towards the inguinal  canal.   In  afterwards  descending
into the scrotum, the testicle drags with it a  prolongation of the pen- 
INGUINAL  HERNIA.
655
toneum in the form of a canal, which is more or less dilated below
the external  ring, and which  communicates with the cavity of the
lower bellv through the posterior ring.  As this serous canal gets more
and more contracted, and finally even becomes altogether obliterated,
from  the iliac fossa to below Poupart's ligament, and throughout the
whole length of the inguinal canal, it necessarily results that in the
adult, inguinal hernias, of whatever form  they may be, take  place
upon the" outside  of. or on the inside or in front of the  spermatic
cord, earrving down with them another portion of peritoneum.   In
the infant, on the contrary, the hernial organs finding there a cavity
alreadv prepared, become lodged in it in such manner as to be placed
in  contact with  the  testicle  itself.   Congenital  hernia, moreover,
offers several modifications.   In  the most  simple cases it occupies
s c.v and exclusively the tunica vaginalis, having the testicle  at  its
inner, lower, and posterior side.  In  other cases, the testicle having
become arrested  at the external ring, which  it appears to close up,
retains the viscera in  the portion of the tunica  vaginalis which is
situated  in the inguinal canal; so that the tumor is then divided, as
it were, into  two  portions, one of which, which is a sort of incom-
plete hernia, and formed by  the  viscera, is  situated in the canal,
while the other, represented by the testicle, exhibits itself under the
appearance of a small globular mass situated upon the external ring.
Sometimes, also, the hernia gets in front, descends into the scrotum
and leaves the testicle behind it: sometimes at the iliac fossa or in
the inguinal  canal, properly so called, or at other times at the dis-
tance of some lines only below the external ring.
  II. In the adult.—From  its title and the  manner  in which  it is
effected, it would appear that hernia of the  tunica vaginalis ought
not to be met with except in young children;  this, however, is by no
means the fact.   Inguinal hernia may take place in the tunica vagi-
nalis, and appropriate this tunic to  itself as a  sac, at  an advanced
period of life.
  Science, at the present day. has  in its possession  a number  of
facts which  come in  support of this  assertion, which I  made in
1>^.  I have  myself noticed  several  instances ;  among others,
three which do  not  appear  to admit of the  slightest doubt: M.
D----. a student  of medicine, twenty  years  of age. was suddenly
seized with violent pains in the groin and  a desire to vomit:  these
were caused  by an inguinal hernia which had just made its appear-
ance  and become strangulated.  At  the operation, which was  per-
formed on the following day.  we found the intestine in contact  with
the testicle, and having no other sac than the tunica vaginalis.   The
most  exact statements furnished by the  mother and the patient satis-
fied us that the two testicles had for a long time occupied their natu-
ral position, and that  no hernia had ever existed there.  The tumor
had rapidly acquired the size  ofthe fist.  M. D----. who was rather
somewhat thin  than  in a state of embonpoint, was in  the habit  of
paying much attention to everything in relation  to his health.   The
second case presented itself in my department at the hospital of St.
Antoine, in lSvJO : t!iis was a wine-merchant's boy. twenty to twenty-
five years of age, who. on the same morning, made a considerable
effort in endavoring to lift a pipe of liquor.   Closely interrogated in 
656          NEW ELEMENTS  OF OPERATIVE  SURGERY.

every way, he constantly replied that up to  that time he never had
had a rupture.  This, which brought him  to  the hospital, was dou-
ble the size of the fist, and  finally rendered it necessary to have re-
course to the operation.   The  intestine contained in the" tunica vagi-
nalis was, as in the preceding case, in immediate  contact with the
testicle.  Death  took place three days afterwards; we found on
opening the body that the inguinal canal had preserved its entire
length and obliquity, and that  the viscera, in  order to make their es-
cape externally, had  been compelled to distend  to such a degree as
to make a rent in, the serous prolongation of  the peritoneum, which
was contracted, but not entirely obliterated.
   The third case of this description occurred  at La Charite, in  1837.
This description of hernia, one of the cases of which was published
at the time, (Journ. Hebdom., X. VI., p. 267,)  was rejected at first as
a thing impossible.  But Dupuytren, to whom I spoke of it, and who
at that time wras also unwilling to admit it,  ultimately himself met
with certain instances of it.   Many surgeons moreover have men-
tioned it, without  apparently having any doubt about it.   M. Roux,
for example, saw a congenital hernia, which took place at the age of
twenty years.   In the works  of M. A. Cooper, we find two  facts
very nearly of the same character.  M. Lawrence  cites a boy who
was attacked with it at the age of twelve.  M. Lafont speaks of an
ecclesiastic  of about twenty years of age, in  whom  the testicle had
not  always been  situated  in the  scrotum, and in whom there sud-
denly took place  an inguinal hernia, which became  strangulated to
such degree as to  require the operation, and  in which case also the
tunica vaginalis formed the sac.  Finally, M. Mayor has published
the case of a patient aged 55, who had to be operated on for stran-
gulation of  a hernia, which had made  its  appearance at the age of
twenty-five, and which was situated in  the tunica vaginalis.   To ex-
plain the formation of a hernia of this kind, we have only to admit,
as Hunter and Callisen have already done, and as I myself have veri-
fied  in many instances, that the tunica vaginalis remains open during
the whole period  of life, or at  least until the age of puberty, in cer-
tain  persons  in the  form of a  small canal, and that in some others
even it does not become contracted except at its upper orifice.  In
such cases therefore it is easily conceived that the  viscera may di-
late its abdominal  opening, and become lodged in it in  mass  as in
the foetus.
  III.  Hernia of the tunica vaginalis, therefore, presents three varie-
ties,  which are sufficiently  distinct: 1st, that which takes place in the
foetus or first years of life, and which  is congenital  hernia, properly
so called; 2d, that which  is caused by the testicle  having become
arrested in the inguinal canal, and thereby preventing the tunica va-
ginalis  from  closing up  above,  by which means the viscera are
enabled to enter  into  it, or are even  dragged into it by the testicle
when it has contracted adhesions with them;  3d, jthat which I  have
just described as met with in the  adult, and the  predisposing cause
of which is to be  found in  the  imperfect obliteration of that portion
of the peritoneum which is contained in the  inguinal canal.  In all
these varieties, the relations of the hernia with  the  spermatic cord
and  the epigastric vessels, are in other respects  nearly the  same as 
INGUINAL HERNIA.
657
in external inguinal hernia, properly so called.   Hey was wrong in
maintaining, and I in  allowing myself to adopt his opinion, that in the
child the tunica vaginalis, when the hernia is not vaginal at this age,
is situated in front instead of being behind or on the inside as in the
adult.  In fact, the tunica vaginalis is sometimes found  in front  of
the sac in the adult, examples  of which are found  in  the works  of
A.Cooper, in the same way as it is sometimes met with behind in very
young children.  The name of hernia infantilis, which the surgeon
of Leeds has proposed to give to this variety, in contradistinction to
that of hernia virilis, which he reserves for  those cases in which the
tunica vaginalis remains behind, would be therefore  altogether erro-
neous, inasmuch as the two  cases of MM. Hunt and Lawrence are
only exceptional.
  L). Inguinal Hernia in Woman.—The inguinal canal is not arrang-
ed altogether in  the same way in woman as in man; it equally offers
as in this last, a  posterior and  an anterior orifice, but  these orifices
are perceptibly of less dimensions, and the round ligament which takes
the  place of the spermatic cord, terminates at the supra-pubic crest,
and does not extend in its totality as  is generally supposed, and as I
myself have elsewhere said,  to the outside of the ring, to become lost
upon the mons veneris, labium majus, and groin.   The ligament of
Nuck, which has been compared to the  tunica vaginalis, scarcely
reaches in woman  into the inguinal canal.  It is also proper  to add,
that the differences of obliquity in the inguinal  canal in a young girl
and young boy,  are not perceptibly more  marked than in adult age.
In this respect, Scarpa and modern surgeons  have allowed themselves
to be deceived by theory, in  place of directly consulting the anatomy
ofthe parts.  Nevertheless,  inguinal hernia is  quite frequently met
with in women,  and must present the same modifications as in man.
It would even appear, though  observation up to the present time is
silent on this subject, that incomplete inguinal hernia ought to take
place more frequently in  woman than in man, to judge at least by the
greater resistance  that the organs meet with  in attempting to enter
at the apex of the labium majus.  In this hernia, the anatomical rela-
tions are the same  as in man, m respect to the umbilical vessels; but
as the spermatic cord is wanting, and is  replaced by an organ of no
great importance in its texture, and  which does not descend to the
exterior, it is readily conceived that inguinal hernia in women could
be operated  upon with infinitely less danger  than in man.   I would
add, moreover, that the character of this  hernia appears to be  yet
very little understood in respect to its anatomical relations.  Whether
it shows itself from the time  of infancy, or  comes on at another period
of life, it is not positively known whether  the organs drag the peri-
toneum with them into the inguinal  canal, or whether they are not
rather, to a  certain  extent,  drawn  into that canal by a primordial
serous infundibulum.

         § IL—Parts composing an Inguinal Hernia.

  The viscera which may make up an inguinal hernia are, the small
intestine, transvers ecolon, epiploon, cascum,  a portion ofthe descend-
ing  colon, of the sigmoid flexure of the colon, or of the ascending
                        42 
658
NEW ELEMENTS OF  OPERATIVE SURGERY.
colon, the bladder, ovary, fallopian tube, a portion of the uterus, the
spleen and stomach; even the kidney, a portion of the liver, and also,
it is said, the doudenum have been found there.  But the small intes-
tine is the part which  constitutes  the  hernia in the vast majority of
cases: frequently alone, sometimes associated with the epiploon, and
in a few exceptional cases with some  one of the other organs just
mentioned.
   A. Sac—The sac of inguinal hernia, though formed by the peri-
toneum as in all other descriptions of abdominal hernia, presents nev-
ertheless certain peculiarities.   Thus in hernia of the tunica vaginalis
existing  previously to the descent of the testicles, the arrangement of
the sac is such that the testicle as  well as the  cord are found  buried
as it were posteriorly in the substance of the inner wall of the tumor.
It descends  in such  cases a little  below the testicle, which  is found
naked in its interior when we operate.  If this description of hernia
occurs in adults, the sac is formed by a second prolongation  of the
peritoneum, which does  not  descend below the testicle  except in  a
few cases, and is separated from  the tunica vaginalis by a septum.
In women, the hernial sac,  constituted in the same  manner, never
hardly descends as far down, and presents no peculiarity by which
we can distinguish congenital hernia from the hernia of the adult at the
time of the operation.   An inguinal hernia, however, noticed  by M.
Quatreveaux (Soc Anat., 1838,1839, p. 301,) in a woman, descended
into the labium majus, and was made up of tbe sac and a superincum-
bent cyst.   A similar  fact is mentioned by M. A. Cooper, (GZuvres
Chir., French trans., p. 285.)
  B.  In  certain  cases inguinal hernia presents only  an incomplete
sac:  this happens when  it is made  up of the bladder, the  cascum
or the lumbar  portion of the colon.   When  the bladder becomes
lodged in the external ring, it is  possible in  fact that this may  first
happen at one of the points on its anterior surface which is not cov-
ered by the peritoneum.   It rarely happens, however,  that this cellu
lar portion  of the  surface of the  bladder will alone protrude from
the canal, or that it does- not soon  draw along with it a portion of the
fundus of its posterior region or a part of the side of  the organ.  It
results from this that in  the first case, in incising the tumor, we
come down upon the urinary pouch without encountering the serous
cavity ;  and that, in the second case, we come down upon a true sac
or the bladder itself, according as  the incision may be directed rather
upon one portion of the  hernia  than  another.  The hernia  of the
cascum is the one which in this respect has more particularly occu-
pied the attention of modern surgeons.  It  is the only one  which
Scarpa is willing to consider as destitute of a sac, and the one which
MM. Sernin (Bull, de la Soc Med. d'Em., 1825, t.  L,  p. 377,) and
Colson have brought  forward in  favor of their doctrine on the sub-
ject of akystic hernias.   Here anatomy readily explains what expe-
rience establishes.   The cascum,  situated in the right iliac fossa and
destitute of peritoneum posteriorly, is  attached there by a  cellular
tissue which, while making  part  of the fascia propria, becomes con-
tinuous with that of the inguinal as well as crural canal.   This intes-
tine, therefore, if drawn in any manner whatever towards the scro-
tum, may pass by degrees by its posterior wall in such manner as to 
INGUINAL  HERNIA.
659
descend in this way into the scrotum, either without deviation upon
its axis or by becoming  turned round to a greater or lesser extent.
It results from this that  a hernia of the  cascum, though sometimes
surrounded almost by a comph£e sac,  is  in other  instances,  so to
speak, destitute of a peritoneal envelope.   It may readily in fact be
conceived that the posterior surface of the intestine will also be found
to be situated posteriorly when it forms a portion of an inguinal her-
nia, and that if the operation is performed under such circumstances
the cascum will be contained in a serous cavity  communicating with
the interior ofthe belly.  If on the contrary this  intestine has become
turned round while  descending, it is possible that its cellular region
may be found to be  situated  upon the inner,  outer or even ante-
rior surface;  and that unless we have suspected this beforehand, or
shall have from  some cause or other directed  the  instrument upon
the actually serous  surface of the  hernia, we  might  penetrate into
its interior without encountering the sac.  I have had occasion in the
dead body to notice these two descriptions of hernia of the cascum.
In an old woman who was admitted into La Charite in 1836, with a
crural hernia,  and who  died in consequence of the  operation,  we
found that the  cascum was situated in the inguinal region in the same
manner that it usually is in the iliac  fossa.   Having diagnosed before
the operation that it was this  description of hernia, 1 considered it
proper to make the incision on the inner side ofthe tumor; but in the
case in question this precaution was unnecessary, as the  interruption
of the sac  did not in  reality exist except on its posterior part.   In a
man who was  admitted  into my department at  the  hospital of La
Pitie, in 1834, and who  had an ancient  scrotal hernia which had
already become  gangrenous at its upper portion, the cascum on  the
contrary was so situated that its cellular region corresponded to all
the outer and  anterior portion  of the tumor.  It was on the inner
side, and  a little posteriorly, that we had to penetrate, and where,
in  fact, I made the  incision in order  to  come down into the  se-
rous cavity.   Another portion of  the  intestine also is liable to  a
certain extent  to take  on the  arrangement   which  I have  just
pointed out, I  mean the  sigmoid flexure of the colon.  It  appears,
in fact, that in certain cases, this intestine has got  lodged in the in-
guinal canal in such  manner  as to present its  adherent surface to
the inner  side of the hernial  coverings;  but the  examples of this
description of hernia  have not up to the present time  been  detailed
with sufficient  minuteness to make it advisable to dwell any longer
upon this subject.
  C. The other envelopes of inguinal  hernia scarcely vary in  any
other respect than in  their thickness,  and this according to the spe-
cies of hernia which  exists.   Thus, in external  incomplete  inguinal
hernia they are composed of all the layers of the walls of the abdo-
men.  The same remark applies to  complete inguinal or to scrotal
hernia, except  that in  these the  coverings  are slightly modified and
generally attenuated.   Underneath  the  skin we  find the superficial
sub-cutaneous fascia, then the dartos muscle, afterwards a prolonga-
tion of the deep-seated sub-cutaneous fascia, after which we find the
expansion  of the diverging fibres or that of the cellular tissue of the
aponeurosis of the external oblique muscle ; then comes the cremas^ 
660
NEW ELEMENTS OF  OPERATIVE SURGERY.
ter muscle, afterwards the fascia transversalis, and then the  pro-
longation of the fascia propria,  which lines the  outer  surface of
the sac.
  D.  Spermatic Cord.—Whether the hernia be external or internal,
the number  of envelopes is almost always the same: but the situa-
tion of  the cord may present essential points of difference.  Gene-
rally it is found on the inner and posterior side, throughout the whole
extent in external  inguinal hernia.   Nevertheless, the contrary has
been several times noticed; Le Dran, and other practitioners after
him are said to have found it in front.  MM.  A. Cooper and Key on
the contrary, appear to call in question this entire displacement of
the spermatic cord, and do not consider it possible  that there can be
anything more than  an expansion  of its various portions.  In  this
respect I differ  from them  in opinion.  Whether  the hernia takes
place in an  adult or is  congenital, it may nevertheless admit of the
cord and testicle being twined round it, either from without inwards,
or from within outwards, and  also from behind  forwards.  I have,
moreover, so frequently noticed the epididymis and  spermatic cord
naturally arranged in this  way, when  there was  no hernia, that I
should be more surprised with the  rarity than the  frequency of its
occurrence in the case under consideration.  Under such circum-
stances  the position of the testicle, moreover, will  suffice to put the
surgeon  upon his guard, and  to  point  out to him the precautions
which are to be taken.   It  is, nevertheless, easy to understand, how
the cord when drawn upon,  flattened and widened, may in certain
cases leave the veins, arteries and vas deferens separated apart  at a
considerable distance from each other.   It  is in  this way that the
vas deferens especially, though situated upon the  inner  side at its
emergence from the ring, and in front at  its middle portion,  has
sometimes been  found upon the  outside of the  tumor at its  lower
portion.   In  certain cases also, as noticed  by M. A.  Cooper and M.
Goyrand, the cord, after  having become expanded  out posteriorly,
allows itself to be perforated  by the tumor in the manner  of a  sort
of diaphragm, and afterwards  takes  a situation in  front of and with
the testicle below the hernia.   In internal inguinal  hernia, the tumor
from passing directly through the  ring of the external oblique muscle,
without being  obliged  to pass through the inguinal canal,  would
rather seem to have the effect to push the cord  to the outside, and
posteriorly, than in any other  direction.  This is what in  fact hap-
pens in  most cases when the tumor  is limited to the condition of a
bubonocele.  But when it  descends farther  into the scrotum, it  is
quite usual to see it cross the front part of the cord, and to find  ulti-
mately the testicle as well as the vas deferens, behind and on the in-
side, in  the same way as if it were  an external inguinal  hernia.   It
may be easily conceived also, that this hernia, on the other hand, in
place of crowding the cord backwards, might in certain cases bring
it forward rather on its  anterior surface, by making  pressure upon it
from without inwards, and afterwards from behind  forwards.
  E.  In inguinal hernia, the adipose layer which I  have  elsewhere
spoken  of does  not always occupy the same tissues ;  in patients
possessing a great deal  of embonpoint, it may be situated in the  sub-
cutaneous layer in  such manner as  to represent a border which is 
INGUINAL HERNIA.
661
more and more attenuated in proportion as it extends in the direction
towards  the scrotum, a border which is distinguished from hernia
properly so called in this, that it is actually adherent to the skin, and
is not prolonged into the inguinal canal.  In other cases the fatty sub-
stance is collected into a mass, sometimes globular and at other times
cylindroidal, upon the external surface of the sac, and in such quantity
as to form actual  tumors, which it  is sometimes impossible to dis-
tinguish from epiploic hernia.   These tumors, which are denomina-
ted adipose hernias, which have been pointed out by  many authors,
and which Morgagni, and especially Pelletan, have more particularly
described, lead to serious mistakes in practice.   Moreover,  though it
be true that the different descriptions of inguinal hernias when ex-
isting under their most simple forms, may be distinguished from each
other without any great degree  of difficulty, it must be  confessed
that in a great number of cases this becomes almost impossible.
  F. Many ancient hernias, for  example, have reacted upon their
coverings in such manner, that they descend below  the inferior ex-
tremity ofthe testicle, so^that they no longer perceptibly differ from
hernias of the tunica vaginalis.  Also  in  such cases they may have
obliterated the inguinal canal, brought the two openings of  this pas-
sage in front of each other, and  no longer present any more  obli-
quity  external to, than upon  the inside  of the epigastric artery.
Nevertheless, it  may be asserted that every inguinal  hernia which
exceeds the size ofthe head of a foetus has been protruded at the ex-
ternal fossa, and traversed the whole  length  of the canal.  Should
the  tumor  have been prolonged  in such manner as to occupy and
distend the entire scrotum, it would be almost useless to seek for any
other  proof of this.  Internal  inguinal hernias, and  those inguinal
hernias which pass  through  a rent in the aponeurosis,  must be inca-
pable  of ever acquiring so great a volume, or of descending to  so
great a distance upon the thigh.  It follows from this,  therefore, that
the  differential  diagnosis of inguinal hernias from each  other, must
present less embarrassment than is  generally believed.  It may  be
considered in fact as established, that when they are in the condition
of bubonocele, the signs mentioned in the beginning of this paragraph
will almost always be found sufficient to  a careful  practitioner, and
that when the hernia actually becomes scrotal, it is next  to impossi-
ble that there can exist anything else than an external inguinal hernia.
  G. At first sight, it would seem that an inguinal  could  never  be
confounded with a crural hernia : it would be an error however  to
suppose so.  M. A. Cooper relates the case of  a crural hernia  in a
woman, which was in this manner mistaken for an inguinal.   A fact
of the same  kind  had been mentioned by Pelletan, who got down
upon the viscera before he found out his mistake.  A similar case is
cited by  M. Marjolin, and another related from the practice of M.
Roux.   It is  in women  especially that mistakes  of  this  kind are
likely to  be made.   Various circumstances moreover may explain
them; in one case there  were ancient cicatrices in the  fold of the
groin, which had forced the crural hernia into a situation in front  of
the inguinal ring.  In other cases, this  derangement is caused  by a
relaxation of Poupart's ligament, the presence of an adipose border,
or the coexistence of lymphatic or other tumors, which prevent our 
662
NEW ELEMENTS OF  OPERATIVE SURGERY.
distinguishing with precision the point  at which the hernia sat out.
In man this mistake may be avoided, by following the course  of the
spermatic  cord,  inasmuch  as  the  finger, if this canal is  free, will
scarcely ever  fail  to  recognize the ring, whereas, if it has actually
served as the passage  for the descent ofthe hernia, it will be found
filled up with it.   In women we have not this guide ; from the ring
being naturally  small, and from there being no prolongation of it
whatever to the outside, it becomes a difficult matter in a great num-
ber of cases to trace its position with accuracy;  M.  Nivet has justly
remarked,  that by first seeking for the spine of the pubis through the
integuments, in order to proceed gradually from that point to the an-
tero-superior spinous process of the ilium, following along the track of
Poupart's ligament, we need not have any apprehension of making a
mistake, it  being  understood that those hernias are crural  which  are
situated below  this  line, and those inguinal which are placed  above
it;  but  Poupart's ligament is sometimes so relaxed and so difficult to
be distinguished from the other aponeurotic tissues, in women pos-
sessing a certain  degree of embonpoint, that this sign, though valua-
ble to be remembered, might  also frequently lead to mistakes.  It
may be moreover readily conceived that, where the hernia has taken
place through a rent in the outer border of the ring, or in Gimber-
nat's  ligament, or  in  the upper border of Poupart's ligament,  the
surgeon might be placed in an  extreme  degree of embarrassment; it
must be admitted therefore, that in certain exceptional cases, inguinal
and crural  hernias may be quite easily confounded.
  H.  If the hernia, were constituted of the iliac colon, either on  the
left side, as I have frequently seen, or upon the right, an  instance of
which is related both  by Lassus and Pelletan, if it be not the same
case, we may suspect it from symptoms, which usually exist in  a her-
nia of the large intestine, and especially from the almost utter impos-
sibility of making the  injections penetrate beyond a  few inches into
the rectum.  The presence of the cacum  in  an inguinal hernia,
would be indicated by the slow and gradual development  of the tu-
mor, the impossibility  of effecting- its  complete reduction, notwith-
standing the large dimensions  of the  rings,  the slight disturbance
which it causes in the digestive functions, the  stercoral prominences
which may be sometimes distinguished  through the envelopes of the
tumor, and by its fixed position in the neighborhood of the ring, even
though it  may have already acquired  a very considerable volume.
The small  intestine, on the contrary, gives  rise to hernias, which in
most cases come  on very suddenly, which afterwards acquire, as it
were by starts, (comme par saccade,) their  ultimate size, which may
be completely reduced while being accompanied with a sort of gur-
gling sound, and  which very frequently give  rise suddenly to colics,
constipation, and vomitings.  A hernia of the stomach would be re-
cognized by its alternate distension  and disappearance, before  and
after a repast, by its almost instantaneous development  at the mo-
ment after a person has been drinking, by its  dull bruit (matite) un-
der percussion  after eating, and by the  clear sound which is emitted
when the patient has been fasting; it is in this manner, at  least, that
M.  Fabre,  distinguished it in the case  which he noticed, and which
M.  Lebert, (Journ. des Conn.  Med. Chir.,  1838, p. 145,)  has since 
INGUINAL HERNIA.
663
 completed.  But since anatomical investigation has already afforded
 some light in this respect,  inasmuch  as  M. Yvan, who found  the
 stomach in an inguinal hernia in the dead body, does not mention that
 it was so recognized during life, it would be advisable in my opinion
 not to attach too much importance to such signs.  The bladder might
 be supposed to be implicated in  a hernial tumor, if this last should
 usually disappear after the expulsion of the urine ;  or  should become
 distended on the contrary when a long space of time had intervened
 since it had been discharged ; or if the pressure made upon the tu-
 mor occasioned  pain in the direction of the urethra, and a desire to
 urinate, or if, when pressure was made upon it, it appeared to become
 flattened and take a direction towards  the pelvic cavity, instead of
 actually re-entering into the abdomen.   As  to  hernias of the ovari-
 um, they might  be confounded with certain lymphatic  ganglions, or
 with some other abnormal tumors; but besides their globular form
 and slightly bosselated character, their  mobility, the  small size of their
 pedicle, and their reducibility, they occasion in women, when  pres-
 sure is made upon them, a pain and  sensation which  are so charac-
 teristic, that it would be difficult to make  a mistake in this matter.
 Hernias of the uterus, apart from the state of pregnancy, have been
 too rarely noticed to enable us to enumerate their signs.  The same
 remark applies  to hernias  of the fallopian  tube,  spleen, liver, and
 kidney.

            § III.—Complications of Inguinal Hernia.

    From what precedes, it is perceived that inguinal hernia,  when in
 its simple state,  may almost always be distinguished from other dis-
 eases ; but this is far from being the case when it is accompanied  or
• complicated with certain conditions.   The complications of inguinal
 hernia, moreover, are numerous and varied.
    A.  Ancient hernias.—When the inguinal hernia  dates to a remote
 period, and never has  been  reduced, it sometimes acquires a volume
 which is absolutely monstrous.  It has been seen  to  descend to  the
 middle of the thigh, and nearly as far  as to the knee.   In such cases
 it must be impossible to say, whether it is on the inside or  upon the
 outside of the spermatic cord, or whether it contains this or that por-
 tion of intestine ; it is under these circumstances that we encounter
 here at the same time, several of  the viscera, the large and  small in-
 testine, bladder, kidney, spleen, liver,  and stomach.   The  old  man
 mentioned by M. Fabre, had a hernia  of 90 centimetres in circum-
 ference, with elephantine degeneration of the scrotum.
    B. Adhesion  of the parts.—The adhesions in  inguinal hernia are
 made at the expense of various organs. In congenital hernia, for ex-
 ample, the testicle may become attached to some point upon the  epi-
 ploon or intestine.  Various kinds of accidents are thereby produced.
 If the external ring is large, the hernia will not return into  the belly
 without dragging the testicle with it into the inguinal  canal or even
 into the abdomen.  In the  contrary case, the retraction  of the  dis-
 placed organs draws  up the testicle against the borders of the ring,
 and may thus cause it to be painfully compressed.   The  instances
 of this complication are  not uncommon, and Zimmermann himself 
664
NEW ELEMENTS OF OPERATIVE SURGERY.
was one of the most remarkable.  An error may take place in these
hernias, because in epiploic hernias, properly so called, it may happen
that the epiploon may present itself below as a globular mass, adherent
to the bottom ofthe sac.   In this case, if there was only one testicle
or if in consequence of a displacement of this organ,  it should not be
found at first, the  surgeon might  mistake the  epiploic  tumor for it,
and thus erroneously suppose that there existed a congenital hernia
of the preceding species.  The intestine in issuing  from  the belly,
may become lodged in the inguinal canal by penetrating above or be-
low a bridle, in such manner as to pass afterwards in  an opposite di-
rection by inclining from right to left, or left to right, so as to become
speedily liable to  strangulation in this position.  It may, moreover,
easily be understood, that in such cases two intestinal hernias may be
formed in the same sac, viz., one  in  each compartment made by the
epiploic diaphragm.  In a patient who died at  La Charite in 183G, I
met with an arrangement of the epiploon which had not  hitherto been
noticed.  This organ existed in the sac in the shape of a cylinder of
the size of a child's fore-arm, four inches in length, and which was ad-
herent by means of some bridles to the bottom of the  sac, and hol-
lowed  out throughout its whole length into  a canal of near an inch
in diameter.   It was in this cylinder that the intestine  had become
lodged and strangulated!
  C. Secondary degenerations.—These epiploic masses sometimes
become, in their turn, the seat of degenerescences.  There are some-
times formed here, for example, cysts which are either multiple or
of the character of hydatids ; in other cases in small number, so as to
resemble large sacs, as in hydrocele.  In such cases the idea of a hydro-
cele, either of the cord or  of  the tunica vaginalis, may equally well
present itself to the mind as that of a hernia, (see Hydrocele.)  Some-
times also they inflame and become painful, and even the seat of actual  «
abscesses.   Should this morbid process be established in the inguinal
canal itself, symptoms of strangulation may be manifested ;  only that
we could almost always, in such cases, avoid making  any mistake by
noticing that the pain is  then  heavy, deep-seated and pungent, as in
phlegmon, and generally confined to the seat of tumor,  that the con-
stipation is rarely obstinate, that there is rather constant nausea than
actual  vomiting, and that the substances vomited at least do not re-
semble  stercoral matters.  Many surgeons  have cited examples of
these kinds of strangulation in the inguinal canal, which have been
mistaken and operated upon  for actual hernia.   It may also happen
that without any epiploic hernia, the cellular tissue in the spermatic
cord will  become  swollen  in  the  inguinal canal to such extent as to
constitute in that part  a painful and hard border, and to give rise to
some of the symptoms  of hernial strangulation, whether a hernia has
actually taken place or may never have existed there.
  D. In certain cases also the adipose matter which  lines the sac
presents an arrangement which has never been pointed out by any
body, and which I  met with in one instance  in March, 1837, at
La Charite.   After the  intestinal hernia was reduced, there could
he  felt  through  the external coverings several borders, (bourrelets,)
which  led to the belief of the existence of some portions of the intes-
tine or epiploon  left in  the  sac.  An incision having  been  made, we 
INGUINAL HERNIA.
665
perceived that these bourrelets, which were an inch in diameter and
slightly flattened, were so nearly similar in appearance to the small
intestine, that we stopped  for  some time  to  examine them,  before
knowing what course to take.   Being free and floating in the interior
of the sac, they appeared  to adhere to this last only by means of a
species of mesentery.  They were composed in  reality of adipose
matter, enveloped in a duplicature of the peritoneum, and projecting
in the hernial sac in a similar manner to those  synovial pelotons
which are seen in the interior of the articulations, and were,  more-
over, continuous with the adipose matter of the fascia propria.
  E. Inguinal hernia is frequently complicated with hydrocele, and
this  hydrocele presents itself under three principal varieties ;  some-
times  it is nothing more  than the ordinary hydrocele ofthe  tunica
vaginalis, which has been  produced by the irritation caused  by the
proximity of the displaced viscera, or by the pressure made upon the
track  of the spermatic cord by the bandages  or by  the tumor itself.
Without admitting that this complication  is as common as M. Tes-
sier thinks, I feel compelled to confess that it is frequently met with.
In such cases it may itself become the source of  another complica-
tion.  Dupuytren, M. Berard the elder, and some others, have related
facts to me which  prove  that the hernia  enveloped Mn its sac has
occasionally penetrated into the cavity of  the hydrocele  through a
laceration in the tunica vaginalis, and  become strangulated in that
position.  In other cases the hydrocele takes place in the sac itself at
the  same time, and in connection with the hernia which exists there.
This is a complication which is frequently met with, and one  which
I have pointed  out above.   In entero-epiploic hernias, after certain
symptoms of strangulation, we may succeed in  returning the intestine
into the belly;  but the epiploon becomes  congested and swollen to
such degree that it soon  fills up the inguinal canal.  There takes
place at the same time an  exhalation of serosity in the sac below the
ring.  I saw at La Charite, in the  year 1837 only,  three instances of
this kind, two in men and the third in a  woman.  In one of these
patients the hydrocele took place under our  observation  from one
day to the next, though it contained eight ounces of serosity.   This
was a man in whom  the hernia,  which was  also ancient and gene-
rally kept up with  difficulty, had become strangulated a great num-
ber of times, but was  also always reduced by the simple taxis.  When
he came into the hospital,  it was after the usual taxis had failed, and
the  accidents  had existed  for the space  of forty-eight hours.   In the
morning, at the time of my visit, I succeeded in returning the intes-
tine into the belly ;  but the epiploon, which appeared to be  adherent,
remained in the sac, and especially in the inguinal canal.   Twenty-
four hours after, when I saw the patient  again,  the  symptoms of
strangulation had ceased,  but the tumor had acquired the size it had
the evening before, and we were greatly surprised to find it had now
become  changed into a true  hydrocele.   I extracted from it eight
ounces of serum.  In the two other cases,  the symptoms progressed
precisely in the same manner, except that the  reduction of the intes-
tine had been effected before their admission into the hospital, and
when  I  visited  them  the  hydrocele had been established.  In Feb-
ruary,  1839, I found in the sac of a hernia of this description,  the 
666
NEW ELEMENTS OF  OPERATIVE SURGERY.
epiploic mass in the midst of a thin  stratum of serosity.  In such
cases we have the signs of an epiploic hernia or strangulation of the
cord in the inguinal canal, together with those of encysted hydrocele
of the cord or tunica vaginalis.

                   § IV.—Irreducible Hernias.

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

                   §  V.—Rupture of the  Sac.

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

                    §  VI.—Hernial Bandages.

  The palliative treatment of reducible  inguinal hernia consists
exclusively in the employment of bandages, vulgarly known under
the name  of trusses.
  A. Whatever some  practitioners may say to the contrary, inguinal
hernia in  children ought to be kept reduced by trusses as early as
possible.  By means of this precaution in fact, we may hope that by
the growth of the little patient and the changes which are wrought
both in the thickness of the abdominal walls and in all the organs, to
effect a radical cure in the space of six months, a year, or at farthest
in two years.  Perhaps at this age, in place ofthe ordinary bandage,
which it  is  sometimes difficult to keep properly applied, it would be
well to recur to  the method pointed out first by M. Lawrence and 
INGUINAL  HERNIA.
667
afterwards by M. Meynier, and which consists in attaching over the
ring graduated plates by means of long adhesive plasters, which sur-
round the pelvis and upper part of the thigh.
  B. The pelote of trusses is generally applied in a manner which is
but  poorly adapted to the requirements  of the anatomical arrange-
ment of the parts.  Taking its point d'appui upon the border of the pubis
in front of the ring,  it leaves the interior of the inguinal canal entirely
free, and consequently presents but a very imperfect obstacle to the
production of incomplete inguinal  hernia and strangulation  at the
posterior  ring.  Again,  the spermatic cord, which  is  almost  always
drawn in  such cases to the external border of the ring outside of the
pubic spine, is almost  unavoidably compressed in such manner as  to
render it incapable any longer of performing  its functions without
much difficulty.  Everything show's, therefore, that a reform is desira-
ble in this respect in the application of bandages.   In  recalling what
we have said ofthe contexture of the parietal walls which are traversed
or may be traversed by inguinal hernias, it will be readily perceived
that a compression  which should be made to  act on the entire length
of the canal in such manner as to maintain its  two sides in contact,
would at the same time be less  painful for the  patient, continued
with greater facility,  and possessed of greater efficacy than  by the
ordinary method.   In this manner, the organs being prevented from
becoming lodged in the posterior ring, which is then  as closely shut
up as the anterior, would allow of the two walls of the sac becoming
agglutinated, and consequently render the reproduction of the hernia
impossible in a great number of cases.   This is a suggestion which
was urged a long time since by M. A.  Cooper, and which A. Thom-
son and  M. Malgaigne have more recently  endeavored to enforce.
Some bandagists had already anticipated it; and the pelotes of M.
Fournier  de Lempdes, among others, appear to have been constructed
on this principle.   It is  also certain that many radical  cures have
been attained by means of these bandages.
  C. The pelote of the truss  ought to make its  strongest pressure
above Poupart's ligament, at the  union of the two outer thirds with
the inner third of the space which separates the spine of  the pubis
from the antero-superior  spinous  process of the  os ilium, or as M.
Cooper recommends,  on the middle of the line which extends from the
iliac spine to the symphisis pubis.    To render the direction still more
anatomical, I should add that the pelote' ought to rest on the triangle
which is bounded, on  the inside by the expansion of the external bor-
der of the rectus muscle, below by Poupart's  ligament, and above by
the  lower border of the transversalis abdominis muscle.  1 have no
necessity of remarking that  these  observations apply almost exclu-
sively to external inguinal hernias, and that for internal inguinal her-
nias, or such as take  place  through a rent in  the aponeuroses, the
bandages which are applied directly over the opening ought still  to
be preserved.
  D. In  inguinal hernia of the tunica  vaginalis, it may  happen that
the testicle remains in the canal above the displaced  viscera, or that
these latter, while being reduced, may draw  it with them;  the appli-
cation of the bandage may in such cases  be  attended with difficulty.
« by means of judicious precautions it  should seem to  be practicable 
668
NEW ELEMENTS OF  OPERATIVE SURGERY.
lo adjust the pelote upon the ring or inguinal canal, between the tes-
ticle and the organs which  have been reduced, then  we  should not
hesitate to adopt it.   The bandage ought still to be applied- upon the
ring where the testicle has  been wholly returned, together with the
viscera.   If on the contrary the testicle ascended only  as hio-h as
the ring or could not in any way be  reduced beyond the inguinal
canal, the  pressure made upon it by  the bandage would be attended
with too much danger to allow of its  application.
   E.  In entero-epiploic hernias, where  the intestine and epiploon ad-
mit of being perfectly reduced, there is no particular direction to be
given in relation to  the application of the bandage; but  should any
adhesions have formed between these two descriptions of organs, and
the epiploon were reducible only in part,  we should have  to proceed
in the same manner as in congenital hernia.  The following is a case
which was attended with considerable embarrassment:  a  filament of
epiploon adhered to the testicle, and one could not ascend  or descend
without the other;  the hernia could not be reduced without causing
pain in the testicle, and the testicle could  not be placed in its proper
situation without bringing down  the hernia.   The case of Zirnmer-
mann  himself was one of this  description.  In  women, the  bandage
in inguinal hernia is  applied  with more facility than in man.   The
absence of the spermatic cord and the anatomical arrangement which
I have described above, sufficiently explain this difference.
   F. Irreducible inguinal hernias cannot  be treated  in the same
manner as the others, by means  of a  truss.   If they are large sized
and ancient, the best plan is to enclose them in  a suspensory or spe-
cies of sac properly constructed,  and  which will support  and  make
moderate  compression upon them from  below upwards.  When any
of the organs of which they are constituted is reducible, it should be
pushed back into the belly.   If the portion which remains  consists of
epiploon, or does not threaten to become strangulated, we  may make
use of a bandage with a concave pelote, which supports and gradu-
ally pushes back the tumor  more and  more against  the  ring.   By
means of suspensories or bandages arranged in this manner, we some-
times  succeed  in gradually  diminishing  the size  of  hernias which
would  appear to be irreducible, and even in effecting their complete
return  into the belly.   This  is what takes  place, especially in hernias
ofthe cascum, the sigmoid flexure of the colon, the bladder, and those
which  are composed  of adipose  masses or of epiploon.

           § VIIL—Strangulation of Inguinal Hernias.

  Inguinal hernias are liable, like all others, to the complication known
under the name of strangulation.
  A. Strangulation spasmodic.—An attentive examination of the
fibro-muscular layers of the  belly, shows that the contraction of cer-
tain muscles may sensibly diminish the diameter of the  rings in the
groin  as well as that of almost all the other hernial openings.  It may,
for example, be conceived that the divergent fibres (les fibres en sau-
toir), which bridle the upper angle of the external ring, and also sur-
round the  lower border of Poupart's ligament, would have a tenden-
cy to become straightened under the influence of the external  ob- 
INGUINAL HERNIA.
669
lique muscle of the opposite  side, and would  thus  partially close up
the space which separates the two borders of the ring.  The fibrous
bands which surround the ring, properly so called,  approximating
together in the manner of the two borders of a button-hole in order
to pass in front of the symphisis pubis, are also susceptible of being
straightened out, and  thus diminishing to a certain extent  the  her-
nial opening, should the corresponding external oblique muscle be-
come contracted.   The fibres which form the posterior ring, arising
almost exclusively from the  rectus abdominis muscle, to become at-
tached to the spine  and crest  of the ilium, may also  be drawn up,
and thus tend to carry backwards the organs lodged  in the inguinal
canal, against the lower border of the transversalis abdominis mus-
cle, which latter also,  when contracting, might  compress them  from
above downwards.  It is therefore evident, that these muscular  con-
tractions may  narrow the  openings of the inguinal canal, and  that
we should be wrong to look upon the spasmodic strangulation of her-
nias, as a thing absolutely impossible.   I have demonstrated  with the
scalpel these various anatomical arrangements, first with A. Thomp-
son, and afterwards by myself, in all subjects which I have had lei-
sure to dissect.  I have elsewhere  published the details of these ex-
aminations, (Anat.  Chir., 1837,  t.  L, Introd.) , M. Astley Cooper,
who sides with the  common opinion, nevertheless admits the possi-
bility of spasmodic  strangulation by the  lower border of the trans-
versalis muscle, at the posterior opening of the inguinal canal.
  B. However this may  be,  strangulation in  inguinal  hernia  may
take place at quite a different number of points.  In some cases it is
at the neck, or the  root of  the  sac, and sometimes in  the  scrotum
below the external  ring.  The  first description comprises strangula-
tion at the posterior ring, and also that at the anterior or pubic  ring
of the inguinal canal.   To the second variety belong strangulation
through a rupture of the sac, either in the direction towards the in-
teguments, as in the  cases above related, or in  the  septum  of a
vaginal hydrocele, as  in the  patient of M. H. Berard, or through the
expanded spermatic cord, as has been seen by M. Goyrand.  Stran-
gulation, also,  is quite frequently produced by some appendage of
the displaced  viscera  themselves.  An epiploic band, which should
pass in front of the  intestine, as if for the purpose of dividing it into
two portions, before becoming attached to the bottom of the rupture;
or an opening  made in a layer of epiploon within the sac, and through
which a portion of the intestine has  passed, are calculated to  pro-
duce this  result.  The epiploon, rolled up into a cord,  may become
attached, first  on one  side and then on the other, making a sort of
bridge, or it may afterwards make another bridge by attaching itself
again on the first wall of the hernial cavity, and react in this manner
upon the intestine in an injurious manner.   Two of these prolonga-
tions, after having  contracted adhesions on each side of  the  sac,
sometimes approximate together in order to become united a  little
lower down,  leaving, in  this manner,  between  them  a separation
through which the intestine  may protrude.  I  have  cited a  case
where the epiploon, fixed at  the bottom of  the sac  by means  of a
bridle, represented,  as high  up as the ring, a  hard  and  hollow cylin-
der, in which a noose of the ileum  had become strangulated.   Hey 
 670          NEW ELEMENTS OF OPERATIVE  SURGERY.

 has figured a scrotum in which we see a portion of epiploon attached
 by its two extremities to the sides of the sac, and presenting in its
 middle portion  a complete circle, through which the intestine pro-
 truded.   In  a case which I had an opportunity of examining after
 death, the strangulation was caused by a mass of epiploon of the size
 of a large pullet's egg.  In a patient operated upon by Pelletan the
 same result was produced  by a tumor of the mesentery.   The ap-
 pendix of the cascum would have the same effect if it should  be in-
 cluded in the hernia,  and  its point had  contracted some  abnormal
 adhesions.  A man forty  years of age, whom I operated upon in
 1833 at the hospital of La Pitie, had the inguinal canal  dilated to an
 extreme degree ; but the cascum, which especially formed the hernia,
 had  become turned round to the outside and front, in such manner
 as to strangulate upon  the body of the pubis  a noose  of the  ileum
 which had slipped  into the bottom of the scrotum.  We may com-
 prehend, moreover, in how many different ways and by  what various
 kinds of morbid alterations a strangulation of the intestine may be
 produced in the interior of the sac.  In respect  to strangulations
 caused  by the sac  itself, they are constituted of different varieties.
 Below the ring they sometimes depend either upon a rent in  the
 septum,  which  separates the hernia from  the tunica  vaginalis, or
 upon a laceration of the sac; but in  such cases this result  most fre-
 quently takes  place in the  contracted portion of  an ancient sac.   It
 is  necessary to  recollect,  in fact, that  multiple  sacs are scarcely
 ever met with except in inguinal  hernias, and that if one  of these
 should have remained empty below the new sac, and was  still open
 at its upper extremity, it might possibly happen that  the intestine
 would protrude into it in consequence of some  violent effort.  In the
 vicinity of the inguinal canal, the sac or its neck sometimes acquires
 so great  a degree of thickness and so much density, that this of itself
 may cause a strangulation.  In  ancient hernias the agglutination of
their folds augments this thickness to a still greater degree; various
lamellae of the fascia propria become attached and adherent to its ex-
ternal surface; white the plastic lymph which unites all these parts
together, may, in this manner, bring about a very considerable thick-
ening of the sac.   Arnaud states that he met with one which was
 half an inch in  thickness, and M. Graefe has since related a similar
 case.   Strangulation under such circumstances  may be so entirely
independent of the fibrous openings, that we may succeed in return-
ing the tumor into the belly without difficulty, but without removing
 the constriction.
  Arnaud and Le  Dran were the first to urge attention  to this ar-
 rangement of  parts, which have since become generally recognized
 by the exertions of Pott, Scarpa and Hey.  Dupuytren  is one of
 those who has done most to spread the knowledge of these anatomi-
 cal arrangements among French surgeons.  In such cases the stran-
gulation may be altogether annular or exceedingly circumscribed, or
it may occupy only the entrance or the exit or middle portion ofthe
neck, as it may also the whole track  of this prolongation, and trans-
form it into a sort of ring or encasement.  Strangulation at the neck
ofthe sac, however, which,  according to the  school of Dupuvtren,
occurs in eight or nine cases out of ten, or even still more frequently, 
INGUINAL  HERNIA.
671
according to the observations of M. A. Berard and M. King, (Gaz.
Med., 1829, p. 76,)  and which MM. A. Cooper and  Lawrence are
far from admitting in  this large proportion, is in reality quite a rare
occurrence.  If I venture to place myself in opposition to such high
authorities on this subject, it is because I consider that I have dis-
covered the error by which they have been misled.  The strangula-
tion in inguinal hernias takes place, as a general rule, at the external
or internal ring of the canal.   The neck of the sac, properly so call-
ed, is rarely the seat of strangulation, except in certain ancient her-
nias. When it takes place at the posterior ring, if we push back the
hernia we frequently succeed in making it pass through the external
rinu, and in transforming it from a complete into an incomplete her-
nial  During the operation the finger introduced into the canal, soon
perceives a movable  ring, which may be easily pushed back in a
direction towards the belly.   In such cases it has  been supposed
that this circle had been formed by the neck  of the sac, while in
reality it is made by the posterior fibrous ring of the inguinal ca-
nal.  Nor  do I hesitate to affirm that in a  great  number of cases
attributed to the neck of the sac  itself, the strangulation takes place
at the orifice in question.
  C. The signs of strangulation in inguinal hernia are in general the
same as in any other hernia, but they differ somewhat according to its
nature and precise situation.  At the external opening of the canal the
strangulation is characterized by a species of tense neck tightened on a
line with the ring; by the hardness of the tumor and its fixed position
immediately below; by its softness and the ability to depress the viscera
which are placed above or at the iliac fossa; by the pain which is caused
by the pressure at this point, and also by the impossibility of detect-
ing  the slightest void between the spermatic cord or root of the her-
nia  and borders of the inguinal ring.   Strangulation at the posterior
ring is  distinguished by other  characters.   Here the organs are ex-
empt from any kind of pressure  at the external ring.   On the con-
trary we remark that the species of cylinder contained in the canal
is tense, elastic and painful.   If the hernia is complete we find that
under the taxis it appears  to  return through the external ring, but
that it  comes back immediately and without  abandoning the ring
which strangles it, as soon as the» cylinder of the  inguinal canal is
allowed to go back towards the  iliac fossa.  This reduction is  not
accompanied by any gurgling  sound, and the viscera only leave the
scrotum to  augment  the  tumor contained in  the inguinal canal.
When the  strangulation  is caused by the neck of  the sac, we usu-
ally find the external ring free, as in  the preceding  case;  but the
inguinal canal  itself is no more distended than in  strangulation  by
the  anterior opening of the canal.  If the tumor appears to return,
it is for the purpose of becoming lodged  in the  fascia propria under
the  peritoneum  of the iliac region.
  Strangulation in the interior of the scrotum would be distinguish-
ed in this way, that while the rings, as well as  the canal appear to
be free, the hernial tumor, nevertheless,  continues irreducible,  and
also by  the fact, that the most  painful  point in such cases, is not
either at the  posterior or at the anterior  opening of the inguinal
canal, but in reality in some  part of the scrotum, properly so called. 
672
NEW ELEMENTS OF  OPERATIVE SURGERY.
  As to the  mode of ascertaining, under such circumstances, whether
  the strangulation is produced by a laceration of the sac, a rent in the
  tunica vaginalis, or by some bridles or perforation ofthe epiploon, or by
  a contortion ofthe intestine, or by the neck of some ancient sac, this ap-
  pears to be a point utterly impossible.   The distinction of the different
  kinds of strangulation in inguinal hernia is reduced, therefore, nearly
  to the following points:  1st, we may decide  whether the obstruc-
  tion  exists below  Poupart's  ligament, or at some one point in the
  parietes of the abdomen; 2d, in this last mentioned region it is fre-
  quently in our power to avoid confounding a strangulation at the ex-
  ternal, with one which may be  produced  at the  internal ring, and
  these two last  with a strangulation caused  by the neck of the sac.
  It is  well  to remark, however, that symptoms of strangulation in in-
  guinal as well as in any other hernia, must present modifications ac-
  cording as the hernia is found to be composed  of this or that organ.
  Thus, in hernia  of the cascum, as  the  course of the matters are not
  obstructed, except at a very advanced period of their elaboration, nor
  scarcely ever entirely intercepted, it rarely happens that the vomiting
  and constipation at first  are as marked as in hernias that are purely
  intestinal.   If the hernia in question is one of the appendix only of
  the cascum, as in a case related by M. Bougon, (Bull, de  la Fac. de
  Med.,  X. V., p. 248,) and in  that  of  M. Taramelli, it is  difficult to
  understand how there could  be  produced by it symptoms of an ac-
  tual  strangulation.   M. Taramelli, however, affirms, that  in the pa-
  tient  he  operated upon successfully, all these  symptoms existed.
  Mery also speaks of a hernia in which an appendix analogous to that
  of the cascum appeared to have been  strangulated ; but as there was
  a strangulation  also  of  another portion of intestine, it would be
  wrong to conclude from this case that the accidents were exclusively
  referable to the appendix.  M. H. Larrey (Revue Med., 1830, t. IV.,)
  has seen one of these diverticuli near the ring, and another similar
  case  was shown to me in 1838.   The sigmoid flexure of the colon
  is to  be considered with the same restrictions as the cascum; nor do
  the bladder, ovarium, womb, spleen, kidney and liver appear to be of
  a nature to give rise to either constipation or vomitings of stercoral
  matter. I would make the same remark of the epiploon and the tes-
  ticle, of strangulation of the cord, nnd of adipose  tumors and inflam-
  mation of the sac;  so that in  inguinal  hernia, as  in any other, an
  insurmountable constipation with stercoral vomitings, positively indi-
  cate  a strangulation or obstruction of a portion of small intestine, or
:  of a  noose of the colon.  Mistakes, moreover, in a case of inguinal
  hernia, are  almost  always owing to  other diseases, which  have
  effected an alteration upon the seat of the lesion.   If, for  example,  a
  man  affected with hernia in the groin should  be attacked with symp-
  toms analogous to  a cholera,  as  was seen in  the case of M. A. Vidal,
  or in that of  M. Briquet, the surgeon would naturally be  induced to
  believe that it was a case of strangulation.   An inflammation  in the
  interior of the sac, or the transformation of the  sac  into  an  actual
  abscess, causing a revulsion, as  has been seen by  Dupuytren, M.
  Duparcque and M.  Key, sometimes either on  the viscera,  which
  have not  been reduced,  or  upon  the peritoneum, intestines  and
  stomach, to such degree as to  bring  on vomitings and constipation, 
INGUINAL  HERNIA.
673
would in the same way lead to deception.  So also strangulation and
inflammation of the epiploon, testicle, or  cord in the interior  of the
canal  or sac, might equally give rise to error; but a mistake  would
almost always be avoided by recalling to mind what I have said
above.  Strangulation in inguinal hernia being clearly ascertained,
there exists an obvious necessity of removing it as speedily as  possi-
ble.  All the rules and remedies pointed  out  in speaking of hernias
in general, are especially applicable  to inguinal hernia in particular;
so that there is no necessity in my dwelling in this place on the sub-
ject of bleeding, nor of leeches, baths, purgatives, tobacco injections,
acupuncture and galvanism, nor  of the various  topical applications
which have been successively extolled under such circumstances.

                      § VII.—Operation.

  The operation for inguinal hernia is performed at every period of
life.
  A. In Children.—It would be erroneous to  suppose that it is never
required in young  children.  Pott and other authors had  already
remarked that enterocele might become  strangulated and cause death
in the first months of infancy.  M. Denonvilliers has communicated
to me another proof of this: A  child, eight months old, died with
symptoms  of peritonitis, when upon opening the  body it was discov-
ered that death had been caused by a strangulated inguinal hernia.
M.  Heyfelder operated for hernia in  an infant that  was only eight
days old, and Dupuytren  upon another  that was twenty days old.
The one cured  by M. Hunt was  twenty-nine days old,  and of  the
two cited  by M. Goyrand,  one was four months old and the other
six.  M. Lawrence operated upon one fourteen months old,  and  the
hernia was not congenital.   The case of M. Long was that of a child
of the same age, while M. Hildebrand's was eighteen months.   Out
of these eight operations, five at least were successful.  It is readily
to be conceived  also, that strangulation at this period  of life is easily
confounded with most of the  diseases of the lower belly.   In a male
child, fifteen months old, whom I operated on  at La Charite, in 1837,
the  hernia  was complicated with hydrocele.  The want of exact  in-
formation, the cries of the infant, the condition  ofthe scrotum, in fact,
every thing conspires, in such cases, to render the diagnosis obscure
and difficult.  As to the operation,  properly  so  called, it is evident
that, from  the indocility and want of reason  in  the  little patient, it
must necessarily be extremely difficult, and  require a degree of cau-
tion, both in respect to the manual or the subsequent symptoms, which
it is far from so imperatively demanding in adults.
  B. In Man.—As the integuments in general  preserve a certain
degree of pliancy at this point, it is almost always practicable to take
up a fold of them for their incision without being under the necessity
of stretching them, as is done in making a simple  incision.
  I. Incision.—Whether we adopt,  moreover, this  or that method,
it is  advisable that the incision should extend to a half an inch  or an
inch above  the ring, and that it should descend, unless there should
be some special reason to the contrary, as far  down as to the bottom
of the tumor, following its greater axis.  This incision requires some
                              43 
674           NEW ELEMENTS OF OPERATIVE  SURGERY.

precautions.   From the spermatic cord not having a fixed position,
we might  be liable,  in certain cases, to wound the vas deferens or
spermatic artery, as happened in two instances to Hey.   In external
inguinal  hernia, it  has been  seen to  pass in front of the tumor in
such  manner as to be found upon the outside when  it  reached  the
lower part of this last.  I have  seen three examples of this in  pa-
tients who each had an enormous hernia.   In internal  inguinal hernia
the same thing may happen, but  in an inverse sense ; that is to say,
that the spermatic  cord placed externally at its emergence from the
canal, may come gradually in  front and then on the  inside, then
unite  with  the  testicle which  is  below, and also  on the inside.
There can be no doubt that, in  cases of this description, the instru-
ment  would  almost inevitably wound  one of the parts  which make
up the sp*ermatio  cord, as must  have easily  happened  in the cases
related  by Schmucker,  Camper, Le Dran,  Boudou, M. Fardeau,
Scarpa, A. Cooper, Lawrence, Blizard and  some others.  The tis-
sues therefore which separate the integuments from the  sac are to be
incised with  caution.    The division of  these intermediate layers
moreover is to be made according to the rules we have  laid down in
the beginning.  When  the  inguinal  hernia is direct,  the incision of
the integuments is to be parallel to the axis of  the body.  When on
the contrary, the tumor is external and not of large size, it must be
oblique from  above downwards and from without inwards; but when
the hernia is very large it will be found advisable to give the  incision
a very elongated  semilunar  form, with its convexity looking upwards
and inwards.
  II.  As to the sac, if it should present  no  inequality,  it would be
most prudent to perforate it below, in front,  and slightly to the  out-
side.  After  having laid  it open freely above, as high up as  the
ring, the  question then is to  be asked whether it is indispensable to
prolong this  incision  completely down  to the bottom  of the  sac.
Some persons consider the contrary the correct course.  Hey among
others, as well as  Scarpa, from an apprehension of wounding the tu-
nica vaginalis, which lies in this direction, recommend that we should
leave  below a half an inch at least of the sac undivided.  In reality
it is almost a matter of  indifference  whether we adopt either the one
or the other of these  methods.   When we have to operate upon a
congenital hernia, the organs having enlarged and  distended the tu-
nica vaginalis below the testicle,, present in this respect two formida-
ble difficulties to be avoided. If the sac is opened throughout its whole
length, the testicle constantly tends  to escape from the bottom ofthe
wound, and may thus  give rise to accidents.  If we incise the serous
pouch only in its upper half, we shall find it  much  more easy to re-
strain the testicle, but the pus, if it  should form, will become accu-
mulated  in the cul de  sac  preserved below,  and  thus give rise to
other  serious  symptoms.   The best course  therefore would be to
make a large opening, and be satisfied with afterwards  bringing the
borders of the tunica vaginalis in front of the testicle, and in main-
taining them there by one or more points of suture.
  III.  To remove the strangulation.—Owing to certain vessels which
it is important should  not be wounded, inguinal hernia  presents  one
of those cases in which it would be most advisable  to have recourse 
INGUINAL  HERNIA.                      675
to dilatation, if this method were at all  practicable.   Theory lays it
down that the debridement, the only resource employed at the  pre-
sent day, should be performed by this or that process, according as
the case under consideration is this or that form of bubonocele.
  a. For example, for those hernias in which the neck is situated ex-
ternal to the epigastric artery, that is to say, for all those which have
passed through the iliac opening of the  inguinal canal, the debridement
is to be made to the outside, on one ofthe points ofthe external semi-
circumference of the ring.  On the contrary, to the inside for inter-
nal inguinal hernias, and directly upwards when there is an epigas-
tric artery on  each side, as in the  case communicated to me by
Lauth.  These  different indications explain why such opposite rules
have been given on this  subject by  the most respectable authors.
Sharp, La  Faye, Pott, and Sabatier  recommend  that  the  debride-
ment should be  upwards and outwards, because the epigastric artery
is usually found  upon the inside ; Verduc, Garengeot, and Heister, on
the contrary, recommend that it should  be made to the inside, and
Bertrandi, who saw a case in which the  debridement was outward,
cause a hemorrhage by the division of the epigastric  artery, ending
in the death of  the  patient, gives  the  same  advice.   Finally, it  was
from the dread  of finding this artery upon the one side or the other,
that J.  L. Petit, before Rougemont, Autenreith, Cooper, Scarpa,
Richerand, and  Dupuytren,  who followed the same practice,   ad-
vises that  the  stricture should  be divided  directly upwards.  It
is true  that Desault and  Chopart had  already  remarked,  that  the
artery is upon  the  inside  when the spermatic cord is. found poste-
rior to  or upon the inner side of the  tumor, and  that  it is upon
the outside in the contrary case.  But to arrive at  a definite  opinion
upon this  subject,  there  was wanting the  anatomical knowledge
which exists at  the present day.
  b. To lay  it  down as a rule that  we should divide  the stricture
outwardly when the hernia is external, and  inwardly when it is in-
ternal, could be  a  matter  of no importance, unless there were  less
difficulties in distinguishing those two varieties of the disease from
each other.   Moreover, when  there are  two epigastric arteries, or
when the only one which exists arises from the  obturator  at  a  cer-
tain distance from the external  iliac, it might very  naturally be
found upon the  inside in internal inguinal hernia, as  it is usually ob-
served to be in external inguinal hernia, in the same way that the
external epigastric artery in the case  mentioned by Lauth might
have been situated outside of an oblique  inguinal hernia.  It  was
precisely owing to this uncertainty that MM. Cooper, Scarpa, Riche-
rand, and  Dupuytren, prefer the method of Petit or  Rougemont.
By incising directly upwards they remark, that it is a matter of lit-
tle importance whether the artery be  upon  the outside  or upon the
inside, whether  there be two  of them  or  one only, or whether the
hernia be internal  or external, as we have no hemorrhage to dread,
for the  instrument  always divides the tissues parallel  to  the usual
direction of the vessels.   An objection however which  exists is this,
that the epigastric artery, in place of  following a line parallel to the
axis of the body, is directed obliquely from  without inwards,  and
from below upwards, in  order to reach the umbilical  region, while 
676
NEW ELEMENTS OF  OPERATIVE SURGERY.
 passing above an internal inguinal hernia: while in an external in-
 guinal hernia, I have seen it depressed so much to the  inside, that it
 formed, so to speak, a semicircle, the upper extremity of which mif lit
 have been very easily wounded in a perpendicular incision.  As it
 rarely fails to be displaced by the root of the tumor, we cannot in
 reality  ascertain whether it  is vertical  rather than oblique, in one
 direction or  another.
   c  I will remark that in internal inguinal hernia, the pubic branch
 furnished by the epigastric, would almost inevitably be wounded, and
 that in  cases where its great size was abnormal, an alarming hemor-
 rhage might result from this, as appears to have been the fact in two
 cases noticed by  M.  Lawrence.   No method therefore effectually
 protects us from hemorrhage.  Nevertheless, the epigastric arterv is
 but rarely wounded.  From whence does this happen ?   In  the first
 place, because this  artery, from being  pushed back by the  neck of
 the sac, is almost always situated at the distance of two or three lines
 from the constricting circle, and that  in most cases we do not give a
 greater  extent to the incision than  this.  In the second place, we
 escape the artery because, in the strangulation caused by the ring of
 the external oblique,  the incision is made upon a circle too remote
 from the artery  in question to incur any apprehension of our  wound-
 ing it;  from  whence it follows that after rigidly examining this mat-
 ter, it is found  that the debridement may be made in any direction
 without  danger, provided we do not  give it too great an extent, and
 that the  successful results obtained at Vienna  at the beginning of this
 century  by Rudthoffer, who always  divided  the stricture upon the
 inside, after the manner of Bertrandi, present nothing remarkable in
 this particular.  If we add to this that internal inguinal hernia is a
 rare occurrence, and  that in our days the debridement outwards is
 preferred in the  great majority of cases, we may readily comprehend
 why hemorrhage, as a consequence of kelotomy, is so uncommon an
 occurrence.  Nevertheless, as it has been noticed in several instances,
 attention is still required on the subject of the means to be employed
 to avoid it.
  d.  The author.—In every strangulation at the inferior opening of
 the canal, the debridement, whether made by means  of a  convex
 bistoury, guided upon the pulp ofthe finger, as Bell recommends, or
 what would be better still, by making use of  the point of a  straight
 bistoury, also protected by the finger, or of a blunt-pointed bistoury,
 which incises from  the free border of the ring towards  a point more
 or less remote from its circumference, would  secure us  from every
 danger,  inasmuch, as by following these directions, the  instrument
 does not penetrate as far as the posterior surface of the fascia trans-
 versalis.  To glide the bistoury of Pott, or the common blunt-point-
 ed, or in fact any straight bistoury whatever, into the ring, in order
 to divide its internal border  near its lower  attachment, and trans-
 versely   from  without inwards, is a still  more  easy and  certain
 method.    I have  found that we  could  in this  manner divide the
 stricture without danger, as largely as was desirable.   In the other
 cases, the repeated divisions, whether by means of the blunt-pointed,
straight, or with the curved bistoury, inasmuch as one  or two lines
of depth only are  sufficient to  each incision, are,  if I  am  not de- 
INGUINAL HERNIA.
677
ceived, calculated, in whatever direction they may be made, to ren-
der the lesion of the  epigastric  artery a thing almost impossible.
  IV.  If in spite of all these precautions, the artery should have been
wounded, two instances of which were  related to Gunz at Paris, the
evidence of which was established on opening  a dead body by Ber-
trandi,  and  by the  cases related by  Richter, Le  Blanc. Hey,  A.
Cooper, Scarpa,  Lawrence, M.  MacKay, &c,—what  is to done ?
M. Lawrence states  that he found the epigastric branch completely
divided in an individual operated upon for strangulated inguinal her-
nia, but in whom death took place from another cause.   In a second
case the hemorrhage was suspended in consequence of syncope, and
the patient was  perfectly restored.   But the question to be ascer-
tained is, whether the blood in this case really did make its escape
from the epigastric artery.  I myself have seen in the dead body of
a patient, who died in consequence of a penetrating wound of the
abdomen, an  entire  division of  this vessel, the hemorrhage  from
which had been quite inconsiderable, and had ceased spontaneously.
It might be  possible,  therefore, that a wound of this description might
repeatedly occur, without the surgeon being conscious of it.   A lig-
ature applied, as recommended  by Bogros, upon the root of the artery
itself, or through the interior of the wound, by means of the  various
instruments proposed by Arnaud, Schildner, Richter, Desault,  and
many  other practitioners, would be attended with too much difficulty
in its execution, and  offers too slight a prospect of success to justify
our attempting it.  It is  better to pass beyond the  ring a sort of
chemise or  small sac of fine linen, the bottom of which has  been
filled by soft lint, in  order to  constitute it  into a tampon, by means
of which we afterwards  make compression upon the parts from be-
hind forward,  or  from  the  peritoneum towards the integuments.
This is the process which Hey and Boyer adopted in the successful
cases related by them, or which are given upon their  authority.
  V. Reduction.—The  best  mode of effecting the reduction of the
liquids or matters enclosed in the intestine, is  to embrace the whole
mass of this latter with  the palm of the hands, and  to make gentle
pressure upon  it, until it is  almost  entirely emptied.  It is  at the
groin particularly that we should be  on our guard not to force the
viscera in  between  the  peritoneum  and the fascia transversalis,  or
into the substance of the parietes of the abdomen, for it is in this de-
scription of hernia that Le Dran, Callisen. La Faye, Sabatier, Pelle-
tan, Lassus, Hasselbach, M. Delmas, M. Lawrence, and myself have
noticed the accident  I  have  mentioned.  Nor do  we anywhere
also so often  find bridles behind the ring, caused by an  adhesion
of the appendix of the cascum, a prolongation of the epiploon, or  an
accidental band, &c.  If was at that  part  also, that  Hey found the
sac divided  horizontally  by the epiploon into two  distinct  pouches,
one anterior, containing only serum, the other posterior and enclos-
ing the intestine.   There  is scarcely  perhaps any  anomaly what-
ever, or any of the  degenerescences of the digestive  organs, or the
epiploon, which has not  been found in inguinal hernia.   This is the
variety, moreover,  which  has presented those appendicula, in the
form of fingers of a  glove, which have been noticed by Ruysch,  F.
de Hilden, Mery, Littre, and M. II.  Larrey, as well  as  by myself, 
678           NEW ELEMENTS OF  OPERATIVE SURGERY.
and which were connected with a point more or less higher up upon
the ileac portion of the intestine.  When the inguinal hernia is an-
cient, and of excessive volume, as it  is rare that the displaced vis-
cera, under such circumstances, have not contracted adhesions with
each other, which are difficult  to be destroyed, or that they have not
in some respects become agglomerated together, in such manner as to
represent in certain cases a mass purely fleshy,  an attempt at reduc-
tion in such cases is not always  advisable.  If in such cases the
hernial envelopes have been divided  throughout their whole extent,
we confine ourselves  to returning the  free  portions into the belly,
while  the rest is left externally ; the whole is then covered with com-
presses, saturated with emollient liquids, which, with the horizontal
position  to be preserved by the patient, vyill gradually bring  back
the organs as far as to the ring, if not  even into  the interior of the
belly itself.
   VI.  It is in  this modification  particularly that Ravaton,  Monro,
Boyer, Scarpa, and MM. Cooper, Crawther and Lawrence recom-
mend,  as J. L. Petit did,  that we should divide the stricture without
opening  the sac, after the method  which  M. Raphel supposes he
had invented, but which he had only combined with a suggestion of
Bell upon debridement in  general.  In such cases therefore we make
an incision of some inches in length at the root of the tumor, in order
to arrive gradually upon the neck of  the sac without opening into it.
A canulated sound  is  immediately introduced between this neck and
the ring, which latter is then divided in conformity  to the rules laid
down above. As soon as  the strangulation is destroyed, the reduction
is to be undertaken immediately, if the viscera  can  be pushed  back
into the belly without its being  attended with too much difficulty.  In
the contrary case  we confine  ourselves to returning those which
readily yield to our  efforts, while  the  remainder are supported or
kept up by a suspensory or a bandage,  which is  to be arranged in a
proper manner.  If, after having divided the ring, the strangulation
should  continue, we should perforate the neck of the sac and then
introduce into  this opening  a  blunt-pointed bistoury, and divide  it
with the usual  precautions.  In ordinary cases  after the  organs are
reduced, the sac  is  sometimes so movable and so little adherent
that we  are enabled  to  detach it  as it were,  and to gather  it in
mass,  as Garengeot  says, to impact it in  the  ring or to excise it.
Without recurring again to what I have  said on this method in
the preceding pages,  I cannot omit remarking that if we decide upon
adopting it in  inguinal hernia,  we ought at least to assure ourselves
previously of the situation occupied both by the vas  deferens and the
spermatic vessels.
   VII. Another method still has been  proposed for inguinal hernia,
viz: that of M. Colliex.  The  incision  is made  from  the exterior to
the interior, from the  beginning  to the end of the operation, in such
manner  as to  divide the sac  completely  in the same  way as the
skin.   The incision in the first place is directed upon the whole length
of the inguinal canal, in order  to open  into  the sac on a line with the
external ring;  but  this kind of incision, which presents no advantage
and which immediately   strikes  one  by  its  dangerous  character,
was doubtless  suggested  in consequence of those serious accidents 
INGUINAL HERNIA.                     679
which are no longer possible at the present day.  No one in fact  at
the present time has any apprehension of wounding the intestine  in
seven cases out of ten, but  which M. Colliex states he  has  seen  in
many hospitals, (Revue Med., 1834, t. IL, p. 20.)
  VIII. When the case is one of strangulation in the scrotum itself,
there is no need of making  the incision of the hernial envelopes  as
high  up as has been mentioned, but it ought to descend lower down.
If on the contrary the case  is one of incomplete hernia, the  incision
ought to be made to reach from the outer third of Poupart's ligament
down to the root of the scrotum only.  In this case our object is  to
divide successively the two layers of the sub-cutaneous fascia, the
aponeurosis of the external oblique muscle, some of the fibres of the
internal oblique, and finally the entire anterior wall of the inguinal ca-
nal.  In inguinal hernias strangulated by the posterior ring, the incision
should also be prolonged upwards to a great extent; but if they are
not incomplete, it  is advisable to prolong the incision moreover to a
point sufficiently near to the extremity of the lower part of the tumor.
If the case is one of hernia of the tunica vaginalis, we ought to avoid
as  much as possible giving this extension to  the opening of the sac
below, inasmuch as the testicle, after the reduction, would have too
much tendency to  escape from its position.  In cases of hernia of the
cascum, the bistoury should rather be directed upon the inside than
upon the outside of the tumor.  After the sac moreover is laid open,
we ought, should the viscera be found adherent or incapable of being
reduced in consequence ofthe age ofthe hernia, to  confine ourselves
to  destroying  the obstacle to the progress of the matters, to  keeping
the belly in a  depending position, and to  bringing back gradually the
displaced organs towards the ring.   (See Hernia in General.)
  IX. Upon  the  supposition  that we have  operated  in order  to
remove the  difficulties produced by a strangulation of the spermatic
cord, there would, after the debridement was effected, be  nothing
more to do.   In cases of hydatids and adipose tumors we must have
recourse to the excision of the  morbid parts, and the  same must  be
done in respect to  lymphatic ganglions, if any of these should chance
to  be developed in the inguinal  canal.  A more embarrassing case is
that in which  the testicle is present in the interior itself of the ring.
It almost always happens in such cases  that  the testicle "is changed
either in its conformation or structure.  If it  is excised the patient
finds himself deprived of an  important organ;  if we confine ourselves
to  the removal of the strangulation and  the testicle cannot descend,
the same accidents may be reproduced.  Before  the  operation it
would be so  much the more difficult to pronounce with certainty,
inasmuch as a true hernia in a person with but one testicle (chez  un
monorchide) may  manifest  itself, in the  place of the  one gone,  an
example of which has been met with by Fages.  It remains therefore
for the practitioner to determine by the arrangement of the parts and
the particular circumstances  in which   the  patient  is  placed,  the
course which  it is  most advisable to pursue.
  X. As to the  mode of dressing and the treatment  subsequent  to
the operation, they should be based upon the  same principle as after
the operation  for hernia in general.   I would only add  that there is
no operation in which immediate union presents fewer advantages or 
680          NEW ELEMENTS OF OPERATIVE  SURGERY.

exposes to as many inconveniences as it does  in strangulated inguinal
hernia.   It is  true that it succeeds sometimes, as the practice of AI.
Serre and that of the English surgeons sufficiently establish the fact •
but the transformation of the sac into a vast abscess, leading  to a
supposition  of the reproduction of  the  hernia and  producing  effu-
sions of pus into the belly, and  those cases of erysipelas and purulent
collections mentioned by authors, and  especially by M. Key, what
are they imputable to unless to those attempts at union  by the first
intention ?   In cicatrizing the wound by second  intention we avoid
this description of accidents, and we have moreover, as I have men-
tioned, a possible chance of closing up the hernial canal radically.
If after the operation of inguinal hernia, the inflammation  and the
suppuration ascend along the cord towards  the  supra-pubic canal,
spreading under the skin of the iliac region rather than in the direc-
tion towards the thigh or perineum, this result is owing to the fact
that the sub-cutaneous fascia, which is very adherent below, becomes
thinner and thinner as it ascends upon the  abdomen.
  C. In woman  the operation  for inguinal hernia is attended with
but very little difficulty;  and  we proceed  moreover in the  same
manner as in man, except that we have nothing to fear from the lesion
of important organs before we reach the sac.  From the absence of
the spermatic cord the only thing to be attended to in these cases is,
to respect the intestine and the epigastric artery, which moreover
are avoided by means of the precautions mentioned in speaking of in-
guinal hernia in man.  If in this hernia the ovarium should be found
to be arrested  at the ring or to have descended into the labium majus,
examples of which have been  related  by Priscien, (Peyrilhe, Hist.
de la Med., p. 715,)  Veyrat,  Pott, Lassus, Haller, Lallemand, M. De-
neux,  and M. Cruveilhier, (Arch. Gen. de Med., 2e ser., t. IV., p. 275,)
prudence would  suggest, however slightly the accidents may appear
to be connected  with its presence in the ring, that we should  pro-
ceed to its  removal.  The  uterus, fallopian tube and bladder should
be reduced in the same way as the intestines, or would not fail to
become subsequently  reduced of themselves.
  [Inguinal Hernia.—Sir Astley Cooper was so  fortunate in one of
the  last cases  that received  the aid  of  this illustrious surgeon, as to
effect  the cure of an  artificial anus resulting from the mortification
of the gut of an  inguinal strangulated hernia, which suddenly made
its appearance in  a woman  aged thirty-four, at the third month of
her pregnancy,  and  for which  the surgeon operated.  The fecal
matters, which at first flowed through the wound, soon resumed their
natural course, when  the parts  healed up kindly.   (Provincial Med.
and Surg. Journ., April  15, 1841.)
  Radical Cure of Inguinal Hernia by the Seton.—Dr. Moesner
(Medicinisches Correspondenz Blatt, in the Journ. des Conn. Med.-
Chir. de Paris, Janvier 1, 1846, p. 28,)  has already obtained a  radi-
cal  cure of inguinal hernia  in four cases, by the following process:
he raises up the  scrotum and sac by means of a thread, introduced
on  a species of sonde a dard of his invention,  which is  a curved
canula, mounted on  a hollow  handle, and terminated by  an olive-
shaped button of  the  size  of a pea, and which is also hollow.  By
means of a stylet adapted to the curvature of the instrument, and  a 
CRURAL  HERNIA.
681
needle, furnished with a thread, which he can pass through the olive
button, he causes  the skin of the  invaginated  scrotum, and  also the
inguinal canal and the skin of the  belly, to mount up into the interior
ofthe canula.  The  thread, having been introduced with the precau-
tions necessary to avoid wounding the viscera, is left in the wound
to perform the duty of a  seton, and not for the purpose of retaining
the invaginated scrotum,  as in the methods denominated those  of in-
vagination.  The inguinal canal is then compressed and the patient
kept in bed eighteen to  twenty days, a period usually sufficient to
cause an adhesive inflammation of the whole  canal, after which the
thread is withdrawn.  The compression  is afterwards continued as
a precautionary measure, by means of a truss,  for some weeks.
  Large Reducible  Hernia.—Mr. Bourne, of  Bath, (Eng.) success-
fully operated for inguinal reducible hernia on the right side, of very
large size, which had existed for fourteen years in an old sailor aged
seventy, paralyzed  on that  side.   The firm and  old adhesions  of
thickened omentum  to the sac, allowed of no other resource for the
strangulation than  the operation.  (Lond. Med.  Gaz.,  May,  1846,
pp. 882, 883.)
  New species  of Inguinal Hernia.—At  the  sitting of the Royal
Academy of Medicine of Paris, December 8th, 1840, (Arch. Gen. de
Med. de Paris, 3e  ser.,  t. X., 1841, pp. 107,  108,) our author, M.
Velpeau, exhibited an anatomical  specimen presenting a new variety
of inguinal hernia, which  authors have not mentioned.  The intestine
instead of descending through the  inguinal canal, has made a passage
for  itself through an aponeurosis, between the outer  border of the
rectus abdominis  muscle and the umbilical canal.  T.]            ,

                Article II.—Crural  Hernia.

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

                       § I.—Anatomy.

  The crural canal, constituting a communication between the inner
side of the iliac fossa and the inguinal depression, represents a sort
of funnel, the base of which would be situated in the pelvis and  its
point on the thigh.  Its upper opening, measured transversely, has a
diameter of  about two inches, and in women frequently two inches
and a half.  From before backwards, in its greatest diameter, it has
but from ten lines to an inch, when it afterwards becomes narrowed
as we  recede  from its  middle portion.   In  its  natural  state it is
divided into  two portions  by the crural vessels, in such manner that
from the iliac  fossa we  should reach, it through two small fossas,
which  I would denominate crural fossettes, one  internal, the  other
external, and which must not  be confounded  with  the inguinal
fossa:, which I have mentioned farther back.   Its internal portion,
which is the largest, forms what has been specially described  under
the name of the  crural ring.  Its limits on the inner side  are the 
682
NEW ELEMENTS  OF OPERATIVE  SURGERY.
 concave border of Gimbernat's ligament; in front, Poupart's liga-
 ment ; behind, the ilio-pectineal crest;  and on the outside, the crural
 vein, the  artery of the  same  name, and the epigastric artery,  ft
 usually contains a lymphatic ganglion separated from the vessels bv
 a sort of partition, a prolongation ofthe fascia propria, and some adi-
 pose cells which almost  completely close it up.   It is this crural rin^
 which gives passage to  the viscera in crural  hernia.  Also its exter-
 nal portion is triangular;  in its ensemble, then, it constitutes a large
 and nearly elliptical opening, formed above by the abdominal branch
 ofthe ilio-pubic  band, below by the iliac branch of this same band and
 by other intercussating  fibres.  Its internal angle is rounded  off by
 Gimbernat's ligament, while its external angle continues quite acute.
 The femoral vessels divide it into two unequal halves.  In the direc-
 tion  of the thigh this  opening is continuous  by  means of a fibrous
 expansion with the whole extent of the crural canal, under the form
 of a cone, the apex of which terminates upon the external tunic of
 the vessels, on a line with the entrance ofthe saphena into the  crural
 vein.   The  walls  of the crural canal are  formed  by the femoral
 aponeurosis.
   Viewed on the outside this aponeurosis is found to be wanting; its
 superficial layer passes in front of the crural vessels, and assists,  where
 it attaches itself at its  apex very near the supra-pubic spine, in con-
 tributing to the formation of Gimbernat's ligament.  It is triangular
 or falciform, and one ofthe borders, viz.,  the superior, is attached to
 Poupart's  ligament.   Another, which is  the  external border, is  its
 point  of origin.   The third, representing a  species of arcade, cir-
 cumscribes the upper  and outer part of  the inguinal opening  of the
 fascia lata.  The inguinal opening of the crural canal, the internal
 and  lower half of  which resembles rather a gutter, has an oval form
 with its large extremity outside or below, and its point  at the  exter-
 nal border of the ring of the obliquus externus muscle.  Viewed in
 the direction of the pubis, this opening is  turned round at first into a
 semicircle to the outside  and below, in order to mount up afterwards
 from without inwards, and then from below upwards, as if its point
 of termination was about to glide under its place  of origin; in such
 manner, in fine, as to form in its totality a spiral  convolution, and to
 make its axis fall obliquely from within  outwards, upon the antero-
 posterior axis of the thigh.   As lamellar tissues, which are a sort of
 attenuation of the fascia  lata, fill or shut it up  in quite a solid manner,
 many  observers have  been induced to believe that it does not in re-
 ality exist:  but in taking the saphena for our  guide we always meet
 with it, provided we leave out  of consideration the reticulated  mem-
 brane  or species  of cribriform  layer which conceals  its  shape.   The
posterior wall of the crural canal is formed by the deep-seated layer
 of the fascia lata.  Its external side, which is about two inches and
 a half long, and oblique from above downwards, and from without in-
 wards, is made by  the separation ofthe  two layers of the fascia lata.
 Its internal side, which  does  not, properly speaking, exist, extends
 only  from the pectineal crest, or Gimbernat's  ligament, to  below
 Poupart's ligament.  The notch of the  superficial layer of the apo-
 neurosis replaces it in this direction.  Its lower orifice leaves un-
 covered a portion  of the vein, and incloses  deep-seated lymphatic 
CRURAL HERNIA.
683
ganglions, and especially cellular tissue, which unites the sub-cuta-
neous fascia to the sub-peritoneal fascia.  This canal, which is an
actual continuation ofthe iliac fossa without the viscera, peritoneum,
infundibulum and fascia propria which occupy that, passes under the
internal half of the femoral arcade, and is  directed towards the thigh,
forming a passage, whose anterior wall is to a  great  extent wanting
in order  to  receive the saphena  vein, and ultimately becoming con-
tinuous below with the sheath of the sartorius  muscle.   It is thus
easy to comprehend  how matters effused  into the abdomen, between
the  peritoneum and  the  aponeuroses, may be  transported into the
groin, produce an infiltration of the limb, and give rise to abscesses
by congestion, which might mislead to the supposition of a hernia or
some other tumor.

              "' § II.—Formation of the Hernia.

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

 bly divide it.  A second variety, which is more remarkable, is the
 one which I have already indicated, and in which the epigastric ar-
 tery is seen to arise from the obturator, at more than  an inch distant
 from  the external iliac, as has been  noticed by M. Hesselbach and an
 instance of which I have also met with.  There can be no doubt that
 in this case the crural hernia  would be found upon the  outside, and
 the same thing would take place if the vessel in question  took its
 origin from the hypogastric, as I have seen it do.  A  much  more
 dangerous arrangement  still would exist if the hernia should form in
 persons who have at the same time  two epigastrics, one originating
 from  the iliac and the other from the pelvic artery, as  was seen in
 the individual whom I mentioned  above.  In  man  especially, the
 neck  of the sac  would  then have  the pelvic  epigastric on its in-
 side,  while the  iliac epigastric  would be on its  outside,  and the
 spermatic  cord  in  front.   Another  anomaly  is  the one,  for the
 knowledge of which we  are  indebted to M. Michelet, that is, where
 the internal  circumflex  of the  thigh arises from  the epigastric it-
 self.  The artery in this case might be found in  front  of the  body
 of the hernia, cross  it  obliquely from without inwards, and reach
 the abductor muscles  of  the  thigh.   But  the variety  which is
 most  frequently mentioned, is that  in which the obturator  and epi-
gastric arise by a common trunk from the external  iliac.  It is in
fact the most frequent.  The examinations which I have had it in my
 power to make of it on  several  thousand  dead bodies, either in the
hospitals, amphitheatres of dissections, or at the school of practice, do
not permit me to  assert that it is met with  in one case  out of three or
five or even ten, but only once in every fifteen  or  twenty instances.
It is an arrangement, moreover, which  is much more simple than is
generally supposed.   Before birth, the obturator artery arises almost
constantly by two roots, one  from  the hypogastric,  the  Other  from
the epigastric.  But by the law, the epigastric root is soon  oblitera-
ted, while the hypogastric continues, and forms in fact the vessel.
When the contrary takes place, the anomaly in question is noticed.
Many practitioners have supposed that in such cases, the neck of the
crural hernia would  have the  epigastric artery upon the  outside, and
the obturator in front and within, in such  manner as to be almost
completely surrounded by an  arterial circle.   Even if this were pos-
sible,  it would at  least be a very rare  occurrence.   These arteries
take their respective  position  a  long time  before the  period of any
hernia whatever.   As the  epigastric  trunk  is  placed between the
peritoneum and Xhe fascia transversalis, or the ligament of Poupart,
the obturator, should it arise from it, would  be  necessarily situated
in the  substance  of the fascia propria.  To reach the  infra-pubic
opening,  it would be necessary that  it should follow the lower semi-
circumference of the crural ring.   The viscera in  escaping, and
thereby necessarily crowding it  backwards  almost unavoidably, do
not appear to incur any risk of bringing it upon their anterior sur-
face.   Up to the  present time, moreover, I am not aware that there
is any positive evidence from examinations of the dead body, that
it has been wounded  during the operation, though many persons have
stated that this result has taken place in  those who continued to sur-
vive.   For the reason alone, that the iliac  artery on arriving at the 
CRURAL  HERNIA.
685
 ring, divides this opening into two halves, and that the epigastric ar-
 tery is given off from its inner or anterior side, there must necessarily
 exist a point which has but little resistance  upon the outside of the
 latter vessel.  In directing the finger on this point, we soon perceive
 in fact that it is  possible to pass by that route from the interior to the
 exterior of the belly, from whence it would appear to result, that her-
 nia might sometimes take place  on the iliac side of the epigastric
 vessels.  We might therefore admit the  possibility both of an exter-
 nal and  of an internal crural hernia.   An instance has been related
 by M. Cloquet, and another was shown  to me by A. Thompson.  It
 is true that Arnault, and the greater part of the pathologists  of the
 last century, together with Sabatier and M. Walther, do assert that
 the intestine in coming  out of the abdomen, passes  from without in-
 wards, over the anterior surface of the prural vessels, and they  con-
 sequently leave  it to be inferred that the  epigastric artery remains on
 the inner side of the neck of the sac ;  but on this point they confine
 themselves to bare assertions, and there is no  evidence to show that
 they have positively ascertained the fact  by dissection.
   II. Femoral hernia is not enveloped in  as many tissues as  bubono-
 cele.  We find  here nothing more than the peritoneum, the fascia
 propria, the fascia superficialis, and the  integuments.  Moreover, it
 is in that intermediate layer which lies between the skin and serous
 envelope, that  we  meet with  those lymphatic ganglions, sound or
 diseased, hypertrophied, indurated, or  congested in any way what-
 ever, or inflamed or in a state  of abscess, with those hydatid cysts
 and  those inflamed and cold or congested abscesses, which  some-
 times surround a crural hernia, in such manner as to render  its diag-
 nosis so  difficult and the  operation so  delicate.  It was in  this  part
 doubtless that the pus accumulated in the two  cases of cold or con-
 gestive abscesses mentioned  in the thesis of  M. Bayeul, and which
 led to the supposition of the existence of  a hernia.  It is in this layer
 also that we find the veins which return from  the integuments of the
 abdomen as well as their corresponding arteries, and it  is here  that
 are seen those  adipose tumors and growths of every description
 which I  have mentioned while speaking of hernia in general.  As to
 the saphena  vein, though situated in  this  intermediary layer, it is
 always  crowded behind and below the tumor.

                    §  III.—Strangulation.

  The opening which gives passage to  a crural hernia, is so firm and
 solid, and the tissues which receive and envelope it  at the thigh, op-
 pose to it in general so great a degree of resistance, that it rarely ac-
 quires any very considerable  size. Being obliged  to  traverse an
 orifice which is  deeply situated; liable to be arrested in  the  canal
 itself, either above, at its middle, or at its  femoral orifice ; or  to make
 its escape through a rent in Poupart's  ligament, as has Ifcen seen by
 M. J. Cloquet, or through an opening  in  Gimbernat's ligament, as I
have seen in the pelvis of a woman operated  upon by M. Laugier,
the diagnosis of  the existence of thi,s hernia in persons who are fat,
and particularly  in women, in whom it is so common, is frequently
attended with a good deal of difficulty.  It is readily  perceived that 
686          NEW  ELEMENTS  OF OPERATIVE  SURGERY.
the same arrangement renders the operation more laborious than that
of inguinal hernia.  It is moreover owing to this narrowness of the
passages, and to their  slight degree of distensibility, that this hernia
becomes strangulated with so much facility, and that it is so difficult
of reduction as soon as the slightest degree of constriction exists.  In
its interior have been found the same  organs as in the inguinal, to-
gether with the same  anomalies and  the same pathological altera-
tions.  Though experience establishes  thatfts sac, which is general!v
thinner than in oscheocele, does not usually contain but a very small
quantity of serum, frequently a few drops only, and sometimes even
none  at all, there  are  nevertheless examples in which it  has been
found there to the  amount  of over several  ounces, that is to say, in
great quantity, as  I have seen  in  supra-pubic hernia.  In a woman
whom I operated upon in 1830  at the hospital of La Charite, the  sac
contained nearly two tumblers  of serum.  M. A. Berard (U Experi-
ence, X.  III., p. 216) has since noticed  a similar fact  in a lady who
died from hernia of the fallopian tube.   It is moreover in the vicinity
of crural hernia that I  have most frequently met with those adipose
layers and  productions which have been described farther back.

                        §  IV.—Operation.

  Kelotomy at the fold of the groin requires still greater precautions
than that at the scrotum; in  the first place, because we arrive more
suddenly down on  the sac when there is no complication, and because
in the contrary case wre  have to distinguish  all the  diseases which
may be developed in  this  region, from hernia properly  so called;
again, because the sac being  very thin and frequently confounded at
its external surface with the cellular tissue, is readily opened before
we are aware of it, and because from its containing scarcely any se-
rum we may easily wound the  intestine; in the last place, because
we have to act at  a great depth and to divide the  stricture through
parts which are almost invariably surrounded with vessels.
   A.  The division of the integuments  should, or almost always may,
be made in the direction at the same time of the inguinal groove and
the great diameter of  the tumor.  A simple incision in general  an-
swers ; nevertheless if the hernia should  be of large size, and diffi-
culty should exist  in laying bare its neck, there would be no objec-
tion to our transforming this  first division after the  manner of Boyer,
into a T incision, by directing the bistoury subsequently upon its up-
per or lower lip, according as there  may exist a necessity of laying
bare the inner or the outer side of the  canal.  Moreover there would
be no  reason why we  should in all cases  make aT incision, the
vertical branch of which should be directed upwards, as is recom-
mended by M. A. Cooper, in order to run  no risk of wounding the
internal saphena vein.   The  crescentiform incision would be prefer-
able.   The fl-ucial incision moreover, as recommended by Pelletan,
and which Ddpuytren frequently used, can  be but seldom required.
If however we should decide upon having  recourse  to it, the appre-
hensions of the English surgeon in regard  to the  saphena, need not
in any  manner deter us, for this vein is always  placed below and be-
hind the hernia. 
CRURAL  HERNIA.
687
  B. After the opening of the  sac it is, as Boyer remarks, as rare to
find ourselves enabled to reduce the organs without debridement, as
it is common to see the intestine excoriated, ulcerated, or even per-
forated  in the portion which sustains  the strangulation.  The con-
striction being in general caused by the  cutting border of the falciform
or cribiform fold of the fascia lata, it is the circle of the intestine em-
braced by these two parts which we must first examine/  The ulce-
ration existed in this place in the patient operated upon in my presence
by M. Wessely, also in the women whom  I have operated upon
myself,  and upon several  of the individuals operated upon by MM.
Roux, Boyer and Lawrence, as I have  already mentioned.
  C. It was in consequence of the dangers of debridement in crural
hernia,  especially, that dilatation was suggested.   Upon the outside
it was said you will have the epigastric artery, above the spermatic
cord, and on the inside, you will wound the obturator, if it originates
from the epigastric.   Happily these dangers are infinitely less in prac-
tice than in theory.   Sharp divided the stricture upwards and  out-
wards, and though he operated upon a  great number of persons, we
do not find that he wounded the supra-pubic artery, the ligature upon
which,  moreover, he considered a  very easy matter.  Pott divided
upwards, and the  spermatic  cord  does not  appear to have been
wounded by him.   From the time  of Gimbernat most  surgeons
divide upon the inside, and there  is nothing to show  that by this
mode the infra-pubic branch  has been frequently  wounded.   It is
sufficient, however, that the thing is possible, to induce the practitioner
not to neglect the means by which the wounding  of this artery may
be avoided  with the greatest  certainty.  M. Jacquier  d'Ervy  and
M. Pigeottes de Troyes (communicated by M. Jacquier, 21st March,
1839,) have each lost a patient in consequence of wounding this ves-
sel.  The process of Sharp is evidently the most objectionable of all.
Dupuytren, who appears to have reproduced it, and to have followed
it in his practice for a long time, has modified it in such manner  that
it no longer possesses the same dangers in such cases.   It was upon
the external border ofthe opening at which the saphena vein enters,
that is, at the opening of  the  fascia lata, that this surgeon directed
the cutting edge of his  convex bistoury, in such manner that he
divided the tissues  from before backwards, or from below upwards,
and in this manner destroyed the strangulation before arriving at the
place in which the artery to be avoided is situated.
  I. The debridement upwards and slightly jnwards is  unattended
with any danger in women when there is no anomaly in the vessels.
In man, on the contrary, it might expose to the risk of wounding the
spermatic vessels.   Arnault states that he was witness  to an opera-
tion, in  other respects well performed, but  from which the patient
nevertheless died in consequence of a hemorrhage from the spermatic
artery.   Scarpa especially endeavored to demonstrate that it is almost
impossible  to divide in this direction without meeting with the acci-
dent pointed out by Arnault.   Experiments  undertaken by this last
mentioned surgeon, in  presence of Bassuel and Boudon, would go to
show, in fact, that by dividing Poupart's ligament from below up-
wards to the extent of two or three lines, we almost inevitably wound
the spermatic artery.  Accident or other circumstances have misled 
688
NEW ELEMENTS OF OPERATIVE SURGERY.
these surgeons.  In the first place, it is incorrect to maintain that the
spermatic  cord lies immediately upon the bottom of the groove of
Poupart's ligament.  Some fleshy fibres and cellular tissue, occasion-
ally in considerable quantity, usually separate them.   It is not under
the border of the internal oblique  muscle that the cord passes, but in
fact between its fibres.  Moreover, this ligament, at  the inner half of
the ring, has a height  of four to five lines.
   II. Outwardly we could divide it entirely, which is never indis-
pensable, without incurring any risk. Though when  there was given
from six or eight to ten lines to the  debridement, the  danger which
gave so much alarm to Arnault, Scarpa and other modern surgeons,
could not  be denied,  at  the present day, when we generally give
it only from two to three  lines, such  fears have, in fact, but  very
little foundation.   The case related by M.  Lawrence would furnish,
moreover,  an additional proof of this, for, notwithstanding  the com-
plete division of the external border of the  obliquus externus muscle
in the case  which he speaks of, the  cord was not touched.  Moreover,
can it be that an artery of such little importance as the one which
comes from the epigastric to the scrotum, or the spermatic artery itself,
can be of a nature to give rise to so serious a hemorrhage ?  Besides, it
would be upon the  outside ofthe peritoneum that such division would
be made, and upon this  supposition we cannot perceive how there could
be any difficulty  in obliterating it, either by a suture, ligature,  tam-
poning, or  compression.  Finally, was not Arnault himself deceived?
and was it in fact the  hemorrhage which caused the death of the in-
dividual in the case which he mentions ? Were there not in this case
some particular circumstances which he had omitted to mention ?
   III. Gimbernat, whose  labors had already been made known by
M. Parcet e Venuales in  1807, having studied with more attention
than his predecessors the anatomical arrangement of these passages,
considered that we might avoid the danger of the process of Sharp,
and the lesion of the cord, by dividing the stricture  inwardly.  His
object being to separate, by means of the curved or straight bistoury,
the triangular  expansion which has  received  his name, from the
lower border of Poupart's ligament, he directs his instrument to the
upper part of the inner semi-circumference of the  ring, and  after-
wards carries it obliquely inwards and downwards, as if for the pur-
pose of reaching the  pubis by following the course of the  external
border of the inguinal  canal. In this manner, he says, we are certain
to avoid the epigastric artery and the spermatic vessels.  Scarpa
and  the moderns assert that we  might also, in the same  manner
avoid the obturator when it comes from the supra-pubic artery, pro-
vided the incision followed in some respects the same turn which the
vessel makes ; but to obtain this advantage it would be necessary not
to divide the ligament of Gimbernat  transversely upon its middle
portion, and still  less to do  so obliquely, from below upwards, while
grazing the body of the pubis,  as a considerable number of French
surgeons appear to have understood this direction, and as they daily
practise.  Though  this method may  be  preferable, what  we  have
said above of the varieties which  have  already been frequently
noticed in  the epigastric and obturator vessels, proves that it  does
not completely secure  us from  hemorrhage.  We should even incur 
CRURAL  HERNIA.
689
considerable risk of this result, if the epigastric artery, or one of the
epigastrics when there were two of them, should be found situated
upon the inside of the neck of the sac,  and also in the event where a
large sized branch  proceeding from the internal iliac vein or from the
hypogastric vein, should also ascend upon the inside of the ring, in
the manner pointed out by M. Manec in  his thesis, and as M. Me-
niere also states he has seen it.
  IV.  In  this respect the  debridement upwards is perhaps the one
which would  protect  us, with most certainty, from  the  danger of
wounding the arteries, especially if, as  is  recommended by M. Ma-
nec, the bistoury should be directed to the upper angle of the ring,
in order to make a partial division of Poupart's ligament perpendicu-
larly to its axis.  r Some persons, moreover, object to the debridement
inwards from  its exposing  us  to the risk of wounding the womb and
the intestines in pregnant women, or the bladder when it is distended
with urine.  Hey, who cites a case of  this last description and who
had never wounded the epigastric artery nor never seen it wounded,
concludes therefore, notwithstanding the remarks of A. Cooper, that
it is generally better to incise  the ring upwards and outwards, in the
manner practised by Sharp;  but it is evident that a careful surgeon
may always avoid, without any difficulty, both  the bladder and the
uterus, so that did  not the  process  of Gimbernat involve other dan-
gers the objections of the skilful practitioner of Leeds  Would  be of
very little value.   The circumflex artery  arising, by some anomaly,
from the epigastric or vice versa, in such  manner as to pass in front
of the hernia,  is the only one which we are utterly unable to escape
wounding, unless we should have had it in our power to recognize it
while laying bare the sac ;  fortunately, as its division would be  made
very near the outer surface, it could easily be seized and tied.
  V. Process ofthe Author.—In conclusion, the most certain method,
in these  cases, of  effecting the  debridement without danger,  is to
incise successively, on several points, the  sharp  border of the crural
canal,  to the extent only of one to two lines for each division.   The
anatomical arrangement of this passage, and the operations which I
have already performed, induce  me to believe that the constriction
there is always caused by the free border of the falciform process,
the concavity of Gimbernat's  ligament, or the  neck of the sac, and
scarcely ever  by the  upper ring, properly so called; so that it will
almost always be found that we  can effect the debridement required,
by incising the lower opening of this passage  upon one  or several
points, and without the necessity of directing the bistoury into the ab-
domen. Having almost constantly divided  the stricture in this manner
since 1831, I have  been enabled to satisfy myself that it is the most
certain process.   The blunt-pointed bistoury  directed  from within
outwards or transversely, and from below upwards, upon the fibrous
ring, would have to divide the entire base  of the falciform fold of the
aponeurosis and the  whole thickness of Poupart's ligament, before
running any risk of wounding the epigastric vessels.   It is the only
kind of incision  which has nothing to fear from anomalies in the
course  of the  arteries, and  which enables  us, without any difficulty,
to obtain a debridement of  from six lines to an inch in extent.   If
this opinion is not adopted, the debridement will have to be performed 
690           NEW ELEMENTS OF OPERATIVE SURGERY.

according  to the rules laid down by the surgeon of Madrid, or if we
are no longer  disturbed  by the apprehension of wounding the sper-
matic cord, it  may be made from below upwards.
  D.  An operation of kelotomy performed at La Charite in the time
of Boyer, proves, nevertheless, that the debridement inwards may be
followed by hemorrhage.   Arterial blood flowed in large quantity
through the wound, and an assistant was obliged to apply his finger
to the bottom  of the ring in order to make compression from  behind
forwards.   Boyer immediately had recourse to the introduction of a
small linen sac passed as far as into the iliac fossa, and which being
afterwards filled with lint served as a substitute for the finger of the
assistant.   This application was not removed until at the expiration
of five days.  The hemorrhage did not reappear, and the patient was
completely restored.  To assert what artery had been  divided would
in my opinion be a difficult thing.  Was  it  the  obturator coming
from the epigastric ?  It must  then  be admitted  that  it had  passed
above the neck ofthe hernia.   Was it the epigastric or an abnormal
epigastric,  as  in  the  case  of Lauth ?   Was it not rather a small
branch which  is usually sent off by the supra-pubic artery behind the
symphysis,  and which,  from  having been more  developed than
usual, had  given  rise to this accident ?  On this point we can form
conjectures only.
  E. The  relations of the vessels  with  the neck of the sac  would
render a mistake so dangerous, if, as has been seen by Richter and
A. Cooper, an inguinal  could be mistaken  for a crural hernia, and
vice versa, that the surgeon should never lose sight of them.  A crural
hernia pushed  back, in front of the inguinal canal by ancient cicatrices
in the  fold  of the groin, as has been seen by M. Boulu,  might so
easily deceive on this subject,  that a debridement outwards as in
bubonocele would  expose the  epigastric  artery.   M. Roux, who
divides the stricture like Gimbernat, considered himself very fortu-
nate in ascertaining by dissection  that  an inguinal, which he had
mistaken and operated upon for a crural  hernia, had protruded upon
the inside ofthe artery, and was in  fact direct or internal.  Had  not
Pelletan in a similar case discovered his  error  upon arriving at  the
viscera, it is quite  probable that chance would not have served him
so good  a  turn and that the epigastric  artery  would have been
exposed to the greatest danger.
  F. Two other methods of debridement for crural hernia have been
proposed by MM.  Else, Colliex and  A. Cooper; I have already made
some mention of them while speaking of hernia in  general, and of in-
guinal hernia in particular.  In the  first of these methods the surgeon
incises the  aponeurosis  of the external oblique  above and  in  the
direction of Poupart's ligament, separates  the cord which he pushes
aside  inwards and upwards,  penetrates down to  the peritoneum,
glides  from behind forwards, or from the interior to  the exterior a
curved  sound between the neck of the  sac and the ring, and  then
divides the  stricture without danger and to as  great an extent as he
desires.  In the second method it  is also necessary to divide  the
aponeurosis ; but the debridement is effected from the exterior to the
interior, though without  opening  the.  sac.  These  two processes,
which were tested in several  instances  in  the hospitals of London, 
CRURAL  HERNIA.
691
before M. Colliex had spoken of them, are attended with  too  many
inconveniences  to  be generally adopted or to make it necessary for
me to describe or to refute them in detail.  To make the debridement
directly backwards,  as  is recommended by M. Verpillat, and who
advises that we should  incise  the pelvi-crural  band, would answer
only in certain cases, and would moreover be attended with too
manv difficulties to be adopted in  practice.
  [Femoral Hernia with complication of foreign bodies and worms,
in the practice  of  Dr. Proudfoot  and  Professor Mott.—A  remark-
able case of femoral.hernia,  complicated with foreign substances
occurred to Lawrence Proudfoot, M. D., of this city, (private com-
munication from the author.)   This surgeon thus describes it:
  " On the 24th March, 1842, at 5 P. M., I was called to visit a maiden
lady, aged 72 years, whom I found much debilitated, and laboring un-
der symptoms of strangulated  hernia, with hiccup and stercoraceous
vomiting;  upon inquiry and examination I found a tumor of the size
of a hen's egg, covering  Poupart's ligament on  the left side, and  a
general tumefaction of the abdomen.   By the application of pound-
ed ice the tumor was  somewhat diminished in  size, and I employed
the taxis as long as a reasonable  hope and the  safety of my patient
admitted, but the extreme tenderness of the parts, the prostrate con-
dition ofthe patient, and a continuance of those distressing symptoms
attendant  upon  a strangulated hernia induced me to delay the means
for her relief no longer, and at 10 P. M.  the same evening I pro-
ceeded with the operation.  The intestine had  been strangulated
about eighteen hours.   There was an unusual quantity of fluid in the
sac, for a femoral hernia; the intestine was in a good state to return,
and the adhesions were slight and easily detached.   I  divided the
stricture, and after gently drawing  down the intestine, returned ft and
closed the wound with a suture and adhesive straps, applying a firm
compress and a T  bandage.
  " In two hours the bowels were freely moved, and all  unpleasant
symptoms disappeared.   On the fourth day I dressed the wound and
it had all the appearance of doing  well.  On the sixth day, a profuse
discharge  of healthy pus  took place, and at least a  pint was dis-
charged in twelve hours, which  continued for three.-or. four  days,
gradually diminishing.   On the twelfth day after the operation the
patient complained of a sensation  in the wound as of the fluttering
of a bird,  and on  removing the dressings, the  poultice which had
been applied the night previous  was tinged with a bilious yellow
color, and flatus escaped from the  wound, which was followed  in the
course of the night by a fascal discharge.
  " On the eighteenth day after the operation, on dressing the wound
I  discovered a  black projecting point, and with a dressing  forceps
removed a piece of a sewing needle one inch and a quarter long.
  "An artificial  anus was the result, and  a considerable portion of
the contents of the bowels daily escaped from the  opening,  over
which firm  pressure was constantly made, and  enemata daily used
to solicit discharges by the natural outlet.
  " The artificial opening continued about  three months, at the expi-
ration of which time it was permanently healed, and the discharges
took their natural course. 
692
NEW ELEMENTS OF OPERATIVE SURGERY.
   "The calibre ofthe intestine at the aperture was much diminished
 and there was at times a considerable  collection of fascal  matter in
 the colon immediately above  it, but by gentle pressure and manipu-
 lating with the fingers the contents passed through the stricture, and
 the bowels were relieved.
   " The needle is believed to have been in the  system twenty years.
 as  at that time her family remembered of her having swallowed
 the two parts of a  broken needle ; the  piece taken out of the wound
 was the pointed extremity, and about two-thirds of the entire length.
   "She had  very frequently and  for a  long period  complained of
 pain in  her left side, but sought no other relief than was afforded by
 grasping the side  and applying  pressure.  There was no swelling
 or attendant  symptom whereby an abscess could be  detected or sus-
 pected,  and I know not how to account for the immense discharge,
 other  than being the contents of a psoas abscess evacuated through
 the agency of the needle."
   Dr. Proudfoot refers to  the case of Dr. Mott, as follows:
   " I  may here make mention of  a case which occurred in  the prac-
 tice of my preceptor, Dr. Valentine Mott, while I was  his private
 pupil, and in  which operation I had the great privilege of  assisting.
 I believe the  case has not  been published, and as it may be consid-
 ered as  bearing some relation to the above, I will take the liberty of
 alluding to it.   The patient was a lady of middle age and of robust
 constitution, who had a femoral hernia.  The operation was perform-
ed by Dr. Mott, in  his accustomed cautious manner, and with great
elegance.  The wound was closed by sutures, adhesive straps, com-
 press  and bandage, and on dressing it on the fifth day, a worm about
four inches  long, of the  species  of the lumbrici, was  discovered
coiled up below the sutures and between the lips of the wound. The
intestine was in a good state to  return, there was not the slightest
appearance of sphacelus  or ulceration, and if it had been  acciden-
tally wounded  by the knife, would have been  immediately discov-
ered by the  bowel becoming collapsed previous  to its being re-
turned.
   " The records of cases furnish examples where worms of this spe-
 cies get  into  the cavity of the peritoneum, or  insinuate  themselves
 into the  bladder or vagina:  the wound healed very kindly and the
 patient had not an unfavorable symptom.
   New  York, July  21th,  1846.                           L. P."

                Article  III.—Umbilical Hernia.

                   § I.—Anatomical Remarks.

   The  umbilicus during life presents itself in its relations to hernia.
 under two very different  conditions.   Before  birth  it is a slightly
 resisting ring,  which is  traversed at the same time by  the three
 umbilical vessels and that prolongation from the  bladder, known
 under the name of the urachus.
   A.  As soon  as  the infant  is separated from its mother the parts
 contained in  this ring contract and consolidate, and thus cease to fill
 it up entirely; hence it is through this part that the intestines, during 
UMBILICAL HERNIA.
693
the first months of life, have a constant tendency to make their escape.
Subsequently the ring itself, in its turn, contracts, closes up, and be-
comes attached upon the fibrous nucleus formed by the remains ofthe
vessels; in such manner that the whole finally presents itself under the
aspect of a very dense inodular  cicatrix, so that in adults umbilical
hernias no longer take place  at the  ring,  properly so called, as in
infancy, but by protruding through the aponeurotic fibres  at the dis-
tance of some lines upon the outside of it.
  B. We are to understand ourselves, however, when it is said that
umbilical  hernias  do  not take place through the  ring  in adults.   If
we reserve the name  of exomphale to  the hernia  alone which pushes
in front of it the cicatrix by dispersing or destroying it as  it were, it
is true that it is to be  met with only in infants; because, in fact, it is
not possible, excepting in so far as the various branches of the ompha-
lo-placental cord have not yet been enabled to become consolidated
together and  transformed into a fibrous nucleus.  But if it be con-
ceded that there is an umbilical hernia in every case where an organ
has  escaped through the ring, which during  foetal life was  filled up
by the expansion of the vessels, there can be no doubt that such her-
nia is possible,  and that it has been observed at every period of life.
If in this case the cicatrix is usually deviated either to one or the other
side of the tumor, this is owing to its always being a little less adhe-
rent upon some points of its circumference than upon others.  Scarpa,
however, relates that in one of his patients the sac was divided into
several compartments by  the ligaments of the  umbilical nucleus.
This fact,  which I was  the first to call  attention to among us. has
been since confirmed by the researches of  M. Despres (Arch. Gen.
de Med., 2e ser., t. IV., p. 275,) and M. Cruveilhier.   Moreover, as
in this place there is no circle or canal naturally  open, it is very na-
tural that  hernias should take place almost as frequently through a
rent in the aponeurosis or linea alba as through the umbilicus  itself;
so  that Monteggia, who was  one of the first to declare that hernias
in this region might take place external to the ring, was wrong only
in stating that to  be constant which is  only very frequent.
  C. However this may be, the viscera at this part never protrude
except  through a simple ring.  There  is  no umbilical  canal, and
scarcely an instance  is known in which the arteries have  preserved
their calibre up to adult age.   According to the assertions  of Haller,
Boerhaave, and some  others, the case is different with the vein, whose
permeability, however,  is so rare an occurrence that it need not dis-
turb us during the operation.
  D. As it is through  a simple circular  opening, and not along  the
track of a canal,  that the viscera  make their  escape,  umbilical her-
nia, unlike inguinal or crural, has no fibrous or serous sheath to stran-
gulate it at a certain variable distance  from its root.   The  peritoneal
layer which is found here, does not possess, or but very imperfectly,
the  characters  that belong to it in hernias of the upper part  of the
thigh,  and it is to exomphale  that the remarks I have made on the
subject of the absence of  the sac while treating  of the operation in
general, are rigorously applicable.  It is this which Lassus states that
he found destitute in one case of envelope, or surrounded by such as
were so attenuated, that he opened into the intestine, which had passed 
 694          NEW ELEMENTS  OF OPERATIVE SURGERY.

 through a rent in the epiploon.   Upon the strength of a fact furnished
 by M. Pierquin, (Journ. de Prog., X. XIV., p. 253,) this author also
 maintains that umbilical hernias are destitute of a sac.   The external
 surface  of  this  membrane,  in  fact, is  so  closely united with the
 surrounding tissues, that it  is impossible to separate it from them.
 It  was  nothing  else,  in  tiuth, but a  portion of the peritoneum
 which originally lined that part of the  ring, which the organs have
 pushed  before them  in forming  the hernia.  Having  become en-
 larged by simple distension, in the manner of a cell of lamellar tissue,
 which is dilated in order to form a cyst,  and not  by the progression
 of, or traction upon, the abdominal peritoneum,  properly so called,
 this sac cannot, as in the groin, be distinguished from  the other tis-
 sues.
   E. A peculiarity no less important in practice is this,  that in umbi-
 lical hernia the  sac scarcely ever contains  any serum, from whence
 it  happens  that  it is  almost  constantly found  in  immediate contact
 with the viscera.   I would remark,  however, that this law has been
 laid down  in too peremptory a manner.  In a woman  whom I ope-
 rated upon  for strangulated exomphale, there were  more than six
 ounces  of reddish colored serosity in the interior of the hernial en-
 velopes, and  about three ounces were discharged in another case
 which was operated upon at  Tours, in 1818, by Pipelet, and to which
 I was a witness.
   F. The organs which may be displaced in order to form an umbil-
 ical hernia, are, according to the order of their frequency, the epiploon,
 transverse colon, small intestine, stomach, cascum, sigmoid flexure ofthe
 colon, liver, and duodenum, and even the pancreas.  These different
 organs  are  sometimes  found in so great  a number, and under the
 form of a mass so considerable, that their containing'pouch becomes
 extremely attenuated, and to so great a degree even as  ultimately to
 burst, as took place in  the patient mentioned  by  Boyer, and whose
 life could not be saved by the operation.  In more than one instance
they have beeh seen, in the foetus especially, totally deprived of enve-
lopes or only covered  by an  exceedingly attenuated membrane.
Mery and Balzac have  cited examples of this kind.  I myself saw
one at Tours in 1819, in the practice of Mignot, andM. Dupuy show-
ed me another in  1835.
  G. It sometimes happens, but not always  as some facts at first in-
 duced me to think, that the digestive  tube is  sometimes lodged du-
 ring the first periods of foetal life, in the root of the umbilical cord.
 Now if the  intestines do not return, or only partially return before
the end of pregnancy, the infant is  born with an exomphale.  The
 viscera in such cases would be enveloped only by the attenuated tu-
nics of the omphalo-placental cord, and  it may be easily conceived
 that distension might rupture this feeble partition in such manner  as
 to expose the hernia completely naked.    The same thing might also
 happen in the first hours or during  the  first days of birth.  Under
 this point of view therefore, there is an essential difference  to  be
 made between umbilical hernia in the foetus, that of the first periods
 of extra-uterine life, and that of adult age.  In the first, it is the na-
 tural tunics  of the cord which  form the  sac  and the envelopes; in
 tie second,  the cicatrix having had time to form, the organs in pro- 
UMBILICAL HERNIA.                     695
truding have become capped (se coiffer) with the peritoneum, integ-
uments and intermediate cellular tissue ; in the third, the sac, obliged
to pass between the vessels  or upon  the  side of the  common  knot
which unites them, is moreover, in the majority of cases, compelled to
lacerate the interior of the ring  or  the neighborhood  of its circum-
ference, in order to work out a passage for itself, and to arrive  ulti-
mately under the skin in gradually distending the corresponding per-
itoneum.   An umbilical hernia, though very  large, having been  kept
reduced, disappeared spontaneously in a new-born infant mentioned
by M. Requin, (Gaz. Med., 1832, p. 640.)  In  an infant which I saw in
1837, in company with M. Delafolie, it had diminished to the extent
of four-fifths of its dimensions, after a compression continued for two
months.  A ligature  applied incautiously upon the root of the cord,
effected its strangulation in the cases related  by M.  Poussin, (Journ.
de Med. et Chir., X.  I. et IL,)  Burret, (These, No. 162, Paris, 1833,)
and Brun, (Ibid., No. 238, Paris, 1834.)
  H.  Frequently also the  hernia takes  place, in fact, at some dis-
tance  from the umbilicus or in its periphery.   So long as it is  distant
only one or two lines from this  cicatrix, its texture,  and the relative
arrangement of its parts have nothing special;  but  if it is ever  so
slight  a distance beyond  this,  its  sac and  cellular  lining present
themselves  under different characters.   The  peritoneum,  which is
then, more movable and  less adherent, admits of being drawn upon
and displaced without  difficulty, and the hernia  is  found  in this
manner to be  furnished with an unequivocal  sac.  From the fascia
propria having partially  regained  its laxity and thickness, the sac
maybe distinguished from the external tissues, while fatty matter and
serum  sometimes accumulate within  its  lamellae.   Frequently also
adipose tumors or hernias have  been  found to develope  themselves
around the umbilicus. Fardeau mentions an instance of one which was
prolonged as  far as  the interval between the two layers of the sus-
pensory ligament of the  liver.   M. Bigot, M. Ollivier  d'Angers, and
Beclard, as well as Heister, Petsch, Morgagni, Kli'nkosch,  Pelletan,
Scarpa, M. Lawrence, M.  Cruveilhier, and M. Berard, have  also
met with them, and  I  myself have frequently noticed others which
had their root in the infra-peritoneal  layer.   I have  dissected one
also which was prolonged into  the  falciform fold ofthe umbilical
vein.   It was probably above this cicatrix, that the hernia mentioned
by M. Cloquet, which had pushed before  it, while un-lining it, the
hepatic ligament to procure in this manner a sac, made its escape.

                       § II.—Operation.

  The operation for umbilical hernia is considered to be  exceedingly
dangerous, and in reality appears to be more so than that for ingui-
nal or  crural hernia.  If we admit the fact, it is owing perhaps to
our operating near the stomach or diaphragm, to the circumstance
that the organs contained  in the tumor are in immediate relation
with the principal viscus of digestion, or because  we  do not decide
upon the employment of the cutting instrument until at too advanced
a period of the disease.  Another reason would also be found in the
fact that after the operation it is impossible to place the wound in a 
696           NEW ELEMENTS OF OPERATIVE SURGERY.
depending position, and that the pus and other extraneous fluids are
thus compelled to fall back into the peritoneal cavity.
   A. If the tumor is of moderate size it may be laid bare by a simple
incision parallel to the direction of the linea  alba.   In the contrary
case  there is no  reason, whatever Scarpa may say on  the  subject,
why we may not have recourse  to the T, or even  the crucial in-
cision, but I prefer the one in the form of a  crescent.   In ordinary
cases we give sufficient length to this incision to go a slight distance
beyond the hernia at  its two extremities.   In  this hernia the integu-
ments are, in general, too much stretched, and would have too much
difficulty in puckering up to require us to take the precaution to raise
them before dividing them.  We incise them, therefore, from without
inwards in the same way as for laying bare an  artery. The subjacent
layers are also to be divided in the same manner, that  is to  say, by
drawing the bistoury over them with all the caution requisite.
   B.  As it is not possible to isolate the sac, we could not lay it bare
without difficulty if we persisted in dividing  layer by layer,  and en
dedolant, on one point only, the  layers which separate  it  from the
skin.  As, however, it is frequently very near the cutaneous envelope
and does not usually contain but a very small degree of serum, we
cannot  observe too great  degree  of precaution in cutting down
upon it.  Tumors of different character may produce embarrassment
here as well as elsewhere.   In  a woman whose case was communi-
cated to the Academy, I was obliged to cut through a fibrous trilo-
bate mass as large as the fist  before reaching  the  intestine, which
was found strangulated at its pedicle.  From  the moment when the
bottom of the incision presents  the appearance of being formed only
by a  very thin  lamella, the instrument is to be used  with a still
greater degree of  caution; as soon as the  layer which we have
divided is found to be separated from the parts which it covers by the
slightest interval, the grooved sound is then to be glided underneath
it, for we  have now probably arrived in the  sac.  There will now
no longer be any doubt upon this subject should the slightest quantity
of liquid make its escape, or if,  as has been observed  in most in-
stances, some adipose pelotons show a disposition to protrude through
the opening.   Once arrived in the interior of  the  hernial  sac, the
bistoury, guided by the forefinger, if we make use of the blunt-pointed
bistoury, or by the grooved sound in the contrary case, immediately
enlarges the first orifice  and makes a free division of all the envel-
opes of the tumor.
  C. It is  in umbilical hernia,  especially, that  we meet  with the
epiploon, and in such manner  as to form  here,  in some instances, a
mass  of considerable dimensions.   We must not, however, allow
ourselves  to be imposed upon  by appearances.   We almost always
find below it a noose of the intestine, which it envelopes in forming
for it a sort of second sac.   For the same reason we find in this her-
nia, more frequently than  in others, that the  intestine has lacerated
its epiploic investment, passed through it and  become strangulated in
the ring itself which is the source of this hernia, and thus placed itself
in immediate contact with  the surface of the  sac, properly so called.
   D.  After the opening of the  sac therefore, the first thing to be at-
tended  to  is to  identify  the arrangement of the displaced  organs. 
UMBILICAL HERNIA.
697
We therefore search with the finger for some portion of the epiploon
which is  not  adherent, in order  to  raise it up and to unfold and
spread  it out upon one of the borders of the wound.  The intestine,
if there is any of it in  the tumor, is then seen below it.   In  those
cases in which this simple displacement of the parts will allow of
their reduction, we must  immediately proceed to this step.  Hey,
and since him almost all operators, have strenuously insisted that the
reduction should commence with the intestine, and not with the epip-
loon as recommended  by Pott.  For the  intestine being  the last
which has come out, and  being situated at the greatest depth, and,
in general, more easily pushed back, is the part, in fact, which ought
to be first reduced.   Nevertheless if a contrary arrangement should
be met with, and the return  of the epiploon be attended with less
difficulty  than that of  the intestine,  I  can see no  reason why we
should persist in following the rule laid down by Hey.
  E. When the intestine is gangrened, a circumstance which must
be rarely met with, inasmuch  as it is known, that mortification  is in-
finitely more tardy in its development in hernias of the large intestine,
and in  entero-epiploceles, and  especially in hernias purely epiploic,
than in enterocele, we ought  to recollect  that  stercoral  fistulas, or
an artificial anus at the umbilicus can scarcely ever be cured.  This,
as Scarpa has clearly established, is owing to the fact, that there is no
membranous infundibulum formed  behind the umbilical circle and at
the  expense of the sac.  How, in  fact, could such  a formation take
place, since the serous  surface of  the  hernial pouch closely adheres
to it, and  is wholly formed  and developed  out of the umbilicus, and
has not been borrowed from, the interior peritoneum, as  it is in ingui-
nal  and crural hernia ?  Gangrene  or  any perforation  whatever,
therefore, of the intestine appears to require, under such circumstan-
ces, that we should have recourse immediately to invagination or to
the  suture, and not attempt to establish an  artificial anus.   I would
remark, however, that  in the  operation performed by Pipelet, and
which I have mentioned  farther  back,  a gangrenous eschar of the
intestine was removed, and that a fistula was established, which being
left  to itself, ultimately closed up  and cicatrized perfectly.   It  was,
moreover, in a  case  of umbilical hernia that M.  Chemery-Have
successfully performed  invagination, and the remarkable  operation
related  by Scarpa, who quoted it  from the Ancient  Journal of Me-
dicine.
  F. The debridement, when necessary, is so easy and  attended
with so little danger, that we scarcely ever dispense  with it.  We
may make it  almost  upon this or that point indifferently.  Cases
might happen  in which it would be possible to wound  the liver, the
umbilical  vein or arteries, and even the urachus: but this could not
happen, so to speak, unless we did it purposely, or  unless such ano-
malies existed as are too unusual in  such cases to render them the
subject  of apprehension.  We must not, however, forget the abnor-
mal  veins mentioned by MM. Manec and  Meniere, or those that I
have myself mentioned.  Though there may not  be any more per-
ceptible advantage in incising  the umbilical  ring below than in any
other direction, I  see  no inconvenience in  following the advice of
authors  who  recommend  for  greater security, to direct the incision 
698           NEW ELEMENTS OF  OPERATIVE SURGERY.

upwards and to the left.   The danger from incising largely of weak-
ening too much the walls of the belly, and exposing the patient to an
almost certain return of the disease, might, it seems to me, be easily
avoided, if in place of making a single incision, and giving it half an
inch in depth, we  should  make three or  four of them  at different
points, and of one or two lines only in extent, as  was done by me in
the patient whom I operated  upon with M. Gresely, and in  several
other instances ;  if,  in a word, we should adopt  the  multiple  de-
bridement in umbilical hernia, in the same manner as  in  those which
I have already  spoken  of.
  G.  Although there may not be  in exomphale,  properly so called,
any strangulation by the neck of the sac, and that  the ring which pro-
duces  the constriction is almost constantly smoothly  rounded, pru-
dence, nevertheless, dictates that we should examine before proceed-
ing to the reduction, what may be  the condition of that portion ofthe
intestine which has  been strangulated.   If we should decide upon
operating without laying bare the whole tumor, after the method of
Franco, Rousset or Pigray, we should particularly  recollect that the
ring is scarcely ever distinct from the neck ofthe sac, and that unless
we combine the process of Bell with this method, as M. Raphel ad-
vises, we  should not  succeed in destroying the strangulation without
penetrating at the same time into the interior of  the sac.  This pro-
cess,  therefore, is still less adapted to the umbilicus than  to  any
other region, notwithstanding  Scarpa  recommends it with a degree
of complaisance,  and  that M. A.  Cooper had recourse to it success-
fully in two instances under such circumstances.
  H.  Immediate reunion might be attempted with more advantage
and  facility after kelotomy at the  umbilicus than  in hernias at the
groin.  The  sac formed to some extent of a single layer, has less ten-
dency to roll up on itself, and is much more inclined to readapt itself
to the points which it  primitively occupied.   I would not venture how-
ever to recommend it,  because in my view the radical cure after the
operation is so  much the more probable in proportion as the method
of secondary intention is  more completely carried into execution.
Moreover, this  is a part of the body where the organs stand most in
need of being supported by a moderate compression after they have
been  returned  into the  belly, and  this without  doubt because  the
opening which  had given passage to them is usually very large, and
especially because it forms a ring  or perfect circle, which traverses
perpendicularly the abdominal enclosure.

          Article IV.—Ventral  and other Hernias.

                               §  I.
   Hernias at the linea alba, whether above or below the umbilicus,
differ too little from those which I have just examined to make it
necessary for me to  enter into a special description of them.  Should
they  become strangulated,  moreover,  a circumstance which  has
scarcely  ever  been heard of, the  operation in these cases would
have nothing special.  The same  must be said of  the hernia at the
flank, or lumbar hernia, mentioned by J L. Petit, seen in one instance 
VENTRAL AND OTHER HERNIAS.
699
by MM. Cloquet and Cayol in a man 75 years of age, in another in-
stance by Lassus in a man who had one on  each side, and also by
Pelletan in a woman who had her belly at the  same time covered over
with ruptures.  Nor do ventral hernias, properly  so called, that is
to say, those which are formed external to  the linea  alba and the
umbilicus and other natural openings of the abdomen, whether by a
simple rent in the aponeuroses and muscles, or  in consequence of a
cicatrized  wound in those  parts, as  has been seen by Schmucker,
Desault, Lassus, M.  Richerand, M. Anderson, and many  others,
scarcely ever strangulate.   If their strangulation does take place, it
is at least almost always practicable  to reduce them by means ofthe
taxis, position, and other modes pointed out in the preceding articles.
We find however that M. Key or M. Bransby Cooper, could not suc-
ceed in reducing a strangulated ventral hernia until  after having had
recourse to the operation as well as to the debridement,  and that the
patient was thereby restored.   A hernia which had been  caused by
a rupture of the umbilicus during parturition, thereby became, says
Bartholin, so enormous that the  poor  woman (Bartholin dans Bonet,
t. IV., p. 410) was compelled to conceal it in  a bag.  Upon the sup-
position that all those varieties of tumors should require kelotomy,
we should proceed in the same way as in cases of  umbilical  hernia,
and they would require  no other precautions than those which would
be indicated by the track of the  epigastric, lumbar or anterior iliac
artery.  M. Paccini,  (Gaz.  Med., 1833, p. 409,) in  a case in which
he was obliged to operate for strangulated hernia below  the  umbili-
cus, succeeded  perfectly.   M.  Goyrand, (Press. Med., X. L, p. 487,)
operating in a similar case, was  no less fortunate.  A woman whom
I operated upon with M.  Ducos, in whom  gangrene had already
taken place, and where  the hernia was situated at four inches below
the umbilicus, also ultimately got well.  A hernia in the epigastric
region, which I  saw in a young girl, ulcerated and caused death, but
the child was consumptive.   The operation was completely successful
in the  case of M.  Castellacci,  (Bull, de Fer., X. V., p. 175,)  though
the  hernia was strangulated by a cicatrix.  The same result took
place in the patient of M. Aussandon, (These, No. 276, Paris, 1834,)
though the hernia was congenital and upon the inside of the antero-
superior spinous process of the ilium.

                             §H-

  Obturatic Hernia, (Hemic Obturatrice.) examples of which have
been mentioned by Arnault, father and son,  Duverney, Garengeot,
Verdier, Pipelet, and Eschenbach, and which  has since been seen by
MM. A. Cooper, W. M... (Gaz. Med., 1833, p.  576) Gadermann, (Rev.
Med., 1825, t. IV., p. 128,)  J. Cloquet, (These  de Cone, 1831, p. 107,)
H. Cloquet, (Journ. de Corvisart, X. XXV; Bull, de la Fac, t. III.,
p. 80,)  Hesselbach, Marechal,  (Journ.  de  Prog., X. X., p. 247,  and
t. XVI., p. 256,) and several others, (Ibid., X. I., p. 263,) and which is
a description of hernia which also appears to  be sometimes liable to
strangulation, would be  somewhat more embarrassing.   The open-
ing which gives passage to it being then transformed  into a  sort of
canal, whose  pelvic orifice is formed by the pubis outside and above, 
700
NEW ELEMENTS OF  OPERATIVE SURGERY.
and by the obturator membrane throughout the rest of its  extent, is
found to  be circumscribed by the tissues of the  obturator muscles.
Tn such cases the viscera are surrounded anteriorly by the pectineus
muscle,  behind by the adductor  magnus, and within and above by
the adductor brevis  and adductor  longus, (moyen adducteur.)   An
obturatic hernia being  obliged to  traverse these different muscles or
to separate them apart in order  to  make  its way  to the inner and
lower extremity ofthe fold ofthe groin, does not appear to be capa-
ble of becoming strangulated, except at its entrance into  the obtura-
tor canal, as in fact was the case  in the instances  which have been
related.  It would appear  that inasmuch as the infra-pubic artery
must always be found  upon its outer side, either above, below, or di-
rectly outwards, the debridement  would have to be made at its inner
semicircumference.  I  am aware that this  operation was  first at-
tempted by Garengeot on one of  his patients in the Rue de Sepul-
chre, and more recently by a German  surgeon in a case nearly simi-
lar.  But when we reflect upon the parts through  which we should
have to divide to reach the seat ofthe  strangulation, and also on the
depth at which the obturator membrane is situated, and the  difficulty
of ascertaining the  situation  occupied by the vessels, and  also  that
the bladder or vagina might be wounded, I may be well permitted to
dispense with recommending it.   In the case of M. W. M., the stran-
gulation was upon a  small portion of the ileum, and in that of MM.
Marechal  and J. Cloquet,  it was an  entero^-epiploic hernia. Gan-
grene had cribbled the sac  in the  case  of M. Gadermann, and in an-
other patient we perceive  that the artery was found on the inside
and in front.  I have seen a fine example of this hernia in a specimen
carefully prepared by M. Demeaux, an interne  of the hospitals.  In
this case, the vessels being  situated to the outside, and in front, might
have been more easily  avoided ;  but the intestine, which was a  por-
tion of the ileum, was  so entirely concealed  by the obturator exter-
nus muscle, that it would have been impossible to have recognized
the hernia during life.

                             §  III.

  Ischiatic, perineal, vulvar, and vaginal hernias are alike exclu-
sively comprised within the domain of  pathological surgery, properly
so called, and have no  relation to operative surgery, excepting so far
as the taxis, position, and containing means methodically applied, con-
stitute the principal remedy.  The eighteen instances also of perineal
hernia, collected by M.  Jacobson, (Bull,  de Fer., X. XIV., p. 207,)
are not the only ones that science possesses, and the so called vagi-
nal hernia operated upon by  M. Petrunti, (Gaz. Med., l>s-,>6, p. -\2l,)
might have been only  a recto-vaginal  abscess.
   [Internal hernial  sacs, of  the  appearance of pediculated pouches,
filled with  fascal  matter, have been found (Edinb. M d. and Surg.
Jour., Oct. 1, 1845, p.  282) in considerable numbers on the rectum
and  colon, and were ascertained to have been true hernias of the
mucous through rents  of the muscular  coat of the intestine.
  Diaphragmatic Hernia.—M.  Battalia  (Giornale  delle  Seienze
Mediche, della Soc.  Medico-Chirurg. di Torino,  Nos.  April,  Mav 
VENTRAL AND  OTHER HERNIAS.
701
and June, 1845; also Gaz. Med. de  Paris, X. XIIL, 1845, Sept. 20,
pp, 600, 001) furnishes a remarkable  case of a patient aged twenty-
nine, of robust constitution, who, owing apparently to a debauch and
violent efforts  in coition  the  night before, was seized with all the
symptoms of strangulated hernia, as stercoral vomiting, &c, except
the absence of diffused abdominal tension,  distension and pain ; the
abdomen being in fact rather drawn in, or sunk or flattened in the di-
rection towards the vertebral column  ; and affected only with a slight
burning pain in the right iliac region.   This dilemma  and mystery
for the diagnosis, was unravelled in a few hours by the autopsy, when
the entire stomach, the great  epiploon and a part of the transverse
colon were  found  lodged in  the  thoracic cavity, having reached
there through an oval-shaped  transverse rupture in the diaphragm to
the right of  the oesophagus, and which was three and a half by two
and a half inches in diameter.   This had caused  the  strangulation
and gastro-enteritic inflammation, the evidences of which were  mani-
fest upon  the displaced organs, while those of the thorax were per-
fectly sound.  There was on the right  side of the thorax a cicatrix
from a sabre wound, received some  four  years  before; and as the
edges of the rupture were somewhat  hard and irregular, and as con-
siderable adhesions were found between the peritoneum and viscera,
and principally with  the liver, which latter was enlarged, &c, the
editor of the Gaz. Medicate seems inclined to the impression that the
rupture,  contrary to  the  opinion of M. Battalia,  was  ancient and
from the  wound, and not recent.   The editor cites  cases  of con-
genital diaphragmatic hernias, which notwithstanding, admitted of
the ultimate restoration of perfect health,  (Gaz. Med., 1843, p.  192,)
also of tolerable health persisting for years after such  hernias  from
traumatic causes, (Gaz. Med., 1843, p. 776.)
  Statistics and  causes  of hernia.—M.  Malgaigne (Lecons  Clin-
iques sur les  Hernies, fyc,  in 1839-40, Paris, 1841) estimates the
whole number of ruptured persons in France, in 1841, at sixteen hun-
dred thousand, in a population at that time probably of about thirty-
six  millions.   Of these the excess of males to females  is as four to
one.  The most numerous cases are, as is  well known,  among  labor-
ing persons, but we cannot perceive for what reason hernia should
prevail more among the descendants of one race  than another.
Thus the  Celtic or Gallo-Roman races in  the central provinces are
pronounced most liable  to hernia, while those of Brittany and the
Cimbric, Norman, Germanic and Iberian races are peculiarly exempt!
M. Malgaigne also advances  an opinion diametrically opposite  to the
established  one, viz:  (see Op.  Cit. in Arch. Gen. de Med., 3d ser.,
t. XIL, p. 535,) that inguinal hernia, even in women, is more frequent
than crural!   In the work  we  have cited he  appears to  have
furnished much useful systematization to  the subject of bandages or
trusses for hernias, among the infinite varieties of which he gives a
decided  preference  to the English bandage, or  that  invented  by
Samson.
  At Guy's Hospital at London, Mr. P. A. Poland furnishes 42 cases
of hernia from September, 1841, to December, 1842.  Of these 17
were  inguinal and  all in males; 24 crural, of which 19 were  in 
702          NEW  ELEMENTS  OF OPERATIVE SURGERY.

females;  and of 25 strangulated, 19 were operated upon, of which 9
were cured and 10  died.
  In connectior. with this subject the number of cases of strangulated
hernia of all descriptions, treated at Wurtzbourg, from 1S16 to 1812,
was, according to M.  Textor, (Revue  Medico-Chir. de Paris, Jan-
uary, 1843,) 172 ; of which  98 were inguinal, 71 crural, and 3 um-
bilical. Ofthe whole number there were 105 cured by the taxis.  Of
56 operated upon, 32 were cured and 24 died.  Of the 71 crural, (55
were  in  women and only 6 in  men.  Of the 98 inguinal, 85 were
men and  only 13 women.  The  average mortality in operations for
strangulated hernia  at Wurtzbourg, wras 3 out of every 7. T.]
    PART  SIXTH.

ORGANS  OF GENERATION.
                         CHAPTER  I.

                   GENITAL ORGANS OF MAN.

                    Article  I.—Hydrocele.

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

                    § I.—Hydrocele in Man.

  Authors admit  two  species of hydrocele in  man: hydrocele of
the scrotum, properly so called, and hydrocele of the spermatic cord.
Hydrocele of the scrotum comprises two varieties, one by infiltration
and the other by effusion.   Hydrocele by infiltration is no other than
oedema of the scrotum, and should  be  so denominated.  Hydrocele
by effusion, whether it be acute or chronic, has its  seat in the tunica
vaginalis, or in  certain accidental cysts.
  A.  Acute Hydrocele..—I  understand by acute  hydrocele that which
is developed  in the space of a few days and accompanied with in-
flammatory symptoms in the scrotum.   Though common it has gen-
erally been overlooked.   Any external  violence made upon the scro-
tum may produce it.  I have seen two instances of it  after a pro-
longed taxis,  and  the same result produced in three other patients
from the operation for hernia.  It is sometimes caused by the presence
merely of a strangulated hernia.  The same may take place from any
acute inflammation whatever in the tissues of the scrotum ; but it is
nevertheless most frequently imputable to diseases of  the testicle.   I
have met with it as a consequence in every variety of orchitis: thus, 
HYDROCELE.
703
orchitis from external  causes, that from an interruption to the circu-
lation, and also urethral or blenorrhagic orchitis, in fact no variety is
entirely exempt from it.   Acute hydrocele in cases of orchitis being
the most frequent, I shall use that as its type.   Many surgeons have
mentioned it without' apparently attaching much  importance to it;
but no person, I  believe, before M. Rochoux, had maintained  that
"apart from the portion usually very small,  of the  tumor,  which
belongs to the epididymis, the remainder is formed by a peritesticular
effusion which  itself is caused by an inflammation ofthe tunica vagi-
nalis," in the swelling which characterizes the disease  known under
the name  of blenorrhagic orchitis.   I have endeavored  since the year
1833, to ascertain out  of more than 200 cases affected with acute
orchitis, either  at La Pitie, La Charite, or in  private practice, what
is the actual physical or anatomical condition of the tumor.   The
result is a conviction on my part that, in urethral  orchitis especially,
the tumefaction is almost exclusively confined at first to the epididy-
mis or vas deferens, that it then reaches  the  tunics of the scrotum
and testicle, and  finally  that serosity in the tunica vaginalis also co-
operates in producing it in a great  number of cases.   I may there-
fore add,  from  these facts,  that  hydrocele accompanies about  one
half the cases of acute orchitis ;  but M. Rochoux, in affirming  that
in this complaint the hydrocele is  almost  the whole disease  and  the
engorgement ofthe tissues  scarcely anything, has  been most  cer-
tainly deceived.   The epididymis  and  the testicle form in fact, in
general, the third half and  sometimes two-thirds, four-fifths or five-
sixths ofthe tumor ;  the thickened tunics ofthe scrotum also constitute
one part, without counting that in many cases there does not exist any,
or that there is but a very small quantity of serum around the testi-
cle.  When an actual hydrocele exists, it sometimes, though rarely,
forms as  much as one-half or two-thirds  of  the  mass : ordinarily,
however, it makes up from a sixth  to a fourth of the  tumor.   Fre-
quently it is reduced to a thick [?] stratum of a line or two in depth of
liquid around the seminal gland.   What has deceived and what  will
still continue to  deceive on this point is  this, that in acute orchitis
the testicle and epididymis present a proportionate size and consist-
ence altogether different from the normal state.   The first of these
organs, naturally of a soft or spongy tissue, and inclosed in a fibrous
thick shell, being how swollen and dilated as it were by the disease,
and embracing as it were the front part ofthe epididymis, so readily
leads to the supposition  of a collection of liquid that it is almost im-
possible not to  be sometimes deceived by it.   From the unusual ex-
pansion and hardness of the epididymis, which then  has the form
of an egg slightly flattened on its anterior surface,  the testicle pre-
sents the appearance of a fluctuating tumor which is mistaken for the
tunica vaginalis distended by a liquid.
  Having fallen  into this error myself, and having seen very expert
practitioners also deceived in the same  manner,  I  have thought it
advisable  to suggest the means by which we might avoid it, (Diet.
de Med., 2d edit., Art. Hydrocele.)   When there is a hydrocele, it is
perceived that the external wall of the cyst is not obstructed by the
testicle until after we have traversed, while depressing it, a species of
void, cavity or middle portion, manifestly less resisting than the rest. 
704
NEW ELEMENTS  OF OPERATIVE  SURGERY.
It is also perceived that this sensation is communicated upon the sides
as well as on the front part of the tumor, because the tunica vagina-
lis envelopes the epididymis down to its root fully as much as it docs
the testicle.   A  great quantity of liquid sometimes causes the dis-
appearance of the first of these two signs, but in such cases there can
scarcely be  any  room  for ambiguity.  Ancient adhesions might ob-
scure the manifestation of the second sign, but they would render the
other more  clear.   If both failed, it may be said  that  there is no
hydrocele.   I would add, that besides these  signs,  or the transpa-
rency, everything else is  illusory.  Acute hydrocele, constituting
only a superadded symptom in orchitis, does  not require any parti-
cular treatment.   When,  however, it  continues after the resolution
ofthe testicular engorgement, it is advisable to attend to  it.  It is to
this  affection that we  may apply the topical  remedies  which have
been extolled with the view of avoiding the operation for hydrocele in
general.  1 procure  relief to the patient at the  present time by means
of puncture with the lancet.  This puncture, which I first employed
in order to solve  the question of effusion, empties the tunica vagina-
lis,  assuages the  pain, and constitutes the most powerful resolvent
that I  have met with in such cases, however acute the inflammation
may be.   I have now made use  of it  in more than a hundred in-
stances, and  I have never seen it produce any accidents.   MM. Serre
and Lallemand (Petra, These,  No. 65,  Montpellier, 1837,) have also
succeeded  in certain cases of chronic hydrocele by means of these
repeated punctures associated with an antisyphylitic treatment.
  B. Chronic Hydrocele.—Children are less frequently affected with
hydrocele than adults.  In these last it is so common that I have met
with thirty instances in less than a year's time at the hospital of La
Charite.
  I.  Causes.—Irritations  produced in the scrotum, cord or urethra
are the usual causes of this complaint.   Walking, riding, especially
in hot  climates,  and all kinds of friction made by the thighs or by
external bodies against the,scrotum, may also  produce it.   It is thus
frequent at St. Domingo  and Martinique, and the West  India colo-
nies  in  general,  and likewise  among persons who ride.   Another
cause of hydrocele,Which has been too much overlooked, is found in
the diseases of the seminal gland itself.  A great number of persons
in fact  have had an orchitis before having a hydrocele.   Paying
exclusive  attention to the inflammation of the testicles, they sup-
pose themselves  cured when this  ceases to  give them pain, or when
the organ has been reduced to a moderate size.   Several months pass
by without their thinking any more of it.  During this time the slight
irritation remaining  in the scrotum excites an exhalation  from the
tunica  vaginalis;  a  hydrocele  is  slowly developed, and when the
patient  notices it he no longer knows what to attribute  it to.  It is
also  very usual to see the  testicle, and especially the epididymis,
bosselated, hypertrophied, and  double or triple its size, in hydroceles
which  are the most simple  in their appearance, and which seem to
have come on spontaneously.   The progress of a hydrocele is usually
quite tardy.   If some patients  state that they have seen  it develope
itself suddenly, this is  because  they have been almost always uncon-
scious of its first stages, until chance suddenly draws their attention 
HYDROCELE.
705
to it.  As  for the rest, it rarely happens that it becomes developed
in less than a month, or that it requires over two years to fill up the
tunica vaginalis.  Having reached this stage, it may remain station-
ary for  several years.   While, on the contrary, the sac which con-
tains  it  still remains flabby,  it may continue to increase.  Finally, it
invades the entire scrotum, makes traction upon the skin in the neigh-
borhood, conceals and  deforms the penis, and may acquire a consid-
erable volume.
  II.  The morbid anatomy of hydrocele teaches us that the altera-
tions  of the scrotum vary according  as the disease is recent or an-
cient.   They are all referable to tne effused matter,  to the testicle
and the tunics which form the cyst.
  a. The liquid in  hydrocele is usually a  pure serosity, and  of a
slightly lemon-colored  tint, like that of ascitic dropsy.   Albuminous
flocculi  are sometimes  found  suspended in or  mingled with it.  It
was lactescent in a patient whom I operated upon  in  the month of
August, 1836, and perfectly green, or of a porraceous  green in a pa-
tient of M. Salacroux.   M.  Bostock, who has analyzed it, has ascer-
tained that it contains shining colored fibrils (paillettes) whose char-
racter he was not enabled tp determine.  There have been frequently
found in it also concretions, sometimes free, at other times adherent,
of a friable or fatty or  mica-like  matter, or  clots of a  fibrinous and
cartilaginous appearance.   Il; has appeared to me that  such products
resulted from a certain quantity of blood or some perverted albumi-
nous matters.  The chocolate matter which has been so much spoken
of, indicates an ancient hematocele and not  a hydrocele.  Exclusive
of a yellow, whitish, or greenish  color, the changes in the liquid con-
tained in the tunica vaginalis are imputable  to the fact, that  it has
been-mingled with blood, which in the course of time has  decom-
posed or ceased to become recognizable.
  b.  Thickness of the cyst.—The plates or friable bridles of more or
less firm consistence,  and sometimes  cartilaginous  in their appear-
ence, and which irregularly line the interior of the sac, and are often
strongly adherent to it, are also  the  remains of effused blood and
consequently of a former hematocele.  False membranes  that were
purely of an albuminous character could alone belong to hydrocele,
but they are  uncommon,  They are distinguished from  the  preced-
ing in this, that they become organized in the manner they do upon
the surface of the pleura, or are so intimately united with the tunica
vaginalis, that it is next to impossible  to isolate them from it, while
the fibrinous  concretions on the other hand  may be detached with-
out any great  degree  of difficulty.   These  are the  tissues which
sometimes transform the sac into a thick  hard fibro-cartilaginous
shell.   It is nevertheless, true, although this  has  been denied, that the
tunica vaginalis itself and its immediate envelopes then  actually un-
dergo a certain degree of thickening  by becoming blended with each
other.  It is also true that this species of lesion does  not belong to
hydrocele properly so  called, but that it is a consequence  or accom-
paniment of simple or complicated hematocele.  In hydrocele, how-
ever  voluminous it may be. the skin is but slightly attenuated, because
the tumor in  becoming developed draws upon the skin of the neigh-
boring regions.  The same thing takes place in respect to the super-
                                45 
 706          NEW ELEMENTS OF  OPERATIVE  SURGERY.

 ficial sub-cutaneous fascia;  the  dartos, which is the  tissue  we next
 come to, is sometimes attenuated; while in  other cases it becomes
 thicker and assumes  a decidedly  muscular appearance.   The deep-
 seated  sub-cutaneous fascia of the  abdomen, the  divergent sheath
 and that  of the ring, which separate it  from the  cremaster, are
 in  most cases,  wasted,  attenuated, or no  longer  recognizable;  in
 some cases the cremaster is reduced either in part or wholly to the
 condition  of a  fibrous membrane; while in other cases, it is seen to
 be  manifestly thickened.  The prolongation  of the  intermuscular
 fasciae, of the fascia transversalis and the fascia propria, expanded out
 upon the  surface  of  the tunica vaginalis below the  cremaster, are
 more often worn away or thickened from space to space, than infil-
 trated or  transformed into  lardaceous tissue.  The  elevations and
 prominences that are  sometimes presented by the tumor, are owing
 to this, that the fibres of the  dartos,  and of the prolongation of the
 ring, and of the cremaster, have allowed themselves to be elongated
 or separated apart by the distended  tunica vaginalis.  These differ-
 ent tunics, however,  preserve their  pliancy and all the  other  char-
 acters they possess in the normal state.  They are  only altered me-
 chanically, and with the exception of  a  few rare  cases, we do not
 meet here with  any evidence of a pathological process.   It is  from
 having failed to  make a proper distinction between hematocele and
 hydrocele, that a great number  of facts have  been  related in oppo-
 sition to what I here advance.
  c. Testicle.—That  which  is most variable in the  morbid anatomy
 of hydrocele, is the condition of the testicle.   When the  disease has
 begun in the  tunica vaginalis, the  testicle is usually slightly shrunk,
flattened, and wrinkled, and in some cases actually  atrophied ;  if on
the contrary an  orchitis have previously existed, there is  an evident
 augmentation in its volume, but  without any other appreciable  alter-
 ation.   The epididymis, now indurated and  bosselated, is prolonged
 upwards,,  downwards, and  upon  each side, in such manner  as  to
 spread beyond the seminal gland itself.  All this, however, is usually
restricted  to mere  hypertrophy.   Small hardened and whitish-color-
 ed kernels or actual cysts may exist  on the  surface of these organs,
 and present the  appearance of having been developed in the  tissue
of the tunica albuginea.  I  have seen a cyst of this kind acquire
the volume of a nut.  In such cases the  tunica vaginalis will be fre-
quently found to have' contracted  adhesions in the form of bridles,
and in such manner that  its cavity has become divided into several
compartments.   I  have seen many patients at La Charite, in whom
the hydrocele had been constituted in this  manner, of several cysts
 each  containing one  or  two  teaspoonsful of serosity.    I operated
 upon a patient at La Pitie in 1834, in whom the tunica vaginalis had
 been transformed  into an infinite  number of  similar  compartments.
 Is it not one of these conditions which was noticed by  Schmucker,
 (Rougemont, Bibl. Chir. du  Nord, p. 36,)  and which  M. Larrey
 has described under  the name of hydatid or vesicular hydrocele.
 The spermatic cord being more or less  expanded  and compressed,
 is disorganized as it were by the separation of its  constituent parts.
 But in  other respects it is  usually healthy.  Its vessels  are almost
 always contracted, while on the contrary,  the arteries and  veins 
HYDROCELE.
707
which are distributed in the  tissue of the scrotum, are very consid-
erably dilated.   There is also, however, sometimes found here a slight
varicocele.
  III. Signs.—Hydrocele is  recognized by various signs ;  it is gene-
rally developed from  below upwards, or from the  bottom of the
scrotum to the ring of the  external oblique.   At first soft, and as
it were fungous, it ultimately becomes  tense, and  acquires a very
great degree of density -and solidity.
  a. In the first stages the  form of the  tumor  does  not  materially
differ from that of an  hypertrophied testicle.   At a  later period it
becomes elongated and pyriform.  Turned in the direction towards
the abdomen, its apex, which is sometimes slender, at others swollen
in the form of a head  or cylindrical, is prolonged in  some instances
into the inguinal canal, or between the aponeurosis of the external
oblique and the integuments, but it most usually stops  a little below
the ring.   It almost  always  presents a  species of transverse stran-
gulation at the middle  portion of its length, and especially in front;
which gives to it the appearance of a gourd.   When this strangu-
lation is very marked,  and formed for  example by  the ring,  and
when a portion of the tumor has become developed in the inguinal
canal, Dupuytren applies to  it the name of a bisacculated  hydrocele.
Bent into an angle in this manner upon its anterior surface, the tumor
has greater length than breadth ; sometimes, however, it is as it were
crowded down upon itself,  and remarkably augmented in its trans-
verse diameter; frequently, also, it presents prominences on other
points, either above  or below, or upon  its  outer or  inner  side, all
which circumstances are owing to the scrotal envelopes having been
attenuated or  distended in an unequal manner by the tunica vagina-
lis.  It sometimes happens  that it  preserves  the form of a sphere,
either uniform or  bosselated, up  to the  period of its extreme de-
velopment; sometimes also, its  base is  above and  its apex below,
several remarkable examples of which have been seen at La Charite.
  b. The volume of the hydrocele is no less variable than its form.
Limited in certain cases to that of a small pullet's egg, it may in
others acquire the dimensions even of the  head of an adult  In some
cases adherent, as it were, against the ring, we see it in others pro-
longed nearly  as far down as the knee.   It may contain from one tea-
spoonful to two, three,  and even four litres of liquid ;  nevertheless, it
rarely exceeds the size ofthe head of a new-born infant, and usually
does.not contain over from four to ten ounces of serosity.
  c Its weight is generally  less than one would at first be disposed
to think.  Being the same as that of an equal quantity of water when
the hydrocele  is simple and primitive, it  becomes more considerable
when the testicle is engorged, or when some concrete deposition has
been made in the tunica vaginalis.  The lightness of  the tumor also,
is one of the principal signs of its freedom from complication.  These
differences, moreover, are quite natural,  since the  blood  is heavier
than serum, and solid tumors still heavier than  blood, whether the
latter be liquid or coagulated.
  d. So long as the tunica vaginalis contains but a moderate quantity
of liquid, an actual fluctuation maybe recognized.  At a later period,
however, it is sometimes very difficult  to detect  the fluctuation or 
708
NEW ELEMENTS OF  OPERATIVE SURGERY.
displacement of  the  liquid; the exploration, moreover, should  be
made in the same way as in speaking of acute hydrocele.
  e. The pathognomonic sign of hydrocele, and the one which prac-
titioners have for a long time considered the most certain, is derived
from the transparency of the tumor.  To ascertain this, the patient
must be placed in a dark room, or for example, upon a bed with the
curtains  closed, and  the scrotum stretched and raised up, and the
hand  or  any other opaque body applied in the manner of a plate
of wood at its ^border in  front of the tumor, while the surgeon  should
be on one side and  a lighted candle held on the other, in such manner,
finally, that the light cannot reach the eye until after  having  passed
through the hydrocele.   By acting in this manner we perfectly dis-
tinguish, the  transparent contents of the  tunica vaginalis, however
little water it may contain, from the opaque mass  formed  by the
testicle  or epididymis.   It is  possible,  however,  that we may  be
imposed upon in  this case in two ways :  1st. A transparency may be
perceptible though there may be no  hydrocele.  M. Roux states that
he ascertained this in a case in which there was nothing but a sarco-
cele.  This transparency may  exist in  some cases from a  simple
serous infiltration or slight dilatation  of the envelopes of the scro-
tum in children,  and  pale subjects, or in whom the skin is very thin.
If the hand is placed very obliquely, and the fingers are but slightly
shut together, and if the light or the eye are  badly arranged, this
appearance of transparency may be produced by the luminous rays
being reflected back upon  the walls  of the tumor.  2d. This sign is
quite frequently wanting, first, when the  effused  liquid does not con-
sist of pure serosity;  secondly, fluid or concrete blood, and the cho-
colate or reddish colored matter, or  that resembling the lees of wine,
or when lactescent, &c, will not admit of it.  It did  not exist in the
patient whom I operated upon with M. Salacroux, and  in whom the
tunica vaginalis was filled  with a liquid  of a deep green  color, nor
was it found in another patient operated upon  at  La Charite, in
October, 1836, for  a hydrocele  in  which the serosity was slightly
turbid.  Again, it is  but rarely seen when the envelopes of the cyst
have acquired a  certain degree  of thickness, when they have  under-
gone a lardaceous or cartilaginous degenerescence, or plates of fibrin
or albumen have been deposited on  tbe  inner surface  of the  tunica
vaginalis.   I  will, however, add  that its absence  indicates  almost
always either an  opaque liquid or a deep-seated alteration in the tex-
ture of the cyst,  and in all cases a complicated hydrocele or a  tumor,
which belongs rather to the class of hematoceles than to that oi hy-
droceles, properly  so called.   If hlood, in fact, is effused into the
tunica vaginalis, it becomes changed and ultimately forms matters re-
sembling lees of wine, or of a chocolate or  reddish color, or  bridles
and concretions  of all sorts, together with friable  or  fibro-cartilagi-
nous linings in the sac, &c.; but it  may also happen that  the serum
will become  separated  from  the cruor,  that the  coloring  matter
will disappear, and  that at the  expiration of a certain  number of
months or years, there will be no longer anything else in the tumor
but a citron-colored fluid with  the shell  as thick  as it is  hard.  In
other patients the transparency which existed  at first is  no  longer
found during the space of several weeks, but afterwards  reappears 
HYDROCELE.
709
again in a striking manner.  This is a fact which I have ascertained
in three instances, and a similar  one has  been communicated to me
also, by M. Berard, the  elder.  Sometimes  also, the  transparency,
when it has once  disappeared, returns no more.
  It is easy to furnish an explanation  to these anomalies ; and, what
is singular, the clue  to this, so to speak, suggested  itself on the same
day to M. Berard and myself.  I had made it the subject of a lecture
at La Charite in the morning, when this surgeon  informed me that
he had communicated the same idea to the pupils of the hospital of
St. Antoine on  the  day preceding.  The explanation is this, that  a
certain quantity of blood is exhaled and effused in any manner what-
ever, in the middle  of a  hydrocele which is more or  less ancient.
The liquid of the tunica vaginalis from  being translucent  then be-
comes opaque.  If,  at a later period, the coloring matter ofthe blood
disappears, the  transparency is re-established.  In the contrary case
the hydrocele  remains definitively transformed into an hematocele.
As for the rest, the  eye is sufficient to ascertain the transparency of
a hydrocele, if  it  really exists, while, in other cases, no additional in-
formation will be derived  by means of the  tube  of M. Segalas, or
reflecting mirrors of whatever description they may be.   When the
transparency is wanting  it must be imputed  to the alteration of the
sac or of the effused liquid, and not to the imperfection of the explo-
rative means made  use of.  A circumstance, however, which might
lead to ambiguity to a certain extent, is  the  position of the  testicle
and of the cord.  We generally look for the transparency in front,
upon the outside, or above, because the testicle  is  almost  always
crowded to the inside, and downwards and  backwards; but if the
testicle should be  found by anomaly, either ih front, as I have seen it
in four or five instances, or immediately upon the  inside or outside,
we may, in fact, conceive it possible for it to  be placed in such  man-
ner, between the eye  and the light, as  to deceive the  surgeon on
a rapid examination.  The error in a case like this would, to a cer-
tain extent, be  pardonable, especially if  there  were present at  the
same time  a tumefaction or disease  of  the  epididymis or testicle.
The diseases which have sometimes  been confounded with hydro-
cele, though of various kinds, may be referred to two classes,  those.
originating in the  seminal gland and those disconnected with it.   All
the modifications of sarcocele belong to the first class, while the sec-
ond is composed  of enterocele,- epiplocele, varicocele, hematocele,
cysts and adipose or other tumors, which are  developed either in the
scrotum or in  the inguinal canal.  A pupil pointed out  to me in the
septum of the  scrotum upon the dead  body, an ovoid, uniform and
movable tumor, which might'have easily Jed to deception if it had
been less heavy.  A tumor of the same kind had already been  men-
tioned by M. Malere, except that it contained  four pounds of water
and resulted in  the death  of the patient.
  IV. a. Prognosis.—Chronic hydrocele, left to  the resources of
the organism,  will  continue  for an indefinite  length of time, and
scarcely ever disappears.   The cases of spontaneous cure which are
related, are such rare exceptions that it would be impossible to count
upon a termination  of this kind.   Hitherto I have met with but  a
single example,  which was in  a  child seven  years of age, in whom 
710           NEW ELEMENTS OF  OPERATIVE  SURGERY.

the tumor was of the size of a pullet's egg, and had existed for fifteen
months.   It completely disappeared in the space of ten days; but a
month later I perceived that -the serosity again began to be effused
into the tunica vaginalis.
  b. Accidental laceration of the  cyst.—It is nevertheless  possible
that the hydrocele may be dispersed,  at least for the space  of some
weeks, without any treatment, but in  such cases it is owing to the
action of some violence which, by tearing  the  cyst, has forced  the
liquid to infiltrate itself elsewhere.  Bertrandi relates an example of
this kind; the patient, having indulged to excess in drinking, found
himself pressed by an  urgent  desire to  urinate.  The case  mentioned
by Sabatier was attacked with a violent cough, and M. Krimer also
speaks of an effort  made in the case which he cites.  A similar re-
mark is applicable to the case  communicated  to  me by M. Serre.
The patient mentioned by Loder  had  received a kick from  a horse.
A similar  fact was seen at La Charite in 1836.   In another patient,
however,  in whom  the hydrocele disappeared during the night  pre-
ceding  the day on which he was to be operated upon, there was no
infiltration observed in the scrotum, nor had there been any violence;
but the fact was  not  accompanied with sufficient details to enable
me to come to any conclusion in relation to it.   Such results, how-
ever, are  easily explained.  An effort, or some  pressure or  concus-
sion, tears or  lacerates  the  tunica vaginalis, when the serosity is
effused  and  immediately infiltrated either into the spermatic cord or
in the direction of the  inguinal canal, or between the different layers
of the scrotum, and even into the parietes of the abdomen, as in the
patient  of M.  Lacordere.  In  such cases the  cyst shrinks, and is
succeeded by an cedema of the cord, scrotum, or penis, which osdema,
in general, disappears quite  rapidly when the patient is neither far
advanced in age nor of a shattered constitution.   Moreover,  it rarely
happens, in such cases, that the cure  continues permanent.   In the
patient  who fell  under my care  the infiltration continued but for the
space of three days, and  the hydrocele returned soon after.   At the
expiration of three  weeks it was already perceptible.
  In a patient who had ruptured it against the pummel of a saddle,
the tumor at the expiration of six  months had acquired its primitive
volume. The same thing took place in  the cases related by Bertrandi,
Sabatier, Boyer and M.' Nocelet, (Gaz. Med., 1838, p. 1515,) and if it
has not been always observed, it is because the persons who have met
with these injuries have not probably been seen again a few months
after the accident.  Thus it  is  in reality  the hydrocele which is re-
formed  after having been effused by means of a rupture, and not as
might be at first supposed a hydrocele which is discovered after hav-
ing been temporarily masked by an accidental infiltration.  When the
hydrocele is of a large size, this infiltration by spreading to the penis
and walls of the abdomen, in some cases gives a volume to the scro-
tum which becomes alarming to the patient.  M. Roux was consul-
ted in 1828, for a case of this kind, and the physician himself, though
very skilful, was somewhat alarmed.  The  ecchymoses moreover,
which are sometimes   associated with  it, might in certain cases give
rise to the supposition of gangrene, if the practitioner was not acquain-
ted with this accident  from hydrocele.   The cases, moreover, which 
HYDROCELE.
711
1 have collected, prove that it is  unattended with  any danger.  A
suitable suspensory, some topical  resolvents, and  a  few days of re-
pose, will be sufficient to remove the oedema, which probably would
even be dissipated without these means.   The patient mentioned by
M. Serre was so satisfied of this that he caused the dispersion of his
hydrocele by rupturing it  as often  as it became too troublesome.
  V. Treatment.—Hydrocele may  be subjected  to two modes of
cure, one palliative, and the other radical.
  a. Palliative cure of Hydrocele.—The operations to which patients
affected with hydrocele were formerly subjected, were so painful and
uncertain in their results, that the  question might  -well  be asked,  if
they were not worse than the disease itself.  Thus we see, de Vigo
prescribed simply that the tumor should  be emptied twice a year,
while Paracelsus absolutely forbade  an opening to be made into  it.
At  the present  day also, it frequently happens  that the surgeon is
obliged to follow the process of J. de Vigo, in some cases, because the
patient exaggerates the danger of the operation or is  too  timid  to
submit to any ;  in other cases, because it is impossible for him to sus-
pend his occupations and  to  continue  eight days at  rest; and some-
times also because he is too advanced in age to  feel the  necessity of
a radical cure of an infirmity of so  little importance.  We confine
ourselves therefore, in these different cases, to  emptying the tunica
vaginalis so often as its distension becomes too annoying.  As the effu-
sion almost scarcely ever fails to be reproduced soon after, and as we
are thus obliged to repeat the puncture every two, three, four, six, or
eight months, this mode of treating hydrocele has taken the  name of
the palliative cure.  The  operation  is performed in the same way as
in the method for injections, of which in  reality it constitutes the first
stage.  The  patient may remain seated or stand up.  The point of a
lancet or of a bistoury could, in these cases, be substituted without
any inconvenience for the  hydrocele  trochar.   Then however, it
would be advisable to  glide a probe  into the wound, in order to pre-
serve its parallelism during the  discharge of the liquid.   The whole
operation is less important than a simple bleeding, and no precaution
is required either before or after.  The  patient  operated upon  may
resume his occupations on the same day, with the condition only
that he should wear  a suitable suspensory, and  not fatigue himself.
In general, the cyst fills up again in the space of one to three months ;
sometimes, however, and  I  have  seen many instances of this, the
hydrocele does not return to the same extent, until after the expira-
tion of more than a year.   In certain cases, which are more rare,  it
does not return at all.   In some cases too it  happens, and these also
are exceptions, that after the puncture the  tunica vaginalis' becomes
inflamed to such extent as to enter into suppuration^ and  to transform
its cavity into an actual abscess.   One of the patients in this condi-
tion, who fell under my observation, caused  me during  eight days a
considerable degree of alarm.  The fever was  intense, and the in-
flammation reached a  portion of the iliac region.   It became neces-
sary to open  the tumor largely at several places, and the cleansing of
the abscess was not effected until after the expiration of several weeks.
M. A. Cooper also mentions a case in which the simple puncture gave 
712
NEW ELEMENTS OF OPERATIVE SURGERY.
rise to very serious accidents, and he recollects  another  in which it
was followed by death on the sixth day.
  b.  Radical Cure.—The thesis of M. Lesueur contains the evidence
that leeches and derivatives have in several instances succeeded in
curing hydrocele.  On the other hand, we see that Dupuvtren has
effected a cure in several instances by means of blisters applied over
the tumor, and other practitioners have related various facts in sup-
port of this last practice.  According to Bertrandi, moxa in some
cases  has  been no less efficacious.  M. Graefe, as Keate had  also
done  in 1788,  extols a solution of muriate of ammonia in alcohol or
vinegar  of squills.  I  have myself seen a hydrocele dispersed in
two instances  by astringent cataplasms  and mercurial frictions; but
these exceptional cures are scarcely ever met with except in cases
of hydroceles  that are not very ancient  or those which are small in
size, and which have been  caused by either a traumatic lesion or an
irritation the source of which we are enabled to remove.  In the two
patients  whom I saw cured, the  disease had existed only for  two
months and had been  produced  by a blenorrhagic engorgement of
the testicle. Blistering,  muriate of ammonia  dissolved  in water 01
in coarse red wine, and  the most active  astringents have been used
without any benefit in my department on other patients, in whom the
hydrocele had only existed however for  the space  of  six  weeks, and
had been occasioned by an injury done to the testicles ; leeches and
emollients also had  been previously employed with a similar unsuc-
cessful result.
   1.   The operation selected for the radical cure  of  hydrocele has
varied in a remarkable manner since the time of Celsus.   Incision of
the tumor, excision of a portion of the  sac, scarifications upon its
interior, its  cauterization with caustics or the red  hot iron, and the
employment of tents, meches, canulas, setons  and various  kinds of
injections,  have in turn been eulogized.in such  manner as to  consti-
tute a variety  of different  methods, the  greater part of which have
been  finally proscribed by modern surgery.
  2.   Cauterization, which Aetius describes after  Leonidas, which
some practitioners  employed  by  placing an escharotic at the lower
and others at  the upper part of the tumor, repeating it  until it had
reached the liquid, and  which some operators preferred accomplish-
ing by means  of an incandescent metal or the L shaped cautery
mentioned by  Paul  of Egina, was in use as is seen  a long time before
Guy de Chauliac,. to whom Sabatier appears  disposed to ascribe it.
Preferred by G. de Salicet, Thevenin, M. A. Severin and Dionis, and
revived a  thousand times since, it has been eulogized in  England,
France and Germany;  but under whatever form it has  been proposed,
it is a method  which should be totally proscribed.
   3.  Tents and canulas, which  are less dangerous  or at least less
barbarous, would in my opinion deserve the same  proscription, had
not certain surgeons of distinguished  reputation  in our  time still
thought it advisable to accord  to them  a certain degree of approba-
tion.   The use of tents, far  from  being  ascribable  to  Franco,  I'.
ab Aquapendente or Moinichen, as Sabatier and  Boyer would  lead us
to suppose, goes back as far at least as to the time of G. de Salicet,
who,  in  speaking of hydrocele, expresses  himself in these  terms: 
HYDROCELE.
713
» Let the scrotum  be perforated with a lancet, the water be drawn
out and a tent introduced into the aperture, in order that you  may
freely, whenever you desire, extract what there is within the tumor."
Only that in place of a process so simple, F. de Hilden has advised
that we should ligate the tunica vaginalis, and then incise it and leave
a thin meche in it, a process which  Bell has  followed with this last
intention.   Monro, imitated in our time by M. Guerin, (Rey, These,
No. 79, Paris, 1834, p. 89,) recommends that we should irritate the
serous tunic with the extremity  of the canula of a trochar, and M.
Larrey, that we should leave permanently in its interior during the
space of several days the extremity of a gum-elastic sound.   Though
it be unquestionable that we are indebted to the employment of these
means for a certain number of successful results, it is equally certain
that instead  of producing  a  simple  adhesion of the surfaces  they
very frequently cause them to suppurate, and that they do not suc-
ceed sufficiently often to supersede the methods that are generally
adopted at  the present day.
  4.  The same must be said of the seton, of which Sabatier finds no
mention in the ancients, and which Sprerigel ascribes to Lanfranc,
and M. S. Cooper to Franco, though Galen  probably had reference
to this when he mentions that we should extract the  water from the
scrotum by means of a syringe or a seton.  It was also on  account
of the recommendation  of the physician  of Pergamos that Guy de
Chauliac advises that we should grasp " the scrotum by means of flat
tenacula with holes at their extremities, in order to  perforate  it, by
passing through their opening a  long needle, in the head of which
was inserted a seton which was to be  left in the wound  until the
water was  evacuated."  It would seem moreover, as has  been re-
marked by Leclerc, that C. Aurelianus  had spoken of this process.
Peyrilhe also considers that he has found the suggestion in Paul of
Egina.  Though Pare, and almost all authors, had recommended it
up to the termination of the seventeenth century, this method, which
is censured by Pigray, was nevertheless almost wholly  abandoned
until Marini and  Pott undertook to bring  it again  into  repute;  but
there is no  reason to suppose that the seton, which  is still employed
by M. Green, (The Lancet, 1829, vol. XII., p. 388,) will be hereafter
preferred by any person.   However, if any person should again de-
cide upon employing it, the name itself is a sufficient explanation, and
nothing more is required than to recollect that a ribbon of fine linen
or a long meche of  cotton, or any other substance, is to be passed
through the tumor, in order to enable any one to comprehend the
mode of performing an operation of this kind.
  5.  M. Van Onsenoort, who employs the seton under the name of a
ligature, makes use of a semicircular needle with an eye near its point.
In an ordinary hydrocele, he  supposes the tumor to  be divided into
three equal  parts by two transverse lines.  Introducing his needle at
the upper line, he brings it out at the lower, extracts  the serum,  and
then withdraws the needle and tightens the  ligature by means  of a
bow-knot.  In large hydroceles,  the needle containing a double liga-
ture is introduced at the middle portion of  the tumor.  After having
brought out its point above the  upper imaginary line, he separates
one of the threads from it and repasses his needle into the interior of 
714
NEW ELEMENTS OF OPERATIVE SURGERY.
the tumor, in order to bring it out below the lower imaginary line.
The second  thread being now disengaged  from it, and the tumor
emptied, he  divides the  noose which  corresponds  to  the opening
where the needle entered, in order to have two ligatures which are
knotted separately.  In a double hydrocele, a single ligature is pass-
ed  obliquely through the septum  from above  downwards.   These
ligatures, which are slightly tightened at first, and tied  with a bow-
knot, in order to be afterwards tightened again at pleasure, accord-
ing to  the degree of inflammation, should be sufficiently strong to
effect the section of the parts which  they embrace.
  6. M. Kerst having perceived that the serum flows with difficulty
through the opening made by  the instrument of Onsenoort, and that
infiltrations and abscesses frequently take place, has proposed a trochar
needle whose curvature forms  the quarter segment of a circle of three
inches and a half in diameter.   The  body of the  needle is pierced
near its point, and its canula has two lateral  openings near the up-
per extremity.  It is introduced in  the same manner as the needle
of M. Van Onsenoort.  The  thread  is  disengaged and the needle
withdrawn.   The serosity then runs freely through the canula, which
rs gradually brought out in proportion as the  tumor becomes evacu-
ated, and finally withdrawn through  the lower opening.
  7. To treat hydrocele with the seton,  we ought, says M. Laugier,
to traverse the tumor with a trochar, then withdraw  the stilette of
this instrument, and introduce into the canula an eyed probe furnished
with a seton; then  return the canula  into the tumor,  which now
only commences  to empty  itself; and  when it is empty, finish by
withdrawing the canula and leaving in  the seton, the extremities of
which latter are afterwards tied with a loose knot.   But it is difficult
to comprehend the utility of such processes after  having been wit-
ness to the successful results and the simplicity of the  method gene-
rally adopted in France.
  8. Incision.—Incision, which was  made use of at the  time of Cel-
sus  and Guy  de  Chauliac, is  performed by means of a straight or
convex bistoury.   The  patient is laid upon his back with his limbs
moderately flexed, while the surgeon grasps the scrotum on its back
part with his left  hand,  and  in this manner makes the tumor tense.
With his right hand he incises its upper  portion, in penetrating from
without inwards if he uses the convex bistoury, and by a puncture if
he employs  the straight bistoury.   The opening at first should be
sufficiently large to admit of  the introduction  of  the finger, which
latter should be replaced by a grooved sound, if through inadver-
tence we have made too small an incision.  A blunt-pointed bistoury
then answers for completing the division of the entire  anterior wall
of the cyst, cutting with it from  above downwards, and from within
outwards.  As our object is to produce  an adhesion ofthe two mem-
branes of the tunica vaginalis, by  creating-a suppurative inflamma-
tion, the wound should  be  filled with lint and dressed daily in such
manner that the cicatrization can only take place from its bottom to
its borders.   By this means we generally obtain a permanent  cure;
only that it is not an uncommon occurrence  for some points of the
membrane to escape from the  suppuration,  and  consequently to give
rise to the formation of small cysts, which allow ofthe partial repro- 
HYDROCELE.
715
duction of the disease.   The  pain and accidents which sometimes
accompany it, and the length of the treatment, have generally caused
this process to be rejected in France, at least since the time that we
have  come into possession of those that  are  more  simple;  so  that
notwithstanding the reasonings of M. Rust, M. Warren, M. Dieffen-
bach, M. Gama, M. Begin, (Elem. de Chir.,&c, 2d edit., t. III., p. 525,)
and of M. Chelius, (Arch. Gen. de Med., X. IX., p. 230,) who still ap-
pear to give it the preference over every  other, this method appears
destined to form no longer  any other than an exceptional resource.
  9.  Excision.—Excision  also appears to  have been in use at  the
time  of Leonid as.  We find, in fact, in the ancient authors, that some
of them, after having  opened the tumor, seized, in order to extract it,
the lips of the tunica  vaginalis and rolled  them inwards  upon hooks.
It is  to Douglas, however, that we  are indebted for having drawn
the attention of  the surgeons of the last century to this process, and
for the reputation it still retains  among us.  There are many modes
of performing it.  The English surgeon commenced by circumscrib-
ing,  by means  of two incisions, an  elliptical flap of integuments on
the front part of the scrotum, removed this flap and opened the tunica
vaginalis, which he then dissected  little  by little, until he reached
nearly  down to its adhesions  with the testicle, in order to excise im-
mediately its two sides by means of a good pair of scissors.   Boyer
recommends a  simple incision upon the whole length of the hydro-
cele, then to  dissect the tunica vaginalis as far as possible on the side
ofthe seminal gland, before giving egress to the liquid, and afterwards
to open the  cyst  and excise  its flaps.  Finally, Dupuytren found it
more simple  to embrace the whole of the tumor underneath with his
left hand, in order to  stretch its anterior wall as much as possible,
then to incise, like Douglas or Boyer, according as it should or should
not be  found necessary  to  remove a flap of integuments, and after-
wards  to  enucleate,  so  to speak, the tunica vaginalis by pushing it
from behind  forwards, and expelling it, in a word, nearly in the same
manner as we would a kernel  of fruit, by pressing it  between the
fingers.  This  being  done, he  opens  the  cyst  and excises it in the
manner which has already been stated.  Whatever may be the pro-
cess  adopted, the wound is immediately filled with soft lint,  and the
rest of the dressing is precisely the same as after the simple incision.
We  see by  this description that  excision, which is still preferred
by M.  Fricke, (L'Experience, X. II., p. 408,) is a painful method,  and
necessarily more protracted than the others.   Its  advantages are,
that  it does not  allow the disease to be reproduced, since it effectually
destroys the organ which is the seat of it.   Nevertheless, as it is im-
possible to remove the totality of the tunica vaginalis, we cannot per-
ceive how it can absolutely secure us against a return of the disease.
Experience,  moreover, as Boyer has remarked, has shown that hydro-
cele  has sometimes returned  after excision as well as after incision:
this,  therefore, is another method which is to be  rejected in the treat-
ment of simple hydrocele.
   10. Partial excision  and immediate reunion.—A remark of Pott
would seem to indicate that this surgeon did not look upon the extinc-
tion  of the vaginal cavity  as indispensable  in the cure of hydrocele.
M. Ward even maintains that hydrocele is frequently cured, though the 
 716          NEW ELEMENTS  OF OPERATIVE  SURGERY.

 serous cavity of the scrotum may have preserved its original dimen-
 sions ;  and M. Green  (The Lancet, vol. XII., p. 388,) adduces, in
 support  of this opinion, a specimen preserved in  the museum of St.
 Thomas's  Hospital.  M. Ramsden is of the  same opinion, and M
 Kinder-Wood, according to M. Walsh, adopted this idea for the  con-
 struction of a new method.   This surgeon, after having divided to
 the extent of a few lines all the tissues down  to the tunica vaginalis,
 dissects, in order to excise it, a small  flap from this membrane.   The
 liquid being evacuated, the wound  is united by first intention, by
 means of one point of suture.   Without participating  in the anticipa-
 tions of M. Walsh or his countryman on this  subject, I cannot, how-
 ever, omit remarking, that a case which occurred in my department
 at La Pitie in  1831,  might perhaps be adduced in support of Pott's
 assumptions.  The patient was over fifty years of age, and his hydro-
 cele was double the size of the fist.  I operated with the vinous in-
 jection, and the scrotum had almost returned  to its natural condition,
 when an attack of apoplexy carried off this  patient  on the twenty-
 sixth day after  the operation.   Being desirous of ascertaining  the
 progress of the  morbid  process, I carefully dissected  the parts,  and
 was surprised  to  find the  tunica vaginalis entire, with its natural
 polish, and containing nothing else in its lower portion than a glutin-
 ous filamentous matter of a slightly green color, and  which had  not
 contracted any adhesion.   The testicle, moreover, and its envelopes,
 were entirely sound.   In two  subjects whom I have since had an
 opportunity of examining,  the  vaginal cavity, on the contrary,  had
 entirely disappeared.   M. A. Cooper also cites a case in which the
 tunica vaginalis was only  imperfectly obliterated; but could it be
 affirmed that  the cure,  under such circumstances, would have been
 complete.  If a  hydrocele cured by an irritating injection may return
 at the expiration  of thirty  years, as in  the patient of M. Ansiaux,
 (Clin. Chir.,  2d edit., p. 215,)  or after the lapse  of  some years or
 months only, numerous examples of which exist, is  it not evident that
the tunica vaginalis in such cases has not been obliterated ?
  VI. Injections.—'Almost all modern authors, upon the strength of
an assertion of A.  Monro, attribute the  idea of injections, in the rad-
ical cure of hydrocele, to a military surgeon  of the same  name as
this writer.   They had, however, been recommended and  in use a
long time before. Celsus had already remarked, that if there is water
in a  pouch, we must, after  having emptied it,  throw up injections of
a solution of nitre  or saltpetre.   Lembert of Marseilles, whose com-
mentaries and observations were published in 1677, formally states,
that the best method to be  followed  in  the treatment of hydrocele,
 consists in  extracting the water  by means of a  canula, in order to
 be enabled afterwards to inflame the cyst by injecting eau phagedc-
nique into it through the same canula.  Ilis trials with  this process
inspired him with so much  confidence that he  came to  a resolution
to employ no other afterwards.   The eulogiums which were at  first
lavished  upon this  process by Monro, and afterwards  by Sharp  and
Earle. having been weakened  by the unsuccessful results  of many
other practitioners, injections  did not get into repute  in England,
and were in fact not generally  adopted in France,  until after the  me-
moir of Sabatier.  As it is at present the only process almost which is 
HYDROCELE.                         717
followed, I propose to speak of it in a special manner, and to enter
more into its details than with any of the  others.  There is  no ne-
cessity of my refuting the assertions of those who recommend, that
in place of the ordinary trochar, we should make use of one  that is
flattened, or that before  making the puncture we should  divide  the
skin and the subjacent tissues by means of a lancet, since the inutil-
ity of these precautions is at the  present  day generally conceded.
Nor is there any longer  any necessity of discussing the opinion of D.
Schacci, who has greatly extolled an  elastic  canula surmounted
with a cutting point, inasmuch as the hydrocele trochar, either with
or Without a notch on one of the  sides of its canula, has  been long
since regarded as quite sufficient  in every  case.  Though we  no
longer differ in opinion, however, on the best instrument to be employ-
ed, nor  on the manner  of making the puncture, and withdrawing
the liquid, it is not altogether the same with the irritating agent.
  a.  Various liquids.—The ancients had recourse, as we have seen,
to solutions more  or  less acrid.   Lembert  made  use  of lime-water
charged with corrosive sublimate.  The surgeon spoken of by Monro
employed alcohol, either pure or diluted with water.   At  the same
epoch red wine was also made trial  of.  Earle greatly eulogized port
wine, while Juncker preferred that of Medoc, and Leveret confined
himself to a solution  of caustic potash.  The solution of sulphate of
zinc, indicated by Bertrandi and M. A. Cooper, has succeeded 10Q
times out of 106 cases in the hands of M. Mott.   Boyer and Dupuy-
tren finally succeeded in securing the adoption  of red wine, either
simple or with a small quantity of alcohol, or in which roses of Pro-
vence have been  boiled.   I have seen  used, and  have used myself
spirits of camphor, to attain the same object,  Cold water,  (Beclard,
Fricke, L'Exper., X. IL,  p. 408,) air, (Gimbernat, Ibid., p.  404—Ma-
nieri, Journ. des Conn. Mid.-Chir., Mai, 1838, p. 215 ; 5 examples.—
Riccardi, Observat Prat., p. 11, 1838 ;) milk, the liquid of the hydro-
cele itself, a solution of marine salt, of alum, (Gerdy, Arch. Gen. de
Med., December,  1837;) nitrate of silver,  (Parent, private  commu-
nication, 1838,) and  tannin, (Chaumet, Ibid., 1839,) have  also been
made trial of. When we reflect upon the  result which is to be ob-
tained, it is easy to comprehend that these different agents are in fact
in some cases calculated to answer the views  of the practitioner.
The object in fact is to irritate the  tunica vaginalis, and to  Create an
adhesive inflammation in its interior.  Now cold water, wines of all
descriptions, brandy, caustic solutions,  in a word any liquid  what-
ever, even the extremity of a canula or tent, or the presence  of any
foreign body whatever it may be, are evidently of a nature to pro-
duce this result;  the only thing we have to ascertain is, what suc-
ceeds best, and is attended with the least inconvenience.
  b. Red wine.—Experience up to the year 1832 having apparently
decided in favor  of strong red wine,  made stronger by a small
quantity of alcohol,  or by having roses  boiled in it, I could not un-
derstand at that period why it had been thought advisable to make
trial of other liquids.  It must be  remarked, however, that alcohol,
rejected by many authors, who considered  it too irritating, produces
no  effects more  alarming than ordinary wine, and that if  I did not
adopt the employment  of it, it was  because I  had  seen it  fail  in 
718
NEW ELEMENTS OF  OPERATIVE  SURGERY.
three cases out of eleven  patients operated upon, while the  wine,
which I had myself made trial of in  about 60 cases, did not fail but
in five instances.  Justified by new experiments, I shall hold at the
present  day another language, after  having described in detail the
vinous injection.
   1. Operative  Process.—Before  emptying the scrotum we are to
have prepared a syringe  properly arranged and of the capacity of
nearly a demilitre ; we must also  have at the same  time a litre or
twro of  liquid  prepared in the way which  has been described, and a
chafing-dish filled with live coals to heat it.   Sundry basins are also
necessary, either to contain the wine for injection  or to receive the
water of the  hydrocele.    When  every thing is  arranged in this
respect, the surgeon, after the patient is placed upon a bed provided
with  alezes, embraces the scrotum in the same manner he does for
incision or excision, and again satisfies himself that he has an actual
hydrocele  before him and  not  another disease ; also that the tes-
ticle  and  various  portions of  the spermatic  cord are placed in
certain  relations, and not in others.   With  his right  hand the ope-
rator then takes the  trochar armed with its canula, and plunges it
in with a short stroke (d'un  coup sec) upon the anterior, lower and
outer part  of  the tumor, as  far as to the centre of  the liquid.  This
point is to be preferred because,  in the ordinary state, the testicle
and its dependencies are found upon  the inner side, and below, and
behind,  and that it is the best mode  of reaching the  middle of the
vagina]  tunic.   It  is unnecessary to say that if a different arrange-
ment had been ascertained  to exist before commencing the opera-
tion, the instrument  should have been carried  in  another direction
and upon the point which would appear to be the most suitable; the
absence  of resistance,  a small  drop  of liquid, which  sometimes
escapes  between the wound and the canula, the depth to which we
have reached  and the void  in which the point of the trochar appears
to be situated, sufficiently indicate that the instrument  has  entered
into the cyst.  The surgeon then embraces the canula near the skin
with the two first fingers of his left hand, and immediately withdraws
the stilette, in  order to enable the  liquid to run out.   When the sac
is partially emptied he presses it in every direction, taking care that
the beak of the  canula does not become embedded between the en-
velopes  of the scrotum.   Up to that time also, the beak of the instru-
ment must not  be allowed to reach the  inner  side of the  morbid
cavity in such manner as to interrupt the egress of the liquid.  An
assistant immediately fills  the instrument with  the injection, which
should be of the temperature of about 323 Reaumur, or  more, if the
tissues of the patient should  appear to be but  slightly irritable, or
when the liquid itself is not very irritating,  but under contrary cir-
cumstances, the  temperature should be a little less, at  such tempera-
ture, in  fact, that the hand  may support it. but with some degree of
inconvenience.  The syphon of the syringe is then directed  into the
external opening of the canula,  to  which it should have been apphed
beforehand, in order to be sure  that it is exactly adapted to it.  The
assistant then gently pushes upon the piston until the instrument is
empty or the  cyst  filled with liquid ; the operator constantly support-
ing the  canula near its root, prevents it from butting against the inner 
HYDROCELE.
719
side of the sac, or from being withdrawn so much as to become en-
tangled in the tissues of the  scrotum, while  at the same time, with
his forefinger he shuts it and  prevents the escape of the liquid at the
moment when the assistant has removed the syfinge.   An additional
quantity of the injection is now immediately thrown up in the same
manner, or more if necessary, in order to give to the tumor as much
volume nearly as it had  before the operation.  It is to be retained
each time within the tunica vaginalis for the space of three minutes
according to  some practitioners, four or five according to others, and
as some recommend even six or  seven.   Finally, there  are  others
who advise that the tunica vaginalis should be filled a third time be-
fore emptying it definitively.   Moreover  it is advisable, it  is said, if
not incfspensable, to expel  from the cavity even the last  remaining
drops of the liquid,  and also the air which  may have got introduced
into it, before we remove the guiding canula.
  2. Dressing, and natural consequences  of the Operation.—For
dressing, it is the practice to surround the  scrotum with compresses
saturated with wine similar  to that  of the  injection, and to  renew
these compresses three or four times in the space of every 24 hours
until the fifth or sixth day, that is  to  say, until the inflammation has
acquired the  degree of intensity desired, and until we  may replace
them by emollient cataplasms.  In some  patients the inflammation
acquires its greatest degree of intensity on  the day after  the opera-
tion ; in such cases the tumor is hot, red, and painful, and has acquir-
ed a size almost equal to that  of its  original dimensions.  In other pa-
tients this does not happen until about the  fourth, fifth, or  sixth day.
In a patient whom I operated upon in  November, 1831, there  was,
so to speak, no pain or swelling during  the first two weeks.   The
inflammatory symptoms in another did not come on until the 10th
or 12th day, although  he was yet young  and very excitable,  and
of a nervous  rather than a  lymphatic constitution.   He had been
operated upon  also   the  preceding year, and without having been
any more  incommoded  by it.  In both  patients the  success  was
complete.   A febrile  movement, sometimes even  quite  an  acute
degree  of fever, together with  all  the symptoms  of a manifest
general reaction, accompany  this  local inflammation.   M. Blandin
speaks of a case in which the  inflammation extended to the veins of
the cord, and  caused the death of the patient; but it  rarely happens
that serious accidents  result  from  it.  The system sometimes even
appears to be unconscious of  what is passing in the scrotum.   The
matter which is effused in the cavity of the tunica vaginalis has this
remarkable feature, that it is soft, clammy, semi-fluid, and constitutes,
in every sense ofthe word, plastic lymph.   There is, however,  also
associated with it, in a considerable number of cases, a  certain pro-
portion of serosity, but scarcely ever any albuminous flocculi, or ac-
tual pus.  This effusion continues while the inflammation  is increas-
ing.  Its resorption is afterwards effected  by degrees in such man-
ner that the parts may  reacquire their natural volume at the expira-
tion of twenty days, a month, or six weeks, and this process  seems
also sometimes to extend to the envelopes of the scrotum, which were
more or less thickened, as well as to the testicle, whose tumefaction
is in some respects a necessary consequence of the original disease, 
720
NSW ELEMENTS OF  OPERATIVE SURGERY.
or of the operation.  While the more fluid parts of the effused matter
disappear, its concretible portion is imperceptibly blended with the
two walls of the tunica vaginalis, which latter become so perfectly
agglutinated together? that there cannot be found ultimately anv ves-
tige of cavity between the testicle and the surrounding tissues. When
the inflammation begins  to diminish, that is to say about the 8th  or
10th day, emollient cataplasms are generally no longer indicated, and
resolvent compresses embued with wine, or vegeto-mineral water,
should  be substituted in  their place.  As  resolution in some cases
goes  on too tardily, it  is advisable  to  assist it by  suitable means.
Cataplasms  of flax-seed flour,  wet with extract of lead, have in many
cases appeared to me to  be advantageous ;  the applications however
which possess the most efficacy, are mercurial ointment either alone
or under the form of a cataplasm, also iodureted or hydriodated po-
mades, either simple or combined with opium, and employed in small
quantities in the form of frictions on the tumor.   An important precau-
tion during  the< whole course ofthe treatment is to  give perfect sup-
port to  the scrotum by means of a good suspensory.  Though the
inflammation may rarely proceed to the extent of causing abscesses,
this nevertheless is an accident which is sometimes seen : then the
scrotum will be  seen to become red, projecting, and afterwards  fluc-
tuating on a determinate point of its surface, presenting all the symp-
toms of a phlegmon or actual abscess.  The indication is the same as
that for acute abscesses in general.  Thus leeches, if we suppose we
can prevent the suppuration, and cataplasms, and the opening of the
collection as soon as its existence  is clearly ascertained, constitute the
principal treatment.   In  other cases, the  tumor, after having dimin-
ished a third, half, or three-fourths of its original volume, continues to
remain  in the same state, leaving the cure incomplete.  It is in  such
cases that topical astringents and resolvents are especially advanta-
geous.  They have been  seen to triumph over this obstinacy in the dis-
ease, and to complete the cure at the moment when it was supposed
another operation would become necessary.  If finally, nothing should
succeed, we have still the resource of repeating the operation.
  3. Precautions to be taken.—The method by injections, such as I
have described it. does not, in the majority of cases, require any other
precautions  ; but if the tumor should be of large size, equal, for exam-
ple, to the head  of an adult or still larger, it would  be well to follow
the counsel  of Bertrandi  and Schmucker, (Rougemont, Bib. Chir.  du
Nord, p. 37.) who recommend  that before injecting the irritating
liquid into the tunica vaginalis, we should make one  or more precau-
tionary punctures, in order to  enable the scrotum  to return  upon
itself, and not to be compelled to excite inflammation upon  so large an
extent of surface.  I  have, however, operated without this precaution
on a man forty-eight years of age, and in whom the hydrocele, which
was very ancient, was  twenty-four  inches  in circumference.   Ao
"accident supervened, and the cure took place in the usual period of
time.   During  the time the liquid is being thrown up,  the patient
usually experiences a pain, which is transmitted through the track of
the  cord, and  is  considered  as  an evidence  that the irritation has
reached the degree which is  desirable, and some are even satisfied
to find that  this  pain extends to the side and lumbar region, so that in 
HYDROCELE.
721
general quite an  unfavorable result is predicted  when this last is
not  felt.  As all  persons are not endowed with the same degree of
sensibility, and that the tunica vaginalis may be altered to a greater or
less  extent, all patients will not experience this pain to the same  de-
gree.  In persons who are aged, or where the hydrocele is ancient,
and  we apprehend a marked thickening in  the cyst, it is advisable to
heat the wine to  a very considerable  degree, or to render it some-
what more irritating  than for those  patients who are found under
opposite conditions.   Moreover,  it is  not to be supposed  that  the
operation will not succeed because the  pain in question has not been
developed ; experience has a hundred times demonstrated the con-
trary.
  4. Accidents.— Gangrene ofthe Scrotum.—The canula, as 1 have
already said,  readily abandons the vaginal  cavity while the scrotum
is retracting  and  emptying itself.   This accident, which apparently
is very trivial, may lead to the most serious consequences.  The assis-
tant, under such circumstances, almost unavoidably injects the liquid
between the  tunics of the scrotum without  being conscious  of it;
there results from this an inflammation which almost invariably ter-
minates in gangrene, if in fact it does not at the very first jeopardize
the life of the patient.  Boyer was witness to a case of this descrip-
tion.  The surgeon had charged an. assistant  to hold the canula while
he himself threw up the injection: a gangrenous inflammation super-
vened, and the patient died.  A similar  fact is related  by M.  A.
Cooper,  and  another  occurred in 1836, in  one of the hospitals  of
Paris.   I saw an  accident of this kind in 1*24 ; the integuments and
the  subjacent tissues became gangrenous throughout almost the  en-
tire  extent of the  scrotum;  the  symptoms, nevertheless,  ultimately
subsided, and the  patient was restored.  M. A. Cooper states that he
has frequently noticed similar gangrenous inflammations produced by
the infiltration of  the wine into the tissues of  the scrotum.   This  ac-
cident is then indicated,  even at the very  moment of the operation.
by the pain which the assistant  causes in  endeavoring to make  the
liquid  penetrate, by the  resistance which he  meets with, and by  the
projections which he recognizes in the neighborhood of the canula,
and which latter,  moreover, he perceives does not have its extremity
acting freely in the tunica vaginalis.   Upon the supposition that  the
effusion has taken place,  it would become necessary immediately to
scarify to a great  depth the whole thickness of the scrotum at a great
number of points, and to go even somewhat beyond the limits of  the
infiltration.  The  antiphlogistic treatment  and emollient cataplasms
would be first  had recourse  to,  after which  we should make use of
topical resolvents  if, in spite of the means mentioned, gangrene should
become developed or extend.  Gangrene  of the  scrotum may also
manifest itself,  even though  the injection  may have actually been
thrown into the vaginal  pouch.  This is  a  fact which is not men-
tioned by authors, but which, however,  does not appear  to be very
unfrequent.  Many persons have stated to  me that they had noticed
't, and some  intelligent  pupils have informed me that they had wit-
nessed it in three  hospitals of Paris in the  course of the same  year.
i  have myself collected  many remarkable instances of it.  A man,
sixty years of age, who  had a  double hydrocele of moderate size.
                              46 
722          NEW ELEMENTS  OF OPERATIVE SURGERY.

was operated upon by me at the hospital of St. Antoine, in the spring
of  1829.   The  puncture and  injection were made only on the ri<mt
side, and the liquid was thrown up twice into the morbid cavity wfth-
out any impediment  or difficulty.  The proof that it had effectually
entered  into  this cavity is, that we made the whole of it come out
through the canula after the last injection, with full as much facility
as  it did after  the first.  The patient, moreover, experienced only
the usual  pain.   On  the first, second and third day, the swelling  of
the scrotum followed its customary course;  the inflammation con-
tinued even quite moderate;  but on  the fourth  day we perceived a
point mortified  on the lower side of the tumor,  and though I  imme-
diately proceeded to  scarify the parts, the gangrene nevertheless
proceeded so rapidly that it involved the scrotum down to the root
of the penis, and gave rise to the general results which usually accom-
pany it; we ultimately,  however, triumphed  over it.   The sphace-
lated sloughs were successively detached,  and  the globular vaginal
tunic, almost naked at the bottom ofthe wound, appeared to be filled
with a softish matter, as if nothing peculiar had taken place; and
after a long  course of treatment the cure was  accomplished, even
on the  side which had not been operated upon.
  In the second case  treated at La Pitie in the month of November,
1831, nothing could have induced us to  suspect the occurrence  of
such an accident, when, on the  fourth day, without there having been
any pain, or redness,  or any perceptible signs of inflammation, I dis-
covered  a large eschar on the front part of the scrotum.  ATo reaction
took place, the tissues gradually exfoliated, and the cicatrization was
ultimately accomplished.  I  have been witness to three similar facts
since.   In one, everything went  on as in  the preceding patient;  in
the two others the part involved comprised only an inch in  dimen-
sion of the sub-cutaneous tissues of the scrotum.
  In the three patients there was  this remarkable feature, that the
mortification was not preceded by any apparent  inflammation  before
the ninth day, and  that it was announced  by a  simple tumefaction,
accompanied  with  crepitation  on  that part of the  scrotum upon
which  it was to occur.  Where can we discover  the cause of this
gangrene ?  It is certainly impossible to attribute it to the effusion,
by means of the canula, of  a certain  quantity of wine between the
tissues  which  separate  the  tunica vaginalis from the  skin, and yet,
nevertheless, there is  scarcely  any other thing to which we can im-
pute it, except the vinous infiltration.  I can perceive, moreover, four
ways in  which the  fact  may be  susceptible of general  explanation.
In distending'the tunica vaginalis by the injection to a great degree,
we may readily cause a laceration in it, and the exudation externally
to it of some few  drops of the  irritating liquid.  It  would not  be
surprising to me if this had been the result in the second case  I have
described.   In him, however, as in the first, as the accidents did not
manifest themselves until the fourth day, an explanation of th;s kind
can scarcely be  admitted.   We  ought to  refer  it perhaps, in these
two cases at least, to  the existing  debility, absence of reaction  and
state of alarm which  accompanied them, and to the gradual trans-
mission of the inflammation  from  the interior  to  the  exterior.   If
gangrene of the scrotum can  be  produced by a simple puncture, or 
HYDROCELE.
723
even without any previous puncture, we cannot see what should pre-
vent its taking place sometimes in the vicinity of a  hydrocele, which
has  been  operated upon with  the vinous injection.  Lacerations
ofthe  tunica vaginalis, being easily made through its fibrous lining,
surgeons should be careful not to distend the parts during the injec-
tion more  than  they were by the hydrocele itself.   This precaution
is so much the more important, inasmuch as the wine regurgitating
between the canula,  whether it is notched  (crenelee)  or not, and
the tissues, might possibly become in this manner infiltrated into the
substance  of the scrotum.  M. A. Berard, who adopts this explana-
tion, (Gaz. Med., 1833, p. 404,) invokes in its  favor a fact which he
considers  conclusive.   Thus is it a reason, therefore, for dispensing
with the groove which is seen on the outer side of certain hydrocele
canulas.   Too large  a canula, leaving an opening  so wide that  the
tunica  vaginalis may afterwards insinuate some  drops of liquid  into
its track, is also  calculated  to  favor the infiltration  in question ; this
is another argument  for  making use of a small  one.  I  would  add,
that if a certain  quantity of wine  should  be  left in the cyst after
the withdrawal  of the canula, it is readily perceived that this liquid
might  become infiltrated through the puncture and give rise  to the
same accidents; so that  we ought  to  empty the tunica vaginalis as
perfectly as  possible  before withdrawing the  instrument, and after-
wards  abstain from making any kind of pressure whatever upon the
scrotum.
  5. Two other  accidents,  viz.,  hemorrhage and puncture  of the
testicle, may also accompany the operation for hydrocele.   The first,
which  J. L.  Petit was the first  to point out, and upon which Scarpa
has dwelt so earnestly, can  arise  only from three causes : 1st, from
the wounding of the arterial branches supplied to the scrotum,  by the
external and internal pudic arteries or  by the epigastric ; 2d, from
a puncture  of the vessels  of the  testicle ;  and  3d,  from a  simple
sanguineous exudation upon the inner surface of the tunica vaginalis.
From whatever cause it may arise, we can scarcely comprehend any
immediate danger from  it.   None of these vessels are sufficiently
large,  at least in their  natural state, to make their division in  reality
alarming.   As to the means to be employed, they resolve themselves
into that of  making a free  opening into  the sanguineous collection,
should its resolution be too tardy in being accomplished, or should there
be apprehension of any serious symptoms.  Moreover, it would no
longer be  a hydrocele which would have to  be treated, but in  reality
an hematocele, as in the case related by M.  Macllwain.
  G. Puncture  of the  testicle  can  only take place in those cases in
which  it has been impossible to identify with precision the situation
either  of the spermatic cord or of the seminal  gland itself.   There
is danger  of it also when the hydrocele is but slighty  developed.
Dupuytren,  Boyer, and  almost all surgeons of somewhat extensive
practice, have had an opportunity of noticing  it.   The pain which  it
produces,  and which is very acute in certain cases, possesses a pecu-
liar character which prevents the possibility of any ambiguity.  The
organ  sometimes becomes violently inflamed, and  may be destroyed
Dy suppuration;  nevertheless,  this wound  is attended  with fewer
dangers than would be at first supposed.  A patient wounded in this 
724
NEW ELEMENTS OF OPERATIVE SURGERY.
manner, and  in whose testicle the extremity of the  canula had only
entered so far that the injection itself could detach it, scarcely expe-
rienced any  other  symptoms than  those which ordinarily  accom-
pany the operation  by injection.  In another, however, there super-
vened an abscess which I laid open, and which/during several weeks,
gave me much  apprehension that  the  seminal organ would be de-
stroyed.   In  two other cases I have  seen the effects of  this puncture
entirely disappear on the following day.
  7. Emphysema.—A final complication of  injection is the retention
of a certain quantity of air or gas in  the tunica vaginalis.   I  have
seen several examples of this; among others, two in  wrhich the crepi-
tation continued during the space  of nearly fifteen days.  In these
two cases, however, as in the others, no serious  results took place,
and the cure was effectually established.  In other cases resolution
was not effected, and I consider it proper that we should be on our
guard against this complication, which,  in my opinion, throws  a doubt
on the efficacy of air injections.
  VIIL New methods.—I have been a  long time persuaded, from the
inconveniences  and  dangers  of vinous injection, that  we would  be
authorized  or even compelled to have  recourse  to other or new re-
sources.
  a. Acupuncture was the first remedy that presented itself to my
mind ;  a young  physician had informed me, moreover, in 1831, of a
case in which the patient was cured  in eight  days  by the simple
puncture of a long needle which had  accidentally  been  introduced
into the  scrotum, though  his hydrocele  had existed for a period of
three years.  M. Moro has published  a case no less remarkable:  it
is that of a hydrocele which was cured in  six days by perforating
the scrotum with a needle, which was  left in the parts in the  manner
of a seton.   It  would appear  also that in  India this  is  a common
method with those who do not employ puncture at first, followed by
a meche.  In consequence of these facts I made trial of this process.
Two patients were submitted to it  at the hospital  of  La Charite in
July, 1836, but neither of them were  cured.  In two other cases I
introduced a simple thread, crosswise,  through the tumor, instead of
leaving in the needle; I withdrew the  small setons on the third day;
suppuration  supervened, and the cure  was effected, but more tardily
and with greater inconveniences than with  the vinous injection.  I
consider, therefore, that acupuncture,  whether with or without the
threads, is a process which should  be wholly proscribed in the treat-
ment of hydrocele.   Having in  four  other patients  made  trial of
puncture with needles  until  a  small drop of serum  made its appear-
ance, as recommended by M. Lewis, I found the hydrocele  diminish
and even disappear from day  to day, without infiltration;  but the
effusion nevertheless was reproduced, and  a permanent cure not
effected in any of the patients.  This  method, made trial of  success-
fully bv MM. Hacket (Lancet, February, 1837, p. 787,) and King,
(British Annals of Med., No. L, p. 13,) did not succeed in the hands
of  M.Davidson (Gaz. Med., 1838, p. 72,)  and M. Davey,  (Lancet,
February, 1837, p.  741,) and  certainly was not of sufficient impor-
tance  to be  claimed in honor of M.  Travers,  (London  Med. Gaz.,
Feb., 1837,) or M. Cumin, (Ibid., March, 1837, p. 866,)  as it has been. 
HYDROCELE.
725
  b. Compression.—I asked myself the question in 1832, whether a
methodical compression, executed by  means of a retractive plaster,
might not sometimes succeed in curing this affection in those persons
who were not willing to submit, or who could  not be subjected to
any of those operations  which are  generally considered capable  of
effecting a radical cure.   In consequence of this  suggestion, strips of
adhesive plaster, which, when properly applied, so  promptly cure an
acute orchitis, were  made  trial  of by me on three patients in the
course ofthe months of September  and October, 1836.   Though the
scrotum comprising the  testicle on  the diseased side were immedi-
ately enveloped with these plasters  after the puncture, in such man-
ner as to place and  to  keep  in contact the two walls of the tunica
vaginalis, this did not  prevent the liquid  from being  reproduced.
This method therefore should  also  be  proscribed.   Every thing  in-
duces me to  believe  that such will not be the fate of the following
process.
  c. Iodine  Injections.—Having understood  that  preparations  of
iodine had been made  use of as topical applications in hydrocele,
and that cures had been ascribed to them, imputed  to their resolvent
virtue in glandular engorgements, it also occurred to me  that I would
use them in the form of injection.    For that purpose I made use of a
solution or mixture  of  water and  the alcoholic tincture of iodine.
After having emptied the  cyst by  the ordinary puncture, I  injected
into it  the liquid  in  question.  It is unnecessary to fill the vaginal
tunic with it, provided  by kneading (malaxant) the tumor we force
the liquid to come in contact  with the wiiole of its interior.   We im-
mediately withdraw the whole of it, but without  any danger, should a
small quantity of it be  left behind. As it is not necessary to heat
the injection, nor to fill  the cyst with it, nor to extract every portion
of it, the syringe usually employed for  injections ofthe urethra might
be made to  answer;  and if" the  hydrocele should be voluminous, it
would be sufficient to fill it three  or four times.  After  the  injection
the patient is not obliged to keep his  bed.   The part  continues to
swell during three or four days, but without  causing fever or any
severe pain;  resolution  then  commences and is generally promptly
completed.   I have  used  this method in more than one  hundred
cases.  None of the  patients have experienced the slightest acci-
dent ; most of them were cured in less than twenty days.  In  four the
resolution was  only  half completed upon the thirty-first day ;  I re-
peated  the operation,  and the  cure  then  was promptly  effected.
keven had already been unsuccessfully operated upon by the vinous
injection or  cauterization ; six had an encysted  hydrocele of the
cord;  in three the tumor contained  about twelve ounces of serosity;
m twenty-five the testicle was hypertrophied,  bosselated,  and  dis-
eased for a long time; in all except one the malady had  existed over
six months ;  and one had  been  effected with  it for fifteen, and an-
other for twenty-four years.  In  using the tincture of iodine as a
substitution for wine, there is no  necessity for a chafing-dish or par-
ticular kind  of  syringe, nor of any  preparatory means.   As we are
not obliged to distend the tunica vaginalis, we run no risk of causing
a reflux ofthe liquid, or of forcing  it into the tissues of  the scrotum.
As it is an absorbable substance, its infiltration does not seem  to ex- 
726
NEW ELEMENTS OF  OPERATIVE SURGERY.
pose as much  to  the  danger of gangrenous inflammation as wine
does; and there is no  necessity of its being retained  in place longer
than from five to ten minutes.  I designedly left an ounce of it in the
cyst, and  the cure was only so much the more rapid.   The reaction
of the pain in the lumbar region is nothing.  Patients usually suffer
but very little,  and may get up and walk on  the following dav with-
out any serious inconvenience.  A young  man  who  had been sub-
jected to  the  vinous  injection  without any benefit,  came from  the
city to be operated upon that  morning at the hospital, from whence
he returned home, and afterwards  continued to go out  daily.  An-
other patient whom I operated upon in presence of MM. Parent and
Nicolas, took his daily walks without  the  cure being thereby inter-
fered with.   The cure is more prompt, and full as complete, as with
the wine.   One of the patients whom I  treated in  this manner in
1835, and who was cured by the tenth day, afterwards died in con-
sequence  of an amputation of  the leg.  The scrotum,  which was
carefully dissected, showed that intimate cellular adhesions had been
established between all the points of the vaginal cavity, and that any
return of the disease would have been impossible.  With this liquid
a syringe  of the capacity of from three to four ounces is sufficiently
large for  all cases ; only that it would be necessary, if we should
make choice of one specially for this purpose, that we  should select a
substance which should be the least susceptible of alteration by the
iodine, or  of reacting  upon this liquid.  Up to the  present time I
have made use of syringes of pewter.
  This subject  was in this  condition  in 1836 and 1837, when I pub-
lished my first observations on iodine injections.  Made trial of since
by M. A.  Berard,  Laugier, Marjolin and Michon at Paris, it has pro-
cured the  same results.   Moreover, a  memoir, published by M. Du-
jat, (France Mid., p. 2,  1836—Arch. Gen. de Med.. Janvier, 1837,)
shows that a surgeon  of Calcutta, M. Martin, has treated several
thousand  cases of hydrocele in this  manner, and that  out of 1000
cases for example, there was  only  one return of the  disease!  The
efficacy of this remedy, therefore, is at the present day established
beyond all doubt.   I ought to add, however, that at Hamburg, M.
Fricke has not met with any success from it; but besides the fact that
in the same town,  M. Opeinheim has been  no less fortunate than our-
selves, the failures of M. Fricke are susceptible of a  ready explana-
tion.  M.  Fricke, instead of the cold  liquid, made use of that which
was  heated to 30° of  Reaumur ;  and  in  place of one-third of the
tincture, he employed in three of his patients, only one twenty-fourth
part.  This is not  honestly experimenting  with a therapeutical pro-
cess, to make trial of it with  such wide deviations!  For myself I
have up to the present time, (June, 1839,) made trial of it under every
variety of form. With the tincture in its pure state or diluted one-half
or a third  or fourth part, injected tepid or cold, with a part only or the
whole of it left in  the cyst, and  using  it either in recent hydroceles
or such as were ancient  or  small, or of vast dimensions, or simple,
complicated, vaginal, hernial, acquired or congenital; in liquid hydro-
hematoceles, it  succeeds to admiration; but the best plan is to mix it
to the amount of one-half with water at the natural temperature and
to leave a portion  of it in the  diseased sac.  Though  I have decided 
HYDROCELE.
727
upon giving the preference to this formula, I nevertheless sometimes
use the tincture itself alone.   By becoming mixed with the serosity,
a portion of which also I leave in the sac, it  produces precisely the
same effect as if it had been diluted at first with  the same quantity
of water.  We have even the advantage in this way, of preventing
the escape of the iodine externally.   The alcoholic tincture of the
pharmacopeia,  is  the  only one which I have  made use of up to the
present time.   In conclusion, it is demonstrated to my satisfaction at
the present day, that in the treatment of different varieties of hydro-
cele, the alcoholic tincture of iodine in injection,  produces precisely
the same results as the vinous.
  C. Complicated Hydrocele.—We have already  seen in treating of
the pathological anatomy of hydrocele, what might be the  possible
complications connected with it.  If the disease exists at the same
time in both the vaginal tunics, the rule is to perform  the operation
upon one side only at first; otherwise the inflammation might be fol-
lowed with too intense a reaction.   I cannot perceive, however, how
there could be the slightest danger from this source, if we made use
of the tincture  of iodine, except in the event that  the hydrocele was
of very large size.  Though it may be true that in certain cases both
tumors have been cured by operating on one only, this however is a
rare occurrence, and it is also  true  that in operating  on both sides
upon the same day, the patient is restored in one half the time that he
is in performing the operations successively.
  I.  When the hydrocele is composed of a turbid fluid, or one that
is sanguinolent, or simply lactescent, and that  the walls of the cyst
have not lost their pliancy, it is recognized by all  the different signs
above  enumerated, except  that of  its transparency.   Provided the
liquid is not overcharged with flocculi, and that there are no concre-
tions in the cyst, the iodine injection will  effect a cure in  the same
way as in simple cases.
  II.  If, on the contrary, there should exist fibrinous or  albuminous
masses, whether free or adherent;  if the matter,  in place of being
serous, is of the consistence of cream or of diluted chocolate ;  and
if the cyst is constituted of a thick hard shell, whether the contained
 matter be or be not altered, it may be affirmed that the method  by
 irritating injections will in most cases be found insufficient.  In such
 cases, excision is  the process generally preferred.  I have  myself
 made trial of it, and I have succeeded, but it  is a  painful and serious
 operation.  In some cases it is followed  by a considerable degree
 of inflammation  and fever.   The suppuration does not dry up, and
 the wound will not cicatrize until after the expiration of one to two
 months.  Since the year 1834, I have substituted instead of it sim-
 ple incisions  and a  seton.  With  a - straight  bistoury,  I  make  by
 means of a puncture an incision an inch long, upon the point of the
 tumor where  the trochar is to be inserted.   The liquid  escapes,
 while the finger pressed upon the cyst, detaches  and expels from  it
 the concrete pelotons.   If the cavity has but little extent  I stop at
 this  point, and encourage suppuration by keeping the wound open
 by  means  of  a  tent.  In the  contrary  case, I  incise in the same
 manner the depending point of the  sac, and insert through the two
 wounds a thin meche of linen, after the manner of a seton.  By pro- 
723          NEW ELEMENTS OF  OPERATIVE SURGERY.

ceeding  in  this manner, we produce  a tumefaction and reaction,
which reach their highest point of intensity from the fourth to the
eighth day,  and which afterwards decrease and allow ofthe foreign
body being  withdrawn, from the fifth  to  the  tenth day.  The pa-
tients  whom I have treated in  this manner have  recovered in the
space of from twenty to thirty days.  In one of them the seton was
not  employed, but I traversed the cyst with five large incisions in
place of two.'  It is well to recollect moreover, that in this compli-
cation the testicle and its envelopes, after the cure, remain manifestly
larger than upon the opposite side, whatever may be the  mode of
cure which  has been pursued.  Excision, therefore, does not appear
to me to be indispensable, except  in those rare cases  in which  the
liquid is  surrounded with a stony, osteo-calcareous  or simply creta-
ceous shell,  one instance of which has been seen  by myself, another
by M.  Mott, and three by M.  A. Cooper.   Upon the supposition
that we should decide upon this process in other cases, it would be
more advisable, I thjnk, to excise a fourth or fifth of the lardaceous
shell, rather than remove nearly the whole of it, as is recommended
by Boyer.   I have  operated in this manner on two patients, and
with decided advantage.
   III.  The  same remarks are applicable  to a hydrocele  rendered
double on the same side by a complete partition in the tunica vagi-
nalis, as to a double  hydrocele,  properly so called.   That  is to say,
that, we  may operate upon both of them at the same time, or upon
the second,  after having cured  the first.  Their proximity perhaps
would  render the inflammation of the second somewhat more proba-
ble after operating upon the first.  I consider, however, that unless
there are particular objections to the contrary,  it would be better to
proceed  immediately to the injection of both cysts.   In a man 51
years of age I  injected at first only one  of the hydroceles.   The
swelling and other local  symptoms  of inflammation  were  very
strongly  marked,  but it  nevertheless became  necessary to operate,
three weeks subsequently, upon the second sac.
   IV. When the accompanying tumefaction  of the  testicle, or ofthe
epididymis, is unattended  with pain, and inconsiderable in extent, all
practitioners agree that we  should pay no attention to it, and  look
only to the hydrocele; but, if the  tumor constituted of these parts,
says Boyer,  should be lancinating and bosselated, the injection would
accelerate the degenerescence.  Experience has shown me that this
assertion is erroneous.   I have made use of vinous and iodine injec-
tions in many cases of  hydrocele complicated with hypertrophy, tu-
bercles ofthe testicle and scirrhous or encephaloid sarcocele already
far advanced, and yet the tunica vaginalis has been obliterated with-
out  the primary disease having been aggravated  by the process;
moreover this injection, in reality, is one of  the best resolvents  that
can  be employed  in chronic engorgements  of the  testicle. I have
thus used it  in patients who had the epididymis as large as an egg,
slightly flattened, bosselated and painful, and thus  affected for  the
space of several years, but  who  were rapidly cured by it without
other treatment.   I have even come to the  conclusion that in cases
of testicular  engorgements  complicated with hydrocele, and where
doubts exist upon  the propriety of proceeding at once to castration, 
HYDROCELE.
729
it would  be advisable to  have recourse, before doing anything else,
to injections with  tincture of iodine.
  V.  The multiplicity of  cysts  in  the tunica vaginalis,  a disease
denominated hydatid hydrocele by M. Larrey, is  incompatible with
the process of injections.  The  tumor, in such cases, represents a
coarse sponge, (eponge  a large mailles,) which cannot  be emptied
completely by a  simple puncture,  nor inflamed in every part of it to
a sufficient extent,  and the septa of which might be liable to mortifi-
cation, especially from wine.  This is what took place in 1833, at La
Pitie, in an English laborer, in whom it became afterwards necessary
to remove the testicle.  In such  cases the operation  by incision is
evidently preferable to all others.  The scrotum and all its cells are
to be largely laid open by means of a convex bistoury.   Small balls
or a pliant roll of lint being inserted  between the lips and down to
the bottom ofthe wound, compel the whole to suppurate, after which
the cavity is to be  cleansed and  cicatrized in  the  same way as any
abscess laid open by  a large incision.
  VI.  The complication  of a varicocele would change in no respect
the treatment of  a  hydrocele, any more than would  the presence of
a tumor or any lesion whatever, in the track of the inguinal canal.
  VII. It is not altogether the same, however, with a hydrocele com-
plicated with   scrotal  hernia; should it be an enterocele, it may in
fact happen, under such  circumstances,  that  the  intestine has pro-
truded into the tunica vaginalis, and that it shows itself there naked
through some  rent  or actual perforation and may encounter a species
of strangulation.   Cases  of this description have been noticed  in the
practice of Dupuytren, at the Hotel Dieu, and in that of M.  Berard,
the elder, at the  hospital  of St. Antoine.   Setting  aside  the  embar-
rassment which such  an  arrangement must  create in regard to the
diagnosis, whether  in  relation to the  hernia, or the strangulation, or
the hydrocele, the  surgeon should not forget that by means of the
puncture  he may wound the hernia  before arriving into the tunica
vaginalis, should  the intestine  occupy the anterior plane of the tumor;
or that he may do  so  after having traversed  the vaginal sac, should
the intestine be  behind ;  and that if through  an ancient or recent
opening a vinous injection should come to penetrate into the hernial
sac, the most serious  accidents might be thereby produced.  Before
all else, therefore,  the hernia must be returned.   If after that, the
pressure does not cause the disappearance of the hydrocele,  we can
proceed without  danger  to the irritating  injection, inasmuch as  we
then have the  proof that  the  tunica vaginalis does not communicate
with the  peritoneal cavity.   For greater security, however, it will
be advisable to compress the  ring and to^proceed in the same way as
will be mentioned  under the article Congenital Hydrocele.
  VIIL Chronic affections of the integuments of the scrotum, such
as eczema, syphilitic indurations and  pustules, constitute no objection
to the operation for hydrocele, in the same way as in uncomplicated
cases.  I would make the same remark of an incipient elephantiasis,'
if the effusion  into the tunica vaginalis was in such cases worthy of
the "slightest attention.   Should there  exist  a simple erysipelas, we
ought to wait until  this has been cured.   Phlegmonous erysipelas, on
the contrary, as well   as  inflammation  of the  interior of the serous 
730           NEW ELEMENTS OF  OPERATIVE SURGERY.
 cyst, would require that we should proceed at once to multiplied and
 deep incisions.
   D.  Congenital Hydrocele.—By this name is to be understood the
 hydrocele of  a tunica vaginalis, in which the  cavity has not yet
 become separated from  that  of the  peritoneum.   We perceive by
 this that it can rarely be met with except in children.   Its formation
 is explained by the primary relations of the testicle with the abdomen
 on this subject, in truth, there exists a degree of anatomical ignorance
 which ought to be corrected.   The species of cord, in fact, which
 extends from the inguinal canal nearly as far as to the kidney, where
 the testicle is  first found, and which, since the time of Hunter, has
 been  known  under the name of gubernaculum testis, is not consti-
 tuted, as is supposed, of an infundibuliform  prolongation of the sub-
 cutaneous fascia.  I  have seen in specimens prepared by Thomson,
 that it was formed by  the cremaster, and that this muscle taking on
 the form of a noose with  its convexity upwards, and in a direction
 the reverse of that which it subsequently assumes, is perfectly adap-
 ted for depressing the testicle down to the ring.  I will remark that
 according to the same specimens, we are compelled to admit, con-
 trary to the opinion of Scarpa, that  the inguinal  canal  is, to say the
 least, as oblique before as after birth and in the adult;  that the tun
 rings of this canal, so far from being situated exactly one  behind the
 other, are also  separated  by quite a long track.   However this  may
 be, the testicle does not pass  through the parietes of the abdomen
 without being  accompanied by a prolongation of the  peritoneum.
 Now it is in this appendage or in the infundibulum which is produced
 by it, that  congenital  hydrocele  takes place.   If in depressing the
 peritoneum the  liquid should form a tumor which becomes lodged in
 front  of or behind  the cremaster muscle, the hydrocele alone might
 exist  in  the scrotum below the testicle, which has been  still retained
 or which remains concealed  in the inguinal canal.   In some cases the
 arrangement is  entirely the  reverse; the testicle descends first and
 the aqueous tumor is seen  above it;  but in most cases the hydrocele
 and  testicle  present  the  same relations as in ordinary hydrocele.
 This malady, which Viguerie was the first to investigate with atten-
 tion, and which is sometimes seen in new-born infants and  in the first
 months of  life, is also afterwards found up to the  age of eight or ten
 years, but rarely at a later period.   Though we might admit that the
 serosity  could directly  reach this cavity from the abdomen,  I  am
nevertheless of opinion that it is in most cases exhaled by the tunica
 vaginalis itself.   The frictions  ofthe scrotum during the progress of
 parturition, the irritations which are caused by its coming  frequently
in contact  with the urine, and  all those different kinds of pressure
to which it is  exposed during  the first  periods of intra-uterine life,
 furnish, as  it appears  to me, a better explanation than the supposition
 of a diseased condition in the abdominal peritoneum.  Moreover U
 appears  to me  to be  imputable to the same causes as  hydrocele in
the adult, unless it be however that it rarely arises from an affection
of the testicle.   It is  distinguishable from every other kind, by our
being  enabled  to empty  the tumor by  pressure, and  to cause its
 liquid to return  into the belly.   The age  of the  patient is of itself
 sufficient to lead us to suspect  its character.  As  it diminishes when 
HYDROCELE.
731
the patient lies down and augments when he is  standing up, there is
scarcely ever as great a degree of tension of the scrotum as in ordi-
nary hydrocele.  The communication of the cyst with the peritoneal
cavity,  moreover, is so contracted in most cases, whatever may be
the position of the testicle, that pressure does  not cause the disap-
pearance of the serosity, but makes the tumor return rather in mass
through the external ring.  The prognosis of congenital hydrocele is
at the same time less serious and more so than hydrocele in adults; less
so, because the disease disappears more  readilywithout an operation ;
more so, because the operation, should  it become necessary, would
seem to be more dangerous.  Its  two principal inconveniences  are
that of interfering with the development ofthe testicle or in retarding
its descent, and also of exposing the child to the risk of hernia of the
tunica vagnalis. It gets well frequently without any remedies, and by
the progress  of age alone.
  Compression by means  of a  pelote methodically sustained upon
the ring, together with topical resolvents, will be found  sufficient to
cure the patient in a great number of cases.  I  have seen two cases
of this kind cured in children of from  5 to 7 years of age by the em-
ployment of  simple  compresses saturated with  lead water.  Unless
therefore from  some particular  indications to the contrary, we must
not be in too  great a hurry to operate. The  same methods, moreover,
are applied to this as to hydrocele in  general.   Incision, excision, the
tent, the seton,  and acupuncture, would  be  still more dangerous than
injection, by  reason of the suppuration which they give rise to,  and
the effusion  which  might ensue into the   peritoneal cavity.  Con-
genital  hydrocele, moreover, being  scarcely ever complicated with
hematocele  or  any considerable degree of thickening in the scrotal
tunics, presents no indication for  the employment of these different
methods.  As to  irritating injections, these  have been  proposed by
Viguerie; but  almost every surgeon of the  present day is decidedly
opposed to them.   The reason they advance is  this, that during the
operation it is almost impossible, notwithstanding  the most accurate
compression  made upon  the  ring, completely  to prevent the wine
from penetrating into the peritoneal cavity,  and  that in such cases we
should be in  danger of substituting a fatal inflammation, or  peritoni-
tis, in place of an affection of a mild character.   I cannot however, in
any manner, concur with Desault in bis fears on this point.   A young
boy operated upon by Mignot, with the vinous injection, at the hos-
pital of Tours  while I was a pupil there, was cured without having
undergone the  slightest accident.  I have performed two similar ope-
rations, and have been no less fortunate.  In the first place, it is easy
to avoid the  introduction  of any liquid into  the  abdomen at the  mo-
ment of injection; for  this purpose it  is sufficient to  press the thumb
into the ring with a certain degree of force  upon the pubis, while the
assistant is throwing up the injection.   The surgeon might  even do
it himself with one  hand, while holding the canula with the  other,
should there  be no assistant to  whom this duty could be assigned du-
ring the injection.   A  few drops of wine, moreover, in the cavity of
the peritoneum would expose  to but very trifling danger;  a certain
quantity is requisite to produce a serious inflammation.   M. Cloquet
speaks of a patient who had in this manner received several ounces 
 732           NEW ELEMENTS OF OPERATIVE  SURGERY.

 into the abdomen,  but who nevertheless survived.   The swelling
 which succeeds the injection, would not allow of the few drops which
 might be remaining in  the  tunica vaginalis to ascend into the belly.
 As to  the  inflammation of the  cyst, it is of an adhesive  character'
 which has but very  little tendency  to  extend beyond  the surfaces
 which have been in contact with the wine.  Finally, tincture of iodine.
 rendering  it unnecessary to distend the  sac, being readily absorbed^
 and causing only a moderate degree of  inflammation, and but very
 little reaction, presents moreover, if I do not deceive myself, all the
 security required under such circumstances.   I am of opinion, there-
 fore, that congenital should be treated with tincture of iodine in the
 same way as  ordinary hydrocele, with  the  precaution only of clos-
 ing the inguinal canal with  the thumb, during the injection, and with-
 out the necessity of afterwards keeping up this  compression by means
 of a pelote, or  any bandage whatever, as some  persons have re-
 commended.
   E. Hernial Sac.—Hydrocele  of the  hernial sac  differs in more
 than one respect from hydrocele of the tunica vaginalis, and presents
 itself also  under various forms.  In some cases in fact, there is at the
 same time  both  a hydrocele and a hernia  in the same sac. and in other
 cases a hydrocele  only in a sac which has been deserted by the vis-
 cera.
   I. The first case, though  generally passed over in  silence, is quite
 frequent.   The  contained intestine is then found to be at the root of
 the tumor, and plugs up more or less completely either the crural or
 the inguinal ring;  the liquid surrounds it, and  becomes accumulated
 below it.   It is  difficult for a hydrocele of this character to exist
 without some  symptoms of  strangulation, should the hernia  be formed
 by the intestine, and difficult  therefore to confound it with a  hydro-
 cele, properly so called.  Should  there be, on the contrary, any of
 the epiploon,  it is easy to  conceive  that the tumor might  be  so
 arranged as to simulate in almost every point  a hydrocele.  A kind
 mass, of a certain degree  of solidity filling up the canal and pro-
 longing itself  towards the iliac fossa, and' constituting  the root of the
 turnor, together  with the  fixed position  of this last, the presence of
 the testicle below  under the form of a small suparadded tumor, and
 also the signs of epiplocele, should any of these be present, would en-
 able us to distinguish it in a large number of cases ; but it  is evident
 that we would  be liable  to be deceived in some others.  Suppos-
 ing, however,  that the disease should have been recognized, and that
 the hernia  should not have  caused in itself any accident, what ought
 we to do ?  I do  not hesitate to say that it would be advisable to apply
 to it, as I have in three instances done with success, the treatment for
 congenital hydrocele.   Should the hernia occasion ever so slight a
 disturbance, it would be better, I  think, to lay open the sac  and to
 proceed as in strangulated hernia.
  II.  The  second variety is better known than the preceding.  Le
 Dran had already spoken of it, and the case which he relates possesses
also this remarkable feature, that there was  at  the  same time an
encysted hydrocele of the cord, together with hydrocele in the tunica
vaginalis,  and an  hydrocele in a hernial sac.  Its formation, more-
over, is easily  explained:  a reduced hernia  leaves  an empty sac, 
HYDROCELE.
733
which may  be filled with serum on the following day, or closed up
above at the expiration  of a few years,  if a hernial bandage has
been properly  maintained.  This sac  being only a simple serous
cyst then, scarcely differs any longer  from the  tunica vaginalis.
Several  pouches may in  this  manner be successively  established
from the reproduction of  a hernia at different  intervals  of.  time,
more or less distant.   In a patient operated  upon  by M. Belmas
and myself, in 1831, there was one of these cysts of the diameter of
a small egg, together with a small sac of  much less  extent, and at
the same time a large  sized hernia.   This variety of hydrocele, while
presenting, or being capable of assuming  a certain resemblance to
varicocele, might be still more easily confounded with hydrocele
of the cord, or should the cyst  be large, with a  hydrocele of the
tunica vaginalis.  The pre-existence of a  hernia, however, together
with the development of the tumor from above downwards, and the
isolation of the testicle and its  position below the  sac, constitute
so many.characters which might lead to a  correct opinion.  I do not
consider that  there would be the least danger in operating for it,
in the same way as  for simple hydrocele, provided we took  care
to close the ring during  the injection  into the cyst.   Facts  of this
description, collected in my department, have been published in seve-
ral journals, (Presse  Med., 1837—Bull, de Therap.,  1838, 1839—
Gaz. des Hopit., 1839, p. 106.)   Should  the possibility of a commu-
nication  with the peritoneal cavity, or the  multiplication  of sacs in-
spire some apprehensions, incision would be the  best  remedy; the
cyst  should afterwards  be filled with small  balls  of soft lint, in
order to excite suppuration in  it, and  to cicatrize  it after the man-
ner of an abscess.
  F. Hydrocele of the  Cord.—The spermatic cord  being  consti-
tuted of a certain number of lamellae, united together by loose cellular
tissue, presents one of the most favorable anatomical arrangements
possible for  the formation of  cysts  and  different descriptions of
infiltration: consequently  there have been  long noticed in this  part
the two varieties of hydrocele, viz., that  by infiltration and that  from
effusion,  or what is called encysted  hydrocele.
  I. Infiltration, whether sanguineous, purulent, or serous,  and
oedema, whether idiopathic or symptomatic, may well be the  source
of a hydrocele from infiltration of the cord, but do not constitute this
form of disease.   This disease, which is essentially local and chronic,
is made up of  a more or  less considerable  number of small cysts or
cells filled with serosity,  occupying sometimes the entire length of
the cord from the epididymis to the iliac fossa, and sometimes a part
only of this organ, either in the direction of the scrotum or that of
the inguinal  canal.  Its causes are  but little known, and the exam-
ples of it are quite rare.   The tumor presents itself under the  form
of a bosselated soft cord, without any pain or cakiness, (empatement,)
or change in the color of the skin, of the  diameter of an inch, or a
little more, or  somewhat less, and which  is arrested  by a sort of
strangulation  at the root of the testicle or  above it, or occasionally
prolonged to  a considerable  distance into  the inguinal canal.   This
tumor, constituting a portion of the body of the cord, being incapable
of being either depressed  or raised up without  the testicle, and 
734           NEW ELEMENTS  OF OPERATIVE SURGERY.
possessing a very great degree  of mobility, and existing indepen-
dently of the scrotum, properly so called, will occasion, when pressed
upon in a certain manner, a pain analogous to that wiiich is produced
by pressure on the testicle.   Hydrocele, by infiltration, occasions still
less annoyance to the patient than hydrocele of the tunica vaginalis.
As  it rarely acquires a large volume, those who are affected with it
are frequently unconscious of its  existence during the space of seve-
ral years.   When, however, it exceeds the dimensions of an inch, and
occupies the inguinal canal, the solid walls which it is obliged to dis-
tend, ultimately render its presence annoying and sometimes quite
painful.   It may,  moreover, whatever be its position  and size, react
on the vas deferens and  fatigue the testicle.  Finally, its indefinite
increase, or any other circumstance, may cause it to inflame and
transform it in  reality into  a serious  disease.   Provided it  occa-
sions ever so little disturbance  therefore, or has  attained a consider-
able volume, it is advisable to relieve  the  patient of his difficulty.
Though it may be true that hydrocele of the cord by infiltration may
disappear without an operation, this result at least must be a rare
occurrence, for I know no examples of it.   I will add, that the pallia-
tive  cure is not applicable to this disease.   Either we must do nothing
or undertake an operation  calculated to effect a radical cure.  In
these cases,  caustics, excision, the seton, a  tent, and  even injection
itself, should be proscribed as dangerous or  of no utility.  By trav-
ersing the whole tumor in the direction of its length with a simple
thread, as I have done in  one instance, we should not succeed  until
after having transformed  it into an abscess, which it would  almost
always be found necessary to  open largely at a  subsequent period;
incision, in fact, is almost the only remedy for this  disease.  In the in-
guinal canal, this operation would be very dangerous, and we should
not decide upon it unless  the hydrocele should have actually caused
serious accidents.   Between the ring and  the testicle, also, it is not
without its inconveniences, since  it  incurs the risk of wounding the
vas deferens, as well as the spermatic veins and  arteries.  It is im-
portant also, in order to ensure success, that  the  infiltrated cylinder
should be laid open throughout its whole extent.   Whatever be the
method chosen, it  is an operation  more serious than that for vaginal
hydrocele, and one which it would be advisable not to perform unless
we are, so to speak, forced to this step by the annoyance which the
malady produces.   The patient is to be laid upon his back, as in the
operation for hernia.   The surgeon with  his left  hand grasps and
gives tension and  prominence  to the tumor  in  front, while with  a
straight  or convex bistoury in his  right  hand, he divides, layer by
layer, all its envelopes.   Down to the cremaster muscle  there  is no-
thing to fear, but before going farther, he should satisfy himself as to
the actual position of the epididymis, because it. indicates  in  what
direction he is to look for the  vas  deferens.  This last is usually be-
hind, accompanied with the spermatic artery, and on the other- wall
of the hydrocele we meet with the veins.  Nevertheless, it would be
better to penetrate at that point than near the artery, unless it were
found impracticable to go between those two descriptions of organs.
After having laid open and emptied, by making pressure, all the infil-
trated cells, and  after having  checked the hemorrhage, if any has 
HYDROCELE.
735
taken place, the  whole wound  is to be filled up with  a pledget  or
small balls of lint; the perforated linen,  plumasseaux, some com-
presses, and a suspensory, are applied over these, and the dressings are
afterwards conducted in the same manner, as has been said in speak-
ing of the method by incision in general.   As soon as  the suppura-
tion is established over the entire surface of the  cavity, some advan-
tage will be derived by favoring the approximation of the lips of the
wound by means of adhesive plasters.  The cure  will be thus obtained
in fifteen days or a month, rarely sooner, but sometimes later.
  II. Encysted Hydrocele.—Encysted hydrocele of the cord, though
sometimes a  primary disease, quite frequently also succeeds to the
foregoing variety, which latter  constitutes, so to speak, only its first
stage.  It may be easily  conceived, in fact, that in the course  of
time one or  more of  the cells of the infiltrated cord  may  become
enlarged and more distended than the others, and  thereby soon con-
stitute actual cysts that will  engage all our attention.   Encysted hy-
drocele of the cord, moreover, is sometimes simple  and sometimes
multiple.   Its form  is usually globular or  ovoid, and its  volume
varies from that of a small nut to that of the  fist; but in general it is
of the size of that of a large nut or a pullet's egg.   Both  during  its
development, and in  its condition as  a tumor, it presents the same
characters as vaginal hydrocele, but  its differential  diagnosis  is at-
tended with some particular difficulties:  it is not either with varico-
cele, hernia, sarcocele,  or hematocele, that it can be confounded, but
it may be with a supernumerary testicle.   Scarpa gives an  account
of a mistake of this kind, and in 1836 I saw at La Charite one of the
most remarkable facts  under this point of view.  In a man about  30
years of age, the  volume, form,  density, and mobility of the cyst,
were so precisely similar to what is  seen in the testicle, that after
having purposely changed the position of the two masses in presence
of assistants, I was enabled to deceive several very experienced sur-
geons.  In this case the abnormal sac had  existed from infancy, and
the patient considered  that he had three testicles.  In  examining it
more closely, however, it was soon perceived that there was no epi-
didymis under the cyst, and that the cord  which occupied its place
behind was prolonged  as  far down as to the lower tumor.  Com-
pression also  served to distinguish the two tumors, since it caused
scarcely any pain in one, while  in the  other it produced the sensation
so characteristic from pressure  on the testicle.  In associating with
these particular signs, the  transparency of the cyst and the  opacity
of the seminal gland, we had and others will have, in  such  cases  as
I have proved in two instances, in  1837 and 1838, sufficient indica-
tions to remove all doubts, should the other  characters of the tumor
have left any uncertainty in the  mind of the surgeon.  It is never-
theless true that the  diagnosis  of encysted hydrocele of the cord is
sometimes sufficiently difficult.   Whether it  be  monolocular or mul-
tilocular in fact, how,  when the tumor or tumors are  found in  the
neighborhood  of the inguinal canal, can we distinguish this disease
from cysts formed by ancient hernial  sacs? If,  as  I  consider, this
disease is quite frequently established in a remaining free portion of
the  ancient peritoneal  canal, and if in growing large it  inclines in
the  direction  towards  the testicle, who is the.-e  that  would not be
* 
736
NEW ELEMENTS OF OPERATIVE SURGERY.
 liable to confound it with a hydrocele of the tunica vaginalis ?  How
 moreover can we be certain that the pouch or small pouches are not
 caused by abnormal or morbid  adhesions  of the natural serous en-
 velope of the testicle,  as in one of  the cases which I have above re-
 lated ?  Fortunate will it be if these embarrassments in the diagnosis
 have no bearing  either upon the prognosis or treatment of the dis-
 ease, for it may be absolutely  impossible to unravel them.  Encysted
 hydrocele of the  cord is scarcely ever seen under an acute form;  it
 usually progresses, on the contrary, with an extreme degree <>f tar-
 diness.  As  it rarely exceeds the size of a large egg, it scarcely pro-
 duces any reaction upon the testicle, while it  occasions  but very
 little annoyance to the patient.  I  have also met with numbers of
 patients who have never expressed the least desire to make trial of
 any remedy for their relief.  All that I have said  upon the subject
 of the treatment  of hydrocele of the  tunica  vaginalis, is applicable
 also to this disease.  Modern surgeons, who have  asserted that the
 tumor was situated too deep, surrounded with some of the elements
 which make  up  the cord, in too near neighborhood to the perito-
 neum, &c, have overlooked the fact that these circumstances would
 render the incision or excision which they recommend much more
 dangerous still than injections, which they proscribe.  Apart from
 the testicle the relations are in reality the  same here as  in vaginal
 hydrocele ; and should the cyst have  ever so little volume, it would
 still be the method of injections which would be best adapted to it.
 I have operated upon  ten patients in  this  manner, and have never
 procured results more complete or  more  simple..  I would therefore
 recommend that we should  never proceed in any other  manner, and
 that we should not employ incision, or the  seton, which is still pre-
 ferred by M. Brodie,  (Arch. Gen.  de Mid., X. XIV., p. 77,) nor ex-
 cision, unless there should be several cysts, or that the tumor by be-
 ing prolonged  into the  inguinal canal, should lead to the suspicion
 that there was a communication with the cavity of the peritoneum.

                  § II.—Hydrocele in  Women.

  Scarcely any attention has been  paid to hydrocele in women until
 during the last half century.  A passage in Aetius leads to the suppo-
 sition that Aspasius had noticed it.  Pare  mentions a young girl, six
 to seven years of  age, who  was affected with it; Desault  and Lalle-
 ment also have each met'with an example ; but it is in Italy especially,
 in these latter times, that it has  been the subject of special researches.
 Paletta first,  M.  Sacchi afterwards,  and more  recently  still AI.
 Regnoli, have gone more minutely into the details of this matter than
 any person  had ever done  before  them.    The researches of  these
 observers would   go  to confirm the  opinion, which was already
 ancient, of those who consider that in women hydrocele has its seat
 in a peritoneal prolongation known under the name of the ligament
 of Nuck, and  which,  making  its  exit through the inguinal  canal,
becomes the counterpart  to the tunica vaginalis.   M. Regnoli con-
siders also that there may be both a diffused and an encysted hydro-
 cele of the round  ligament: he likewise speaks of a hydrocele in an
ancient hernial sac, and facts are brought forward in support of these 
HYDROCELE.
737
opinions. An attentive examination ofthe principal subdivisions of this
question has long since convinced me that it stood in need of farther
investigations.  I have various reasons for believing, for example,
that several, if not all  the tumors described up to the present time
under the name of hydrocele in women, consisted of nothing more
than serous,  sero-sanguineous  or sero-mucous  cysts of the labia
majora or mons veneris. In the first place, the round ligament of the
uterus  does not,  as I had  supposed with all anatomists, lose itself
ultimately in  the apex of the vulva.  I have proved, as Thomson
has, that this  cord  terminates on the pubis and in the posterior wall
ofthe inguinal canal.  It follows from this, that-the peritoneum is not
prolonged outside of the belly in the  form of a cul de sac as in man,
and thus we cannot understand how a hydrocele, similar to that of
the tunica vaginalis, can take place in woman.  Seeking afterwards
in the facts published the proof of the results they have deduced from
them, I have found none of them conclusive on this point.   The cyst
was between the ring and the labium majus in the  cases of Pare,
Desault and Lallement, and in two of those of Paletta.  The labium
majus itself was the seat ofthe cyst in many other cases.   The com-
munication with the peritoneum was  scarcely established satisfac-
torily except in a single instance, and even  in that it  is possible  that
this communication may have been made by the surgeon  himself at
the moment of the operation.   As to the examples of hydrocele of
the round ligament, whether diffused or encysted, there is no reason
why we should not consider them as facts, with this proviso, how-
ever, that it would be erroneous to compare them with those which
have been encountered in the spermatic cord in man.   I  will add in
the third place, that having seen four women affected with the disease
in question, I  ascertained  in  them, at least  to my satisfaction,  that
the  cases were those  of accidental cysts,  and not effusions  into a
primary peritoneal sac.  These women, who were all of a  certain
age except  one, who was  only twenty,  had severally had these
tumors  for  the space  of one, three,  eight  and eleven years.  The
cyst was of the size of an egg, or somewhat less.  In one it was seen
in the  mons veneris in front  of the ring, but in the others it occu-
pied the upper half of the  labium majus.  Two  of these hydroceles
were filled with  a thin and glairy matter like that of the white of
an egg; in the two others it consisted of a serosity of a slightly rose
colored tint.   The sac, which was  smooth like a mucous or synovial
bursa in its interior, had walls of the  thickness of three  to  six lines,
though quite pliant.  These tumors certainly had no relation nor any
continuous connection, at  least with the  peritoneum or  the round
ligament.  Might not such cysts be the consequence of former effu-
sions of blood produced by frictions  or contusions?   What  I have
seen so often  underneath the  skin and  in serous cavities  in general,
would authorize  me to make this suggestion, but would not  be  suf-
ficient, I confess,  to establish its truth.
 However this may be, cysts known under the name of hydrocele
in women, are movable tumors, without pain and  globular, elastic
and fluctuating, with walls which  are generally quite thick, and in
which it is rarely possible to discover any transparency, having then-
Beat sometimes in the middle portion, sometimes at the upper  part of 
738           NEW  ELEMENTS OF OPERATIVE SURGERY.
the labium  majus, in other cases in front of the ring, or even in the
inguinal  canal.   The  development,  progress  and consequences of
such tumors are the same as those of encysted hydrocele ofthe cord
in man.   Their position, however, in the midst of a  cellulo-adipose
tissue, which  is sometimes considerably abundant, and the friction
which is made upon them during coition or parturition, render both
their  diagnosis more difficult and their prognosis more serious. It mav,
in fact, be conceived that in the course of time a tumor of this kind
might become inflamed and transformed into an abscess, or acquire
a considerable degree of size an i weight.   The treatment, however,
is the same  as in that of encystsd hydrocele of the cord:  caustics,
the seton, tent, acupuncture, incision, excision and the different kinds
of injections, therefore, could be applied to the disease.  Whatever
may be the  method  employed, there is  this thing to be remarked,
that the operation for  hydrocele in women is scarcely accompanied
with  any danger:  there are no testicles or spermatic cord to be
respected; no infiltration to be apprehended during the injection; in
fact, scarcely  any of those results wrhich might create alarm in ope-
rating upon man.  The important point, therefore, is to choose the
best of these different  processes : and in this  respect there can be
no doubt  that injection, incision and excision are much preferable to
the other methods.   If the  cyst is thin, supple and filled with serosity
only, and  if  it is at the same time of considerable size, the treatment
by injections is better  than  any  other.  When the tumor does not
exceed the  size of a small  egg, and its walls are not too much in-
durated, incision is preferable.   Excision  would have more advan-
tages, on the contrary, if the case in question was one of hydrocele
with lardaceous walls filled with thick or flocculent matter, or in
part liquid and in part concrete.   In whatever way we  proceed, I
lay it down  as a rule,  to direct  the  instrument upon the cutaneous
wall of the tumor, even though it might  be possible to attack it upon
its mucous or vaginal  side : this is a rule which I  follow for all col-
lections in the vulva, whether they be sanguineous, purulent, serous
or otherwise, and one  which I have adopted because the vulval and
vaginal humidities are a real impediment to the cleansing and speedy
cicatrization of suppurating cavities in this region.  The cyst, more-
over,  should be laid open throughout its  entire  length or a large por-
tion of it excised, for there is no necessity in these cases of preserv-
ing its parietes.   I would add, that if the tumor should be  very
movable under the skin, we might advantageously substitute extirpa-
tion to excision or incision, and that unless some very particular objec-
tion should exist, cysts developed in the interior of the inguinal canal
should be treated by  incision  only.   The possibility of pushing the
irritating  liquid into the abdomen, and of wounding  the peritoneum
or some important vessels, as the epigastric artery for example, would
not justify the employment of injection or excision in such cases, ex-
cept under  peculiar circumstances, and would be almost always a
sufficient  reason  for restraining the hand of the surgeon.
   [Iodine Injections in Hydrocele,  6fC—In an animated discussion
which took  place in  the  Royal Academy of Medicine of Paris, Sep-
tember 9, 1845, and which  continued during several  subsequent sit-
tings, (see Arch. Gen.  de Med., January, 1846, 4e ser., t. X.. pp. 103. 
HYDROCELE.
739
104, and Ibid., February, 1846, p. 226-234,)  on the occasion of a
report of our author, M. Velpeau, upon a memoir of Dr. J. Roux on
iodine injections, employed  successfully by the latter in a case of
scapulo-humeral hydarthrosis, we perceive that the professor of La
Charite still strenuously  adheres to this practice, which has now,
chiefly through his  exertions and the  successful results he has ob-
tained from it, become  generalized  among the  surgeons of most
countries.  M. Velpeau insists, especially,  on the superior advan-
tages of iodine injections in  hydropsies of shut cavities, and also in
hydarthrosies and hydroceles.  In the debate which succeeded to M.
Velpeau's report, Professor Roux  stated that he  considered vinous
injections had  been unjustly censured: that he  had employed  them
in no less than fifteen hundred cases, of which number four only had
terminated fatally.   Wine  he thinks  full as  good  as  iodine, and
besides it is far cheaper, and also accessible to every one.  In hydar-
throsies he prefers the ordinary treatment, and thinks puncture should
not  be resorted  to but as an extreme measure, as  it is  by no means
without danger.  M. Blandin coincided  with Professor  Roux, and
was surprised that  M. Velpeau had  not  mentioned in his treatment
of effusions into the  joints, the importance of strong mercurial unc-
tions, together with immobility, and compression  by means  of the
starch bandage, (appareil inamovible.) He does not reject puncture,
but  dreads the admission of air into the articular cavity.   In hydro-
cele he considers iodine more feeble -and  less certain than vinous in-
jections, and, in support of this, gives cases where the wine succeeded
in effecting a perfect  cure  after the iodine, administered according
to M. Velpeau's directions, had wholly failed.   M.  Gerdy concurred
in the main with Professor  Roux and M.  Blandin, and seemed to
doubt the alleged successes of iodine in  hydrocele.  His argument,
however, against iodine  because it  acts as a poison, in experiments
on dogs, is at  best but one of a feeble collateral value.  He is to be
applauded, however, as we  think,  for  his  adhesion to the  more
rational doctrines  now prevailing  in favor of conservative surgery,
so far as relates to a rash resort to  puncture of close and  articular
cavities, the  peritoneum,  &c.   M.  Jobert zealously, supported the
principles laid down by M. Velpeau, founded upon the latter's bril-
liant and repeated  cures by iodine, and which cases M. Velpeau
again reproduced in opposition to the assertions of MM. Roux, Blan-
din  and Gerdy.  M. Jobert  does not deny  that  the  disease may
sometimes  return after iodine injections, but much less frequently, he
asserts, than  after the vinous.  Out of seventy cases  of hydrocele
treated by iodine the disease returned in three only.  Again, iodine
even when infiltrated  into  the tissues of the scrotum,  does  not, in
general, occasion gangrene;  and, even when it does, it is limited
and trivial  in importance  compared with  that  caused  by  wine.
And lastly, he asserts that poisoning need not be apprehended, as he
has  injected two hundred to two hundred and fifty grammes of pure
tincture of iodine into cold abscesses without any accident occurring.
  M. Auguste Berard, adopting the same views, stated that in 250 to
300  cases of hydrocele treated by him with  iodine, there were three
only in which the disease returned.   In  two  cases of hydropsy of
the knee-joint, it produced no effect,  and amputation had to be resort- 
740
NEW ELEMENTS OF  OPERATIVE SURGERY.
ed to.   In no case did he find any poisoning.   M. Laugier also con-
curred in these opinions, and considered iodine injections full as effi-
cacious, and also less painful than those of wine, and much more sim-
ple in their manual. He suggested however, that the efficacy of iodine
injections might  probably be  solely ascribed to  the alcohol of the
tincture.
  In conclusion, M. Velpeau eloquently defended his positions.  The
dangers of vinous injections, and the well known resolvent properties
of iodine, and the usual enlargement ofthe testicle, which accompa-
nies hydrocele, were his chief motives for the new practice.  En-
couraged by his remarkable successes, he tested the iodine in cases
of liquid hematocele, cysts ofthe spermatic cord, neck, limbs, and ova-
rium, and in cold abscesses, mucous bursa, and hydarthrosies.   He
found the inflammation thereby produced, in such close cavities, was
not only limited, and rarely diffuse, but that it possessed also the effi-
cacy of entirely destroying the disease by obliteration of the cavity,
or a specific modification of its walls.   He pointed out with minute
directions the  manual of the process, and the necessity of modifying
it according to the disease, and the greater or less irritability ofthe
patient, supporting all his statements on remarkable examples of cures
of unquestionable authenticity.  He then  proceeded to a thorough
examination ofthe pretensions of vinous injections, and demonstrated
with his ready erudition and his felicitous tact, in applying it to the
elucidation of truth, that vinous injections, however lauded to-day,
were deemed highly dangerous by a crowd of authors anterior to
this epoch, as he  showed  by his citations from a great number of
them, and among others, Boyer.  He also established, that a majori-
ty of modern authors are clearly in favor of iodine, and took the lib-
erty of explaining the failures mentioned, by ascribing these reverses
to the  surgeons  themselves, and not to the iodine, and that in the
cases of MM.  Chassaignac and Reihet, the injections were complica-
ted with incisions, and  therefore  that they were not fair data to
reason upon.
   The editor  of the Archives regrets that an exact comparative sta-
tistical table of the relative results of the two processes was not pro-
duced.  He must, however, be sensible of the impossibility of pro-
curing such details with accuracy, from those whose minds are al-
ready biased by preconceived predilections for either one or the other
mode of treatment.
   In respect to the employment of iodine  injections for the purpose
 of obliterating hernial sacs, it is to be remarked that the subject ap-
 pears to have been touched upon in the debate, but disconnected as
 far as we can perceive with any facts as yet obtained in Europe, on
 this new practice.  We have alluded to it in our first volume, and also
 above in this, and believe the idea is, in its application at least, alto-
 gether due to our own  countrymen.   Since our first volume was is-
 sued from the press, nothing has come to our knowledge to show that
 any further advances have been made in this mode of curing hernia.
   M. Guibourt, at the sitting of the Royal Academy of Medicine of
 Paris, Jan. 13, 1846, (Journ. des Conn. Med-Chir., Fevrier 1,1846,
 p. 72,) remarked that the  tincture of iodine produces different  effects
 according as it is fresh or  old.  The fresh or recent tincture is more 
HEMATOCELE.
741
irritating, from the iodine not being completely dissolved, but remain-
ing partially free, in a state of suspension in the alcoholic vehicle, on
which account it is deposited in a natural state (en nature) on the
tissues, and acts upon them with all the intensity that pure iodine is
known to do.   When the tincture, on the contrary, is old, the iodine
is not precipitated, in consequence of the new combinations brought
about by the prolonged action of the air ; it changes, however, more
or less, but its effect becomes less and less irritating.  M. Velpeau
had, up to Jan. 1, 1846, (see Journ.  des  Conn. Med.-Chir., Paris,
Janvier 1, 1816, pp.  10—12,) used iodine injections with entire suc-
cess in twelve to fifteen cases of hydarthrosis of the knee-joint, only
one of which was followed by anchylosis.  To avoid this,  a certain
degree of movement is exercised upon the joint immediately after
the injection, and these movements are to be continued until the func-
tions of the  knee are re-established.
  By the Compte Rendu of the surgical clinique of Prof. Bouisson of
Montpellier, for January, 1846, we are gratified in perceiving (see
AI. H. Rodrigue in Journ. des Conn. Med-Chir. de Paris, Mars 1,
1846, No. III., p. 116,) that the favorite iodine injections of our author,
M. Velpeau, in hydrocele, are  in great esteem at that celebrated
southern university of France.   They  are adopted by MM. Serre
and Lallemand in  lieu of the vinous, because they  rarely find them
followed by a return of  the disease, and are also  less  painful, and
never produce poisoning, (accidents toxiques.)   After the vinous in-
jections, gangrene, according to M. Rodrigue, (Ibid., loc. cit.) is a
very common occurrence ; but as yet we have only one well authen-
ticated accident of this kind from iodine, viz.  that related by M. Ca-
non, 1844.   At the hospital of St. Eloi, Montpellier, the solution em-
ployed is composed of equal parts of iodine and water.   It appears
that as long since as  March 20, 1841, an injection of tincture of
iodine (32 grammes to 4  of iodure of potash and 150 of water,) was
used with success, after tapping, in a case  of ascites, by M. Dieula-
foy, (see Journ. des Conn. Med.-Chir. de Paris, Mars 1,1846,  p. 125,
&c.) of Toulouse.  M. Dieulafoy, according to M. Velpeau, (Journ.
cit., Fevrier 1, 1846, p. 70,) has a second time used  iodine injections
into the peritoneal cavity with success in another case of ascites.
  Spermatozoa, or spermatic animalcules,  have been noticed in the
liquid of hydroceles, by M. Velpeau, (Arch. Gen. de Med.  de Paris,
4e ser., t. III., pp.  402, 403,) and soon afterwards also by Mr. E. A.
Lloyd, (Medico-Chirurgical Review, Oct.,  1843.)   T.]

                 Article  II.—Hematocele.

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

                              § I.

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

                              § IL

  The operation, which would be advisable under such circumstan-
ces, is the same as for an ancient hematocele.  We may then choose
between several processes.
  A.  The excision of the entire  thickened shell was the  method em-
ployed by Boyer and  his school, after the rules which  I  have laid
down above.   Dupuytren, who  also made use of  this  method, re-
moved only the free portion  of the tunica vaginalis, without making 
HEMATOCELE.
743
it a point of necessity, like Boyer, to dissect this shell as far down as
to its connections with the testicle.   These two  modes of operation,
which I have myself occasionally employed, are painful, laborious,
and dangerous.  It is frequently difficult to  respect- all  the  portions
of  the spermatic cord, and the vas deferens  has in more than one in-
stance been included in the excisions.  The  enormous wound which
it is  found necessary to  establish,  and the  abundant suppuration
which necessarily  ensues, expose to the  risk of consequences infi-
nitely more dangerous than those of  castration.
  B.  Some surgeons also- have considered, that it would be more ad-
visable to recur at once to this last operation,  than to subject the pa-
tient to a dissection, the only benefit from which would be to  preserve
a testicle, which in fact is too profoundly altered not to have lost its
principal functions.  Instances of castration performed under such
circumstances, are still met with quite frequently in our days.  M.
Piussan, (These, No. 215, Paris,  1825,) mentions one from the  prac-
tice of AI. Roux.  I am also  induced to believe that  the alledged en-
cephaloid sarcocele, mentioned by M. Sornay, (Ibid., No. 86, Paris.
1837,) and which was extirpated at the Val de Grace, was no  othei
than an hematocele.   I have  myself  adopted this method in two in-
stances in 1832 and 1833, even though I  had ascertained with cer-
tainty that the tumor was disconnected with anything of a cancerous
character.  In  a case of large  sized  and  ancient  hematocele,  M.
Voisin, (Gaz. Mid., 1839, p. 81,) having emptied the sac by  an injec-
tion, considered it  proper afterwards to remove the testicle.  At the
present time, however, it is requisite that this practice should undergo
a reformation on this point.   Hematocele requires ' neither  excision
of the tunica vaginalis, nor extirpation of the testicle.  I have treated
and cured a great  number of patients with this disease by either one
of the two following operations, and  which are the only ones I have
employed since the year  1834, whatever may have been the degree
of thickening or induration of the tunica vaginalis.
  C. Injection.—I begin  with a  puncture by  means of the trochar.
If the effused matter is sufficiently liquid to .escape freely through the
canula, I empty the sac of it as perfectly as possible' in the same man-
ner as in the hydrocele.   Even though  there should remain  some
flocculi or fibrinous clots, I throw up an  injection of diluted tincture
of iodine precisely in the  same way as if it was a case of hydrocele.
A patient whom I  treated in  this manner with  M.  Rivaille, and in
whom the tunica vaginalis contained about a  tumbler of fluid blood
of the consistence of wine lees, experienced neither pain  nor any
evident fever;  resolution commenced on the sixth day, and  the cure
was so complete  before the end  ofthe  month, that the operation
and its consequences in  the  aggregate were all exactly similar to
what takes place in the  most simple form of  hydrocele.  I will re-
mark that an analogous case  was noticed by  M. Gerard, who com-
municated the  details of  it to the Royal Academy of Medicine in
1837.  The important point in these cases is to lay open and to empty
the sanguinolent collection by means  of  a  trochar, and not by the
bistoury.  If the injection should be  made through an incision, it is
probable that the cyst would enter into suppuration, and that the ope- 
   744          NEW  ELEMENTS  OF OPERATIVE SURGERY.

   ration,  besides being less effectual, would be  attended  with conse-
   quences much more serious.
     D. Incision.—When  the tunica vaginalis  is filled  chiefly with
   fibrinous clots, or concrete matter, and it is impossible in fact to empty
   it by the canula of the trochar, it is no longer allowable to have re-
   course  to irritating injections.  In such cases, the remedy should be
   that of the multiple incisions.  The patient is placed in the same way
   as in the operation for hernia.  The surgeon being on the right side,
   grasps  and raises up the diseased side of the scrotum, and stretches
   the integuments while embracing the whole mass below, with his left
   hand.  A straight bistoury inserted in place of the canula of the tro-
   char, or along this canula if it has a groove, serves to lay open the
   scrotum to the extent of an inch,  in the same way as in opening  an
   abscess, from within outwards.   The forefinger being introduced into
   the sac through this opening, detaches the  concretions from it, and
   enables us to empty it completely.   The finger afterwards serves as
   a guide for making at the depending or thinnest point on the hematic
   cavity,  an incision similar to the  first, and which  should be effected
v  from the interior to the exterior,  or vice versa.  Having abundantly
   washed out the entire vaginal cavity by a copious injection of water,
   nothing more remains to terminate the operation, than to pass through
   the two incisions  a flexible probe  threaded with  a long meche  of
   linen, embued with cerate, and the two extremities of which are to
   be tied  into a knot, and left there as a seton during the space of four
   or five days.   The whole is then  dressed with  emollient  cataplasms,
   and  supported by a suitable suspensory.   After having moved about
   the seton in the usual manner, until a proper degree of inflammation
   has been established in the sac, that is to  say, morning and evening,
   for about the space of a week, it is then withdrawn from the tumor.
   It is then advantageous to dress it with emollient cataplasms, so long
   as the inflammatory period lasts, and until the  suppuration has as-
   sumed a healthy appearance, or has considerably diminished in quan-
   tity.
     E. In conclusion, the  operation for hematocele should in every
   respect  be the same as that for abscesses of considerable dimensions
   with  attenuation of the  skin, or  that for chronic purulent cysts.  If
   any  points upon the cyst should be found to have become attenu-
   ated  during  the course  of the treatment, or if any of the matters
   had  become  stagnant in certain culs de sac, it would be advisable
   to make additional  incisions.  I  have treated 14 or 15 patients by
   this  process,  and  all of  them were cured ;  and the greater portion
   in the space  of  from three to  six weeks.   In one only, the  last
   wound  did not  close up until at  the end  of two months.   There
   was  another, however,  who died ;  but  in  him  the  hematocele,
   which occupied the parenchyma  of the testicle itself, was situated in
   an encephaloid  mass,  and  not in  the tunica vaginalis,  properly so
   called.
     F. Liquid Hematocele also may be cured by iodine injections, in
   the same manner as hydrocele; hematocele with grumous clots of
   blood and concretions of degenerated fibrin, may  be cured  by the
   operations generally made use of in cold idiopathic abscesses.
     [Scrotal Hematocele.—AI. L. Gosselin furnishes a remarkable case 
            ELEPHANTIASIS  OF THE GENITAL ORGANS.          745

of hematocele (Arch. Gen. de Med., 4e ser., t. V., Mai, 1844, pp. 93,
96,) of that description of hematic tumors noticed by our author, as
occurring from effusion of blood into the tissues of the scrotum, and
external to the tunica vaginalis: only that in this  case the tumor was
perfectly circumscribed, of the dimensions of a turkey's egg, and of a
pyriform shape, with the base downwards, soft and evidently fluctua-
ting, and with thin walls, not preceded or accompanied by ecchymosis.
A remarkable  sign, noticed by M. Gosselin, and also by M. Blandin,
who operated, was  a peculiar trembling or  tremulous sensation  felt
in the  tumor when  it was held up in the hand.  This mystery was
well explained by the narrator, who very rationally ascribes it to the
isolated, soft clots of blood found floating in the  sanguineous liquid.
The gelly-like character of these clots  wrould naturally impart  the
sensation mentioned, through the thin cutaneous walls of the tumor.
It is well to recollect this as a diagnostic mark, though not noticed in
hematocele of the vaginal cavity itself,  from the  thickness  probably
of its serous tunic.   The testicles were  sound  and distinct, and  en-
tirely separate from the tumor.  See a note of Dr. Mott, infra.  T.]

     Article III.—Elephantiasis of  the Genital Organs.

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

                              §1-

  A number  of  ancient authors, confounding sarcocele  and other
 diseases of the scrotum under the name of fleshy hernia, have ex-
 pressly directed  that we should respect  the testicle when we find it
 sound in the midst of the diseased tissues.  " Let the skin be cut
 with a razor, after  which the carnosity which  you will  find there, 
746           NEW ELEMENTS OF OPERATIVE SURGERY.

must be separated from the testicle (coillon), which latter is to be left
undisturbed if it is not injured."  Although upon the occasion of a
fact similar to the one now under consideration, M. Roux (Melanges,
&c, p. 233,) had already proclaimed the principle upon which Delpech
has so earnestly  insisted, the case described  by this last author is.
nevertheless, one of the most remarkable which had been then known.
A man named Authier had for  a  long time been  afflicted with an
elephantiasis of  the scrotum,  which weighed, it is asserted, about 60
pounds.  The surgeon preserved as large a quantity of integuments
as he  was enabled to procure about the root of the tumor, and from
these  formed various flaps, which  he  used all his efforts to shape in
such manner as  to enable him subsequently to  envelope the testicles
and penis in them.  He afterwards brought down the upper tegu-
mentary flap, and placed it around the penis as if to form a sort of
cap for it;  he then brought the lateral flaps in the same manner over
the testicles, and succeeded in  this manner by means of numerous
points of suture,  in constructing a new scrotum, and afterwards a kind
of sheath for the copulative organ.  This operation, apparently, was
attended with complete success.  But the patient, who caught a cold
also, in going  from Montpellier  to Perpignan, was seized  at the  ex-
piration  of a few months  with  an  internal  inflammation which
proved mortal.
                               § IL

  M.  Larrey states that he  performed, in 1816,  in the presence of
MM. Ribes and  Puzin, an operation nearly similar to the preceding,
or differing from it at least only in this circumstance, that the tumor
was but  from five to six inches in diameter. The same surgeon, it
would appear also, had recourse to this operation  when  he was in
Egypt, where he has seen tumors  of this description which would
weigh, he thinks, 100 lbs. It would appear, moreover, that the operation
which made so much noise at the time, and which Imbert de Lones
performed on the minister Charles de  La Croix, was for the cure of a
similar disease, and that instead  of sacrificing the testicle they might
have restricted themselves, like  Delpech, to a  simple  ectomy of  the
scrotum.  In ectomy of the scrotum,  the object in view being to re-
move the diseased and to preserve the sound parts, it is easy to per-
ceive  that the operative process must be modified according to an
infinite  variety  of circumstances,  that is, according  as the tumor
shall be of greater or less volume, occupy one  of the compartments
of the scrotum only or both  at the same time, and according as it
shall  be found  practicable to find in one direction or in another
the quantity of integuments required to  cover  over the parts which
we are obliged to denude, but  which we do not desire to sacrifice.
Thus  all that can be said in respect to the operative manual is  this,
that we must seek at the root of the tumor for sound integuments, in
order to cut out flaps that  shall be of sufficient size and appropriate
form, before we proceed to the ablation of the degenerated mass; that
we should  then  penetrate, while respecting those parts, down to the
sheath of the cord or tunica vaginalis on the one  hand, and to  the
fibrous  envelope of the penis on the other, should the disease have
extended in this direction, our object being to divest those  parts of 
ELEPHANTIASIS OF THE GENITAL  ORGANS.
747
everything that covers them,  and to leave nothing behind of an
altered character; it being well  understood also, that if we should
find a serious lesion existing in the seminal glands, they should be ex-
tirpated at the same time.   An alteration which we must then pre-
pare ourselves for, is the extreme elongation of the testicular cords;
the point to ascertain is, if this would be a  sufficient justification for
extirpating the testicles if they should in other respects  be sound.
Delpech says that it is  not, and  that the parts will  soon  re-acquire
their natural  position.   I believe  with him, that M. Key might, in
fact, have been enabled to preserve the testicles in the  patient under
his care in 1831, and from whom he removed an enormous  scrotal tu-
mor. May we not say the same of the Malabou operated upon, March
27th, 1830, by M. Clot ?  " The tumor weighed 110 lbs., exclusive of a
considerable quantity of serosity which ran out during and after the
operation."  Though where so great a mass existed as this it might
not  have been any longer  possible to attempt the preservation of the
testicles, this  however might have  been successfully accomplished,
I think, in the  patient from whom Raymondon removed a tumor of
the  same description, but which  weighed only 29 lbs.  The Egyp-
tian patient of M. Clot, however,  was completely restored.

                            §  III.

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

                            §  IV.
  Moreover,  details  of cases of tumors of this description are very
numerous at the  present  day.  M. Clot (Revue  Med., 1833, t. IV., 
748
NEW7 ELEMENTS OF OPERATIVE SURGERY.
 p. 39,)  states that he extirpated one successfulv in 1833, which was
 sixteen inches in length and twenty-six in circumference.  A similar
 case to the one related by Dionis was noticed in 1759 by Alehee de
 La Touche.  Two observations of Alorgagni are  referable to the
 same disease.   In  the patient cited by Schulte, the tumor weighed
 over fifty pounds, that of Lajoux eighty-three and a half, and Chopart
 describes one over  eighty.  That mentioned by Hale still weighed
 thirty-six and a  half pounds after it had been extirpated.  AI. Caflbrt
 extirpated one successfully two feet six inches in circumference and
 was enabled to save the testicles, (see the detail of these facts in the
 Memoir of M. Caffort.)  The operation performed  on the 21st Oct.,
 1831, by AI. Gaetani, (Gaz. Med., 1835, p. 77.) for a  tumor weighing
 fifty-six  pounds,  and in which the testicles were preserved, was fol-
 lowed with complete success.   AI. Pruner (Ibid., p.  78,) was no less
 fortunate in another case.  The patient in whom AI. Gaetani removed
 one weighing 120 pounds  died on the  following day.   AI. Chervin,
 (Ibid., pp. 77, 78,) who mentions one of these tumors  of the weight of
 165 pounds [!?] says that the operation has been twelve or fifteen times
 performed at St. Christopher  and Demerara, and  proved  fatal  in  a
 number of instances.  It  would  appear that AI. Weis and AI. Alott
 (Gaz. Med.,  1835,) have  also  had recourse to extirpation.   I  per-
 formed  it myself (Lancette Franc, 1835,) in one instance, in 1835,
 at the hospital of La Charite, in an adult aged twenty-eight years.
 There was a double hydrocele ; I saved the testicles, and the patient,
 after his wounds had become cicatrized, died six weeks subsequently
 of repeated attacks of erysipelas upon his thighs.

                   Article IV.—Castration.

  Castration is an operation which for a long time since has not been
had recourse to, except for the purpose of relieving  serious diseases
of the generative gland.   We no longer find among  us those  who
 excuse Semiramis for having  castrated men of weak constitution in
her domains,  for the  purpose of having no others than children of
robust fathers ;  nof others  who  maintain, with Brunus of Longo-
Buco, that Seigneurs have the right to mutilate their  domestics in this
manner,  in order to confide to them with greater security the guar-
dianship  of their women.   Even  in Italy itself,  there are none  who
do not now proscribe the cruel  process which had  been introduced
into that country under the pretext of imparting a more harmonious
and musical voice to their men.  Under this point of view castration
is no  longer in  use except among the Orientals, and in countries
 where polygamy and slavery are still permitted.

                        § I.—Indications.

  As  a therapeutical  resource, castration  has been  made use of for
 the radical  cure of hernias.   It was  very much in use formerly,
 although G. de Salicet had already condemned as ignorant persons
those who practised it in his time, and though at the epoch at which
 de Cantemire wrote,  the Albanians themselves looked upon it as un-
necessary and dangerous.  At present it  is not recurred to but  in 
CASTRATION.
749
diseases of the testicle which are considered incurable.   It is, for ex-
ample, employed when a bruise, laceration, or any traumatic lesion
whatever, has effectually disorganized the testicle, or when this gland
has become  the seat of a destructive suppuration, or of a scirrhous,
cerebriform,  colloid, melanotic,  or  merely tuberculous degeneres-
cence.  In order that it may present  some chance of success, it is im-
portant that  the disease  should  be still local and not have extended
to the viscera, and that no trace of  it can be found elsewhere.  A
patient who  had an erectile tissue in the testicle, and who got well of
the operation, died  in consequence of a similar tissue  in the brain,
according to the statement of M. Denis, (Journ. Hebdom. Univers.,
X. XIIL, p. 369.)  Even where the internal organs appear to be sound,
it would be  imprudent to castrate if the cord should be found to be
implicated to a great distance in the ring.   Nevertheless, if the dege-
neration should be of a colloid or tuberculous character, or the result
of previous  chronic inflammations, and without complication  of scir-
rhus,  or encephaloid or melanotic tissue, we might attack the cord
in the iliac fossa, as Le Dran and AI. Naegele did, and  as I have done
in three instances with success,  or we might go as far at least as to
the depth ofthe inguinal canal, as was done by La Peyronie.

                   § II.—Operative Methods.

  The ancients performed  castration in four different  ways in those
healthy persons that were  to be transformed into eunuchs.  Their
method  by  attrition consisted in making violent bruises upon the
organ in order to bring about  its  atrophy; ecrassement was per-
formed by placing  it between two pieces of wood ; while arrache-
ment, or tearing the organ out, (dechirure,) or finally,  excision were
very frequently preferred.   Of these methods, which have been par-
tially retained in the veterinary art, the  only one which remains is
the last, and which Paul, in human surgery, denominates ectomy.  In
all the processes the patient is laid upon his back as in the operation
for strangulated hernia.
  A.  Method of M. Maunoir.—M.  Maunoir, a surgeon of Geneva,
proposed at the commencement of this century,  to get rid of sarco-
cele  without removing  the testicle, by laying bare the root of the
cord, in order to come down upon  its vessels and to be enabled to
tie them. According to  him, he obtained in this manner a number of
cures.  A similar operation, attended with a successful  result, was
reported  to  the  Academy of Medicine; but in a patient of mine at
the Hospital of La Charite, in 1838,  the operation was attended with
no benefit.   Moreover,  if  it is  presumable that it may succeed  in
some cases  of degenerescence, produced by a simple chronic inflam-
mation, reason would authorize  us in believing that in  true sarcocele
it would be found insufficient.
  B.  Method of M.  Morgan.—In  England, a  somewhat different
mode is  made use of.  M.  Morgan (Arch. Gen. de Med., t. XVIL,
p. 613) recommends that we should  attack the vas deferens itself in-
stead of the vessels.   MM.  Lambert and Key, (Lancet, 1828, vol.
II., p. 176,) who have adopted the  principles of this surgeon, each
relate a successful case in its favor.   After having laid bare the sper- 
750           NEW ELEMENTS OF  OPERATIVE SURGERY.
matic cord, they search for and isolate the  senfnal  duct, and excise
from it a segment of the  length  of one  to two inches;  the wound
should be  immediately closed up, and the final cure is  afterwards
effected gradually.  Did one or the other of these processes enable
us to bring back the organ in some cases to its primitive condition.
and to preserve its functions, they  would most undoubtedly deserve
to be made trial of, notwithstand.ng their uncertainty; unfortunately
this is not the case, and I very much doubt that these processes will
ever acquire the consideration  in surgery which some persons  seem
desirous to accord to them.
  C. Ordinary process.—Castration,  properly so called, comprises
three stages which are quite distinct: 1st, incision of the envelopes
and isolation of the sarcocele  ; 2d, the section of the cord and the
application of hemostatic means; and  3d, the dressing.
  I.  Isolation  of  the Tumor.—a.  When the  integuments continue
sound, and have not contracted any close adhesion  with  the tumor,
and that the latter has but little volume, it is unnecessary, as had al-
ready been remarked by Paul,Xo excise a flap from them.  In other
respects the division may be made indifferently almost in any way,
either commencing by taking up a fold of  them, or  by cutting from
the skin to the  deep-seated  parts, as most modern practitioners do.
In whatever  manner performed,  it  is  requisite  that this  incision
should be prolonged to a slight distance above the ring, and descend
to the lower part of the scrotum.   Though there  may be somewhat
less advantage in  stretching with the left hand the  integuments on
the front  part of  the tumor, while they are being divided, than in
grasping it on its posterior side,  as  Dupuytren  recommends, this
however is a mere matter of choice much more  than of necessity.
When  the  skin and tissues beneath it are incised, nothing is easier
than to isolate  the  testicle  with free manipulations, either by means
of the  fingers, after the manner of B. Bell, or with  the  scissors, or
what is infinitely preferable, with the convex bistoury, until we have
passed around its whole circumference.   For this purpose the as-
sistant attends to the lips of the wound, while  the operator with one
hand grasps the tumor, or  vice versa, in  order to stretch the parts,
to separate them in a proper direction, and to destroy their adhesions
by means of the bistoury in the other hand.   The  only  precaution
necessary to be observed, is not to carry the instrument too near the
penis or the septum ofthe dartos muscles, from the danger ol wound-
ing the urethra or the testicle upon the other side.
  b.  A number of surgeons advise  to proceed always in this  man
ner, whatever be the size of the sarcocele, piovided  the  skin is noi
diseased.   In  this  there would  be  serious inconveniences: the meth-
od advocated  by Sharp and De la Faye,  and which Paul  also adopt-
ed, and which consists in removing a portion of skin at the same time
with the testicle, in all cases where the volume of the cancer exceeds
certain limits, is unquestionably preferable.  In such cases  an  ellip-
tical incision, to be  prolonged like the  preceding, from above the
ring to the lower part of the scrotum, is to be made and to include
in it, as is readily perceived, a  cutaneous flap  of greater or less
breadth, according as the sarcocele is of greater or  less dimensions.
  c  Aumont, apprehensive of finding the pus stagnate in the bottom 
CASTRATION.
751
of the wound, wishing also to avoid the necessity of leaving a cica-
trix in front, and believing  also  that the alterations of the skin  are
more frequently met with below  than above, has proposed to  place
this incision on the lower side of the tumor, and not on its anterior
surface as is generally done.   There can be no doubt, in fact, that
we can adopt this course, as I have seen M. Roux do, and as I have
done myself; and that this process  is in some degree even necessary
when the integuments are perfectly sound in the part where they are
usually incised, but altered  in the  opposite direction;  but would it
not be absurd  to attach any importance  to the circumstance, that
after an operation of this kind the cicatrix would be placed rather
behind than in front, under the pretext that it is more visible above
than below ?  Experience has moreover sufficiently shown that  the
pus, in adopting the  ancient method,  will  always  readily escape
through the  inferior angle of  the wound;  moreover the  process of
Aumont, from its not enabling us also to isolate the  cord  into the in-
guinal canal with as much facility as by the other method, possesses
in this respect so serious  an  inconvenience that I have seen AI. Roux
sincerely regret having made  use of it.
   II. Section of the cord.—As soon as the sarcocele  is dissected, and
the cord laid bare  to  beyond the  limits of the disease, the surgeon
should  attend to the separation  of the parts  which he  designs to
remove.  This is the point upon  which there has  been the greatest
variety of opinion among practitioners.
   Two methods, even very distinct from each other, have resulted from
this want of harmony.  In one the  cord or its vessels are  tied before
proceeding to its section ;  in the other a course diametrically opposite
is adopted, and each method comprises a  great number of different
processes.
   a. Ligature of the cord in mass.—Paul of Egina, after the manner
of Celsus, constricted  the whole  cord between the ring and  the dis-
eased mass, in a strong ligature.  The majority of operators at every
epoch have proceeded in the same way; but there are  those who,
after the manner of Purmann, assert that the  ligature ought to be
placed  as near  as  possible  to the  ring, while  others, like Barbette
and Bertrandi, apply it immediately above the epididymis.  Some
again, like Haenel, place it on an intermediate point.  Though  there
may be those who,  after  the manner of Franco and  Pearson, tighten
the ligature  immediately with as much force as possible; there  are
many on  the contrary who, like  O. Acrel, make such  a  degree of
constriction upon it only as  will be  sufficient to interrupt the  flow of
blood.  There are others  again, as  Gauthier for example, who even
only make constriction upon  the ligature  gradually, renewing this
every day until it has completely cut through the tissues.   Pare and
Heister (These de Haller, French  trans., t. II.) recommend a liga-
ture several times doubled to be passed  through the cord,  so as to tie
the two halves  of  the latter separately.   Ravaton, with  a view of
leaving the vas deferens entirely  free, places his ligature in the man-
ner of Pare,  but he constricts  only  that  half of the cord which seems
to him to include the vessels.  Some surgeons finally, with Birch, as
quoted by Sprengel. apply a precautionary ligature very high up and
another an inch lower down, by means  of which latter they strangu- 
752
NEW ELEMENTS OF  OPERATIVE SURGERY.
late the vessels before excising the parts below.  It is to be remarked
moreover that Theden and Flajani have deemed it advantageous to
interpose a small compress  between this ligature and the spermatic
cord, while Pelletan prefers merely a piece of sheet-lead.
  b.  A separate  ligature on the vessels.—Those who amputate  the
testicle at first  differ, nevertheless, on the subject ofthe treatment
afterwards required by the cord.  Cheselden having remarked that
a ligature applied upon the cord had, by gliding in front, made pres-
sure upon the principal vessel, and had thus suspended the flow of
blood,  was one of the first to propose that its arteries should be liga-
ted separately.   Le Dran recommends that we should  surround the
cord with a precautionary ligature, and afterwards  make pressure
upon the vessels with  the fingers at  some distance below, and  that
we should not tighten  the thread except in cases where the pressure
had proved  insufficient to arrest the hemorrhage.  White and Korb
state that they have succeeded by imitating the process of Le Dran.
J. L. Petit applied a small graduated compress upon  the ring, with-
out employing any ligatures;  while  Pouteau confined himself to
keeping the end  of the cord turned back upon the pubis.  Runge,
after having carefully dissected it, twisted it several times upon' itself
before  separating the  testicle from it, and  also dispensed with  the
ligature.   Finally Smett and Schliting maintain that such precautions
are useless,  inasmuch as  men who castrate themselves in a fit of
anger or despair, make use of no means to arrest  the flow of blood,
and yet nevertheless do not die of hemorrhage.
  c.  Appreciation.—It would be erroneous to suppose that these va-
rious opinions are no longer in existence  at the present day.  The
ligature in mass  has numerous partisans, though on the  other hand
there are many surgeons  also who only isolate and ligate the vessels
separately before dividing the  cord.   1st.  Bichat (Roux, Melanges,
&c, p. 230) for  example,  and AI. Roux and AI. Chas. Bell, have  re-
commended that we should  divide the cord down to the vas deferens,
and then to grasp and ligate its arteries before  making the section of
the duct.  Finally,  others detach the sarcocele, as soon as it is sepa-
rated from its envelopes, and immediately afterwards search in  the
upper  end of the cord for such  vessels  as might bleed, either by
means  of a hook, or tenaculum, or with the forceps.  As in the greater
number of patients, the artery or arteries of the cord are of such in-
considerable size, as to lead to  no apprehension in leaving them to
themselves after having  divided them, it  is readily  conceived  that
friction after the manner of Le Dran, compression as made use of
by J. L. Petit, and torsion or reversion by Runge,  has been found
to answer, and  might be made trial of almost without any danger,
by any person who should desire to  do so.   Nor can it be dispu-
ted also that the ligature, after the manner of Bichat or of Desault,
Boyer, Dupuytren, Delpech,  and AIM. Roux,  Mott,  and Serre.
(Compte Rend,  de la Clin, de Montpellier, 1837,)  who adopt  the
principles of Cheselden or of Bromfield, might succeed equally well.
2nd. Nor should we throw any obstacle to the  accomplishment ofthe
cure, by embracing the cord in its totality or only in part, and in  ma-
king upon it direct  or graduated  constriction.   The  important point
in this  matter therefore, very naturally would  be, to  know which in 
CASTRATION.
753
reality is the most advantageous or most prudent, which is the easiest
and most certain, whether to ligate in mass, or not to apply the liga-
ture until after having detached the  organ.  The opponents of the
first method, Siebold among others, adduce as  an argument for its
rejection, the danger of comprising in the  same  ligature  the vas de-
ferens, the nervous branches of the  renal  plexus which  accompany
it, the branch furnished by the genito-crural nerve, together with all
those other tissues which are  not required to be  included; also they
contend that a ligature of this kind must  produce violent pain,  and
incur the risk of causing convulsions  or  even  tetanus,  and  finally,
that the ligature  is sometimes  very slow in cutting through the parts,
and protracts to  a considerable degree the period at which it may be
removed from the wound.  Some have added that the constriction of
so great a number of different organs would soon cause  the ligature
to be relaxed, when it would no longer be  found sufficient to close
the arteries.  To all this it may be rejoined, that immediate strangu-
lation, causes a somewhat acute degree of pain only for  a few  mo-
ments, even though the continuity of the  nervous branches and the
vas deferens have  been divided by it; that hemorrhage has  never
been seen to take place from vessels strangulated  in this manner;  that
tetanus and nervous symptoms are no more to be apprehended from
this method than from any  other; that  the patient thus treated by
Morand, and who  died tetanic, owed  his  disease to quite  another
cause; and that AI. Couronne, (Revue Med.,  1827, t. III., p. 420.)
moreover, has published the case of a man, who also died of tetanus,
in  consequence  of  castration,  even  though the cord had not been
tied in mass.  3rd.  I have seen this operation performed  at the hos-
pital of Tours by M. Gouraud at least twenty times in the space of
four years, also by MM. Richerand and Cloquet at the hospital of St.
Louis, by AI. Bougon at the hospital of the School of Medicine, and
by many other practitioners besides; I have peformed it myself more
than thirty times, and in all these cases, which amount to more than
100, the  ligature in mass was  used without there  ever  having re-
sulted  any inconveniences which could be reasonably imputed to it.
Employed also by AI. Sachs, (Rust's  Handbuch der Chir., vol. IV.,)
who operated in this manner on both sides, by M. Robert de  Chau-
mont,  (communicated by the author,) and  by  M.  Nasgele, Somme,
(Bull,  de la Fac. de Paris, X.  VL,  p. 25,)  M. Gama, (Sornay, These,
No. 86, Paris, 1837,) M. Golfier, (Presse Med,, X. L, p.  452,) and M.
Pasquier, the ligature  in  mass, which M. Boussion, (Bull.  Med. du
Midi—Journ.  des Conn.  Med., X. IV., p. 365,) has also seen  per-
formed five or six times at Bordeaux, and  which is no less approved
of by M. Cazenave, is therefore at the present day the only method
which actually deserves to be received into  general  use.   The ex-
perience and arguments of Mursinna, Wilmer, Loder,  and  Dietz,
who are quoted by Sprengel, have moreover fully  refuted the objec-
tions of Siebold  on  this point.   It is true that with the separate lig-
ature, if the proper  precautions are taken, success is no less certain ;
but it is evident  that it presents more difficulties,  that we  have  in
some cases trouble in finding the vessels, that the explorations  to
which we are then  obliged to  have recourse, uselessly  prolong the
operation, and that  quite a copious hemorrhage, has in more than one
                              48 
754
NEW ELEMENTS OF  OPERATIVE SURGERY.
instance come on from the end of the cord  after the dressing has
been applied.  4th. Another accident which also might create alarm,
as I had occasion to notice in a patient operated upon by AI. Roux, is
peculiar to this operation.  While this professor was looking for the
artery,  the seminal cord itself escaped from his fingers, and slipped
underneath the integuments which had been preserved ; he hastened
to sieze it with the dressing forceps, and to bring it outside in order
to pass a ligature around it, which was applied somewhat negligently;
the bleeding appeared to have been arrested, but towards the evening
copious hemorrhage came on, which returned several times during the
night and threatened to become fatal.
   d. Authors have spoken a good deal of this tendency of the cord to
retract  itself; hence comes their  pro visionary ligature and a multi-
tude of other precautions.  Nevertheless  none of the constituent
portions of the cord are  contractile.   The spermatic vessels and vas
deferens, after having  been a long time drawn upon and elongated,
appear  to be the only  portions which  are  capable  of  retracting to-
wards the belly after they have been relieved  of the weight that
dragged upon them.   As to the tunics which unite them together or
envelope them, we cannot  perceive how these can effect the slightest
retraction in that direction.  The fibres  of the  cremaster, at the
utmost,  might  be capable of  drawing  the parts back to the distance
of a few lines.   It is incorrect, therefore, to say that  the cord, after
having  been once divided, must necessarily recede to a considerable
distance upwards.   It has not  been at the present time only, how-
ever, that any  tendency of this kind had been denied to it.  M. Flau-
bert a long time  since had noticed the error which I have just pointed
out, and M. Senateur  has  collected  arguments and facts well calcu-
lated  to refute it, at the same time that M. Chas. Bell, on his part,
opposed this idea in England.   The following, in  fact, is what takes
place:  If  the  sarcocele is  ancient or voluminous, or  if in any way
whatever  the cord  has undergone a considerable  degree of elonga-
tion, it has, in fact, as soon as it is divided, a tendency to regain the
interior  of the inguinal canal, but  its constituent portions  then yield
only to  their appropriate elasticity, and have no other  result in view
than that of becoming approximated somewhat nearer to their prim-
itive position.  In all cases where this elongation has not taken place,
and where the degenerated  testicle has remained at  the  same dis-
tance  from the ring, no result of this kind is seen and no apprehen-
sion can exist of the  retraction  in question.  It may require  some
attention, in fact, only  in a small number of persons, as, for example,
where the disease  does not  admit of our separating  the cancerous
mass at an inch at least from the inguinal opening; from whence  it
follows, that it is hardly necessary to take  it into consideration so
long as  the tumor has not implicated the cord itself.
   e. Arnaud, Alarechal, Garengeot, Bertrandi and other practitioners,
considering that the root of the cord is  found to be enveloped in
fibrous tissues and lamellae that are not distensible, proposed to divide
the ring in order to prevent the strangulation of the  cord, a stran-
gulation to which they attach a number of dangers, but which must
necessarily be very rare, since no practitioner in  our times  makes 
CASTRATION.
755
any mention of it, although  the advice of Garengeot has been gen-
erally neglected.
 /. As to the manner of dividing the cord, it has necessarily varied
but very little.   The  red-hot iron, which  was preferred by Roger
of Parma, Brunus, &c, no longer finds any partisans.   The scissors
used by Scultetus are manifestly less suitable than the bistoury.  In
making use of this last  instrument it is quite unnecessary to incise
the  organ by a bevelled  section, as recommended  by  Le Blanc.
While an assistant supports the testicle,  the surgeon grasps the sper-
matic cord with his left hand a little below the ring, or at the point
which sustains  the ligature, and divides  it with a single cut from
behind forwards, or from before backwards,  and perpendicularly to
its axis.  It is not probable that hereafter any  person will recommend
that the ligature should be allowed to perform the duty  of cutting its
way, by degrees, through the parts, as in  treating a polypus, and as
is recommended by Runge or Le Blanc.
 III. If the flaps of  the wound should  be too large, it would be  ad-
visable to. exsect them immediately.  Otherwise we should incur  the
risk of their rolling up  inwards, and ultimately rendering the cure
tedious and difficult.   This disposition in the  sides of the scrotum to
roll  up on their inner surface appears to  be  naturally explained  by
the anatomical arrangement itself  of its tissues:  the remains of  the
cremaster, should this muscle have not been completely destroyed,
together with the layer  formed by the dartos, from their both being
endowed with a certain  degree of contractility, retract  more or less
upon themselves and  necessarily draw upon  the  cutaneous  tissue in
the same direction.
  D. Process of Zeller or Kern, (Rust's Handb.  der Chir., vol. IV.)
—A person  of the name of Acoluth, having  a special dread of any
kind of hemorrhage, proposed to draw the tumor  downwards, and to
strangulate it with  a  silken  ligature  placed above its root, in order
that its separation might  take place gradually.  Haly Abbas, and
before him also Aristotle, who had also given  the  advice, recommend
that we should immediately excise  the testicle with a razor below  the
ligature.  In Germany a different process is  adopted.   Zeller, upon
the strength of  the fact  that certain  maniacs and others have them-
selves amputated' their testicles, together  with the  scrotum, with a
single cut, suggested  that this method  might be systematized and
transformed into a regular process.   With this view he  grasps  the
sarcocele with his left hand, causes the skin to- be  drawn back a little
at the upper part, by the hand of an assistant, and  removes with a
single cut of  the bistoury or knife the entire tumor divested of its
envelopes, and afterwards,  in order to  prevent the  hemorrhage,
merely keeps at the  bottom of the wound a sponge  saturated with
cold water.   A surgeon of Vienna, who has  since been desirous  of
bringing this method into repute, has employed it in a great number
of instances, and according  to him,  with  unvarying success, by  en-
grafting  upon it, however, an important  modification, since he adopts
the precaution of not  abandoning the cord  until he has surrounded it
with a strong ligature.  The method of Zeller enables us to remove
the testicle with surprising rapidity, and makes castration an opera-
tion as simple as it is easy.   It appeared to me moreover, in the two 
756
NEW ELEMENTS OF OPERATIVE SURGERY.
 patients who were operated upon in this manner by me, that the in-
 teguments, from not having been dissected, allowed  of the wound
 being closed  up with  much more rapidity than  by  the ordinary
 method.  But  it renders the ligature in mass upon the cord  more
 difficult, and evidently  can  be no longer applicable when the tumor
 is somewhat voluminous, or when its envelopes are altered.
   E. Process  of the author.—If the envelopes of the tumor are suf-
 ficiently pliant and sound to be drawn backwards, I take up a fold in
 them which is  kept tense and  flattened  by one  assistant, while an-
 other disengages, raises up, and draws the sarcocele to the front;  I
 then pass a ligature at distances of four to four lines through the dou-
 ble tegumentary tissue, and as near as  possible  to the tumor, taking
 care to pass  one of the four portions under the cord above the dis-
 eased parts,  and  to strangulate  this last  upon a graduated  com-
 press.  Then removing the entire mass by means of the bistoury, as
 in the process of Kern, I have nothing more to  do than to knot the
 threads, in order to complete the suture  and  the operation.   Two
 patients whom I treated in this manner, recovered perfectly.
   F. The ordinary process, moreover, may be very easily combined
 with the temporary ligature upon  the cord, either directly or  indi-
 rectly.  Being passed through the skin or around the cord, after it has
 been laid bare, all that is necessary is to fasten it by a knot, and af-
 terwards a bow knot,  on  some supple  substance;  we may in this
 manner loosen  or tighten it  according as it may be required, and can
 withdraw it from the third to the sixth day.
   G. Ilio-Inguinal Sarcocele.—The testicle which we  are about to
 remove, in place of occupying the  scrotum, or hanging outside, may
 be confined and arrested in the tissues of the walls of the belly, at
 the interior portion of the inguinal canal ; and this  may take place
 from the individual never having had the  testicle in the scrotum, 01
 from its having accidentally ascended to that point, as  occurred in a
 remarkable case mentioned  by Rossi, or it may be because the cord
 is implicated in the disease of the testicle.   However  this may hap-
 pen,  it may be  transformed  there into the condition of sarcocele, in-
 stances of which are related by Chopart, Boyer, and M. Rheinlen-
 der,  on the authority of Robert, (Journ. das Prog., X. XIII., p.  125.)
 It may readily be conceived how delicate and dangerous the opera-
 tion  must be under such circumstances.   In the first  place, before
 commencing  with it, how can we  determine precisely the  limits of
 the disease ?   Then again it is to be apprehended that in performing
 it we may open into the peritoneal cavity, contrary to our intentions,
 as happened  to M.  Naegele, (Arch. Gen. de Med., X.  XIII., p. 4'2'i;
 Journ. des Prog., X. XIII., p. 156,) or that  we may even be obliged
 to do this designedly, in order to remove the entire disease.  In such
 cases, therefore, we must incise layer by layer the whole  thickness
 of the tissues  which env(slope the  tumor, and isolate it little by little
 by a careful dissection, keeping constantly present to  our minds the
 proximity of the peritoneum, the epigastric artery, and even the iliac
vessels.  Upon the supposition1 that we might apparently lay bare the
 cord with ease, it would be more prudent, under  such  circumstances
particularly, to  apply to it  the ligature in mass, than to attempt to
strangulate its vessels separately.   Should a chronic phlegmasia have 
CASTRATION.
757
blended its different lamellae with the surrounding layers, this mode
of applying the ligature would be still more suitable, and  the thread
ought to be introduced by means of a curved needle.  In the case
of Rossi, related by M. Piussan,  (These, No. 215, Paris, 1825,) it be-
came necessary to divide the cord at more than three inches  above
the  ring,  yet the patient  recovered notwithstanding.  I have per-
formed this operation three times.  In the three I laid open the whole
anterior wall of the inguinal canal, and was  obliged  to  isolate the
cord as far up as into the iliac fossa, at which part I applied to it the
ligature in mass.   I did not find  the operation  attended with any se-
rious difficulty.  The turners were encephaloid.   One of the patients
has continued well since 1836 ;  in a second, a tumor of the same de-
scription developed itself in the groin at the expiration of a year; of
the third, I have received  no intelligence  since he was  discharged
from the hospital.  Should  the inguinal canal only be implicated with
the scrotum, the operation  is then still practicable.
  H. Whether the ablation of the sarcocele has been effected by this
or that method, the wound always contains a certain  number  of ves-
sels which should engage the attention of the surgeon before he pro-
ceeds to the dressing.   Even if we  set aside those of the cord, we
find one or two external to this,  and these  are the vessels which are
usually the largest in size ; some also will  be  found at the lower an-
gle of the division, and which  come from the  pudic artery by the
superficial artery  of the  perineum ; finally, it  frequently happens
that we meet  with one on the  inner side,  and which is one  of the
branches ofthe artery of the septum of the dartos muscles.
  I. In most cases these vessels cease to bleed at the moment when
the operation is terminated, and in some persons it will prove un-
availing to attempt to find  them  afterwards ; on which account it has
been recommended  to  make use of the ligature or torsion to these
vessels in  proportion as they are opened.  It rarely happens, how-
ever, that a hemorrhage takes place from neglecting to tie them, pro-
vided they have not shown themselves when the sponge is applied to
detect them on the surface of the wound.   Schmucker (Rougement,
Bibliot. du Nord, p. 38), omitted in one instance  to apply the ligature
to the cord, but no  hemorrhage followed. M. Puchot (These, No.
207, Paris, 1835), noticed the same thing in a maniac.  A'patient, in
whom the testicle was hanging down from a wound, had  it removed
on the fourth day ; the vessels were not tied ;  the wound  was united
by means of the whip suture,  and the patient recovered  (Roulot,
Journ. des Conn. Med.-Chir., X. III., p. 76.)
   II. Whether, however, the ligature has been applied to the vessels
or that we have not considered it  necessary to pay  any farther at-
tention to them, it must be recollected that in  a considerable num-
ber of cases  the dressing  becomes wet with blood at the expiration
of three or four hours, or in the course of the night following the
castration, without,  however, any actual hemorrhage having taken
place.
   I. Dressing.—I. The ancients had recourse to the suture after the
removal of the  testicle, and frequently endeavored to effect union by
the first intention.  From the termination of the  seventeenth century,
however,  no other  treatment  scarcely has been used  but that by 
758
NEW ELEMENTS OF  OPERATIVE SURGERY.
second intention.  A considerable number  of English, German  and
American surgeons, and with them Delpech and other practitioners
in the south of France, have, it is true, again endeavored to brino- into
repute the first named method, but I have not found either in the work
of M. Serre nor in  foreign publications, any well established fact in
proof of the perfect  cicatrization  of a wound of this description by
first intention.  "Of the three patients operated  upon by M. Serre,
an account of which has been published by AI.  Alquie, (Gaz. Med.,
1837, p. 476,) one was cured in 15 days, the second in 34 days, and
the third in two months and a half!    In the first place, it would be
necessary that  there should have been no  ligature  employed,  that
we should  have  restricted ourselves  to the torsion only of all the
arteries, and that we should finally have been enabled to place the
lips of the wound  and the  integuments which had  been  preserved,
in perfect contact with the  subjacent tissues.  The suture, either sim-
ple or twisted, would in such cases become  absolutely indispensable;
hence would arise a  greater degree of pain and numerous difficulties
to be overcome unless we  followed the process I have pointed out.
  II.  The usual practice is attended with  infinitely less embarrass-
ment.   A piece of fine  perforated linen, besmeared with cerate, is
spread out  like a veil over the  entire  traumatic  surface.  Over  this
are immediately applied some small balls of lint.  The sides of the
scrotum are also  padded  with lint  in order to prevent their fric-
tion  against the upper part of the thighs, while several plumasseaux
cover over the whole.  • Long compresses and  then a large  suspen-
sory or a double spica complete the articles of dressing.  The acci-
dents to be apprehended are the  same as those which occasionally
succeed the other great operations in surgery, and require the same
treatment.
  a. Hemorrhage, when it takes place, is far from  always requiring
the wound  to be hastily laid open  in order to discover its source and
to tie the vessels.   We shall frequently find  ourselves enabled to
arrest the  bleeding  by sprinkling and saturating the dressing with
cold water  or lead water, and by renewing these  applications at least
once every  hour.  If however the bleeding should  continue to such
extent as to enfeeble the patient, or give rise to the apprehension of
an internal effusion,  it would  become necessary  immediately to take
off the  dressing, remove  the clots of blood, and  tie the artery or
arteries  that were not  closed  up, or in fact to have recourse to
tamponing,  styptics, and even to cauterization, should the danger be
imminent.
  b. Should the ligature  in  mass have been  preferred,  it is to be
apprehended, if the constriction  has not been  carried so far as to
strangulate  the tissues completely, that the extremity ofthe cord will
retain  its vitality  and  become transformed into a reddish colored
granulation or sort of cauliflower, which, as has been remarked by
J. L. Petit,  and as I myself have  seen in a patient operated upon at
the hospital of St.  Louis by AI. Cloquet, may be confounded with the
neighboring borders of the wound, in  such  manner as to give rise to
subsequent  difficulties.   It is however  probable that even  in such
cases the ligature would  finally cut through the cord it embraced, 
CASTRATION.
759
and that the vegetation in question  might be  repressed  by means
of astringents or caustics.
  c. If in spite of all  these precautions the borders of the  wound
should  have become  inverted, we  might, provided  the suppuration
should not be too abundant, endeavor to approximate the sides ofthe
wound to its bottom and keep  them compressed in such manner as to
effect their adhesion by secondary immediate reunion.
  III.  If all these precautions are  made use of the patient will re-
cover  in three weeks or a month, sometimes in twelve  or  fifteen
days, rarely sooner, but sometimes at a later period.  Castration  in
itself is not a serious operation ;  it causes but very little reaction and
is rarely fatal.  If however we  should insist too strenuously upon
immediate reunion it  may give rise to a purulent inflammation or a
sort of phlegmonous erysipelas, which, ascending along the cord, in-
volves  the inguinal canal, and may reach the fascia propria or the
peritoneal cellular tissue of the fossa iliaca.   In  some cases also the
phlegmasia, though continuing to be  sub-cutaneous, will  follow the
course  of the fascia superficialis and spread with this over the whole
iliac region, in such manner as to place the life of the  patient in immi-
nent danger.   Surgical anatomy, a subject which I  have elsewhere
treated of, (Anat. Chir., X. IL, edit. 1837,) perfectly explains this
phenomenon.
  [New Practice of Incision into the  Tunica Albuginea Testis.—In
cases of parenchymatous orchitis, i. e. where, as is  occasionally but
not frequently seen, the testicle  in young men between the  age of
nineteen and  twenty-four, from certain  pathological  causes, becomes
severely inflamed and strangulated as  it were, within  its  investing
tunica  albuginea, (peri-testis,)  and which might  and does result  in
suppuration and  loss  of the testicle,  M. Vidal de Cassis, of Paris,
has recently recommended a bold practice,  (Journal de Medecine et
de Clururgie  Pratiques, Paris,  October,  1844,)  which has  made
some sensation in that capital  by the  success which  has followed it.
It consists in making incision, layer by layer, to the extent of nine
lines  down  to the albuginea, which  was  readily divided, and by
which  the testicle was laid bare.  There  is no  serosity within the
tunica vaginalis ;  union without any suppuration takes place between
the testicle and the vaginalis at the incision.  In one case, in which
it proceeded  from a  debauch after the cure of a blennorrhagia, the
latter returned as soon as the division  of the albuginea was  made.
In AI. Vidal's two cases given  there was a cure effected without any
previous depletion, and in  support of this treatment we have  a case
of AI.  Cullerier,  (lb.,) where the symptoms  of pain  in the part and
cord were aggravated by bleeding, poultices, purging  and extensive
leeching to the cord, (viz : twenty-five leeches,) and in which nothing
but division of the albuginea checked the disease.   M. Vidal has
already treated, by his mode, fifteen cases with success, (vide also
Lormack's Monthly Journal,  fyc, Jan., 1845, pp. 70, 71,)
  New Treatment of a species of Fungus of the Testicle.—My. Syme
of Edinburgh (Cormack's Lond. and Edin. Monthly Journ. of Med.
Seience, January, 1845, p. 1, &c.,)  proposes in  cases  of  those  well
known  fungoid growths of the  testicle  described by Lawrence, (Edin-
burgh  Medical and Surgical Journal, year 1808,) and which pro- 
760           NEW ELEMENTS OF OPERATIVE SURGERY.

cure some ease to the patient by ultimately making their way by ul-
ceration through the scrotum, to discard escharotics or the knife,
as hitherto used, but in lieu thereof, to make an elliptical incision free-
ly through the teguments  of the scrotum, and after excising the hard
and corrugated portion around the fungus, and dissecting these tegu-
ments back, and detaching them from their connections,  and  abrad-
ing the edges of the wound, to reduce by a sort of taxis the hernia-like
protruded excrescence within the scrotum, and then to unite the lips
of the incision over the included  tumor, by stitches.  The pressure
he has found, by this treatment, will in a short time effectually cure
the disease, by causing an absorption of the exuberant granulations,
which the microscope proves this tumor to consist of.   The brown
divergent strias are found  to be the tubuli  seminiferi, and the white
substance which separates these tubuli to some distance apart, is as-
certained to be organizable lymph, which being absorbed, leaves the
former (the tubuli)  and the testicle to which they belong, in  a natu-
ral  state.   The surface of the fungus itself being also ascertained, as
he says, by Air. Goodsir, through the microscope, to be of a granula-
ting nature, readily unites  with the corresponding internal raw sur-
faces  of the integuments.  The parts under this treatment speedily re-
gain their normal size  and condition—a result which certainly would
not have been anticipated, if we were to be  guided by the received
notions on all  fungoid  growths.   The discovery of this practice by
Mr. Syme, should it be confirmed by future trials, shows the valuable
acquisitions probably which are yet in  store for therapeutics by the
light to be thrown upon morbid structure by the microscope, as well
as by organic chemistry.
  Scrotal Tumor.—Diagnosis of a Tumor in the scrotum  of a living
adult, containing debris of a Foetus.—The  honor of establishing one
ofthe most delicate points  of diagnosis, that has ever occurred, fortu-
nately fell to the lot of one of the most learned,  practical, and dis-
criminative of living surgeons, our author,  AI. Velpeau, viz., in 1840.
at the celebrated hospital of La Charite, to  which he is attached, and
in the year immediately succeeding that (1839) in which this work
was published.  It  is unnecessary to remark how much sensation this
case created throughout the learned world,  and it would be quite
superfluous for us to add our own  individual homage to  the  honors
that have justly accrued to our distinguished author for this brilliant
result of that masterly skill, ready tact, and close  familiarity which
he possesses of the most complicate anatomical relations of parts, both
in their pathological and physiological conditions.   Of the truth of this
remark, this diagnosis unprecedented by any analogous circumstances
in the history of surgery, furnishes a most conclusive evidence. The
patient, whose name was Gallochot, aged 21, (see  an interesting ac-
count of the case,  as  drawn up  by Dr.  N. \rictor Izokalski, in the
Gazette des  Medecins Praticiens, de  Paris, and copied  into the
Archives  Generales de Aledecine de Paris, 3e  et  nouvelle serie,
tome  VII., 1840, p. 299  to  p. 313;  see also  the notes appended to
the case by the  Editors of the Archives, Ibid., loc. cit, p. 302 to p.
313,)  was received  into La Charite, Jan.  18, 1840, with a tumor of
the size of a turkey's egg,  on the  right side of the  scrotum.   It was
perfectly  insensible, and  ha'd, he related  on the authority of his 
CASTRATION.
761
mother, been in that state, and of the same size from his  earliest in-
fancy, which assertion there was reason to believe was true, as it was
confirmed by the family physician.
  The fact of the  insensibility of the tumor, which the patient said
gave him no pain,  even when he thrust a knife through it, was also
confirmed by the numerous cicatrices upon it.  The position of the
tumor was external to the scrotum itself, its shape of a rounded form,
and the skin which  covered it was white and strongly contra-distin-
guished from the  deep brown color of the skin of the scrotum gene-
rally, both by this  circumstance and by the peculiar fine hairs upon
it.  While the  skin of the tumor also was insensible to the touch or
puncture, that of  the scrotum was  exceedingly sensitive.  Generally
this morbid production had the feel of a fibrous mass of different de-
grees of hardness.   In the midst of its tissue there was perceptible,
when it  was examined posteriorly,  an indurated substance which
conveyed the idea of something osseous.   At this part were noticed
three fistulous openings, through which  exuded constantly an unctu-
ous matter, (matiere grasse,) which resembled neither pus nor sero-
sity. Through one of these fistulous apertures  protruded a tuft of
very fine hairs, which had existed  there before hair had appeared on
the pubis. The testicle and epididymis were situated on the inner side
and appeared sound, except that  they  were slightly hypertrophied.
The spermatic cord  also seemed healthy, and the  functions of the
parts were unimpaired.  The patient said he never had the venereal
disease, and the tumor caused him  no uneasiness or trouble.   M. Vel-
peau, proceeding  in his examination upon the  ejective method, (voie
d'exclusion,) at length diagnosticated  a monstrosity by inclusion, or a
tumor composed of the detritus of a foetus.   On the 29th of January,
1840, he proceeded to the operation,  circumscribing the tumor by a
circular incision on the skin of the  scrotum, after which, the diseased
mass was, after a careful and minute dissection, completely separated
from the  neighboring parts.  The testicle, and even the tunica va-
ginalis, were both respected, and  were in sound condition, as  had
been beforehand diagnosed.  A good deal of blood flowed, requiring
three ligatures, after which the wound was  neatly closed  by  four
pins secured by  the twisted suture.  Violent inflammation of the
scrotum and febrile reaction ensued, which, notwithstanding active
depletory means,  ended in death in twenty-four hours after the oper-
ation, by means of metastatic abscesses  which developed themselves
in the chest.
  Dissection of the tumor.—A transverse incision exhibited several
cysts of various  capacities and  containing different matters.   The
largest contained  a fatty matter of a greyish color, composed of small
isolated particles,  but united to each other by a gelatinous substance.
Another cyst, of a chesnut color, was also filled with fatty matter, of
deeper color, and in this was found a quantity  of very fine hairs.
Others contained a  semi-liquid substance, perfectly resembling the
vitreous humor in consistence, but of a yellow color.   The  compact
portion of the tumor had none of the normal or abnormal characters
of known tumors ; it was of a fibrous consistence, but quite soft, and
of a rosy tint in its interior.  It contained also distinctly recognizable
masses of fat.  The most remarkable  contents  of  the tumor, and 
762
NEW ELEMENTS  OF OPERATIVE SURGERY.
which were situated near its middle portion, were a number of bones
arranged in different ways and articulated with each other, (plusieurs
os diversement disposes,  articules les uns avec les autres.)  M. De-
meaux, (an interne of AI. Velpeau,) by means of a careful and minute
dissection of these,  was  enabled to isolate them into three groups.
The largest one appeared at first to consist of three principal portions,
one of them, the most considerable,  consisted of an osseous column
of great strength  and somewhat irregular;  from one of its sides pro-
jected a prolongation which was curved upon itself in two different
directions;  on the opposite side were two osseous fragments articu-
lated together; and the whole united to the osseous column just men-
tioned.   The inference was almost irresistible that these bones were
those of the pelvis.   The second group was composed of long bones
articulated to each other by means of a fibrous mass.  Among this
group was a flat bone.   The third group was composed of several
flat bones, and of a series of small osseous nuclei, (petits noyaux os-
seux,) united together.  These last were probably the remains of the
head and spine.   These specimens were transmitted by AI. Demeaux
to the Anatomical Society, where  the diagnosis of M.  Velpeau was
recognized to have been fully made out.
   This case, as well as the  diagnosis, are,  as wre have said, without
any knowrn parallel in the annals of surgery.   Extra-uterine masses
or debris have, however, been found at various periods of life,  both
in the interior and on the external parts of  the body,  and have been
described by various authors.   For a  very learned and  interesting
account ofthe history of extra-uterine tumors we refer the reader to
(he observations we have already alluded to, and which are appended
to the above extraordinary case by the editors  ofthe Archives Gene-
rales, (loc. cit. supra.)   AI. Geoffroy St. Hilaire, the celebrated natu-
ralist, (now deceased) denominates the individual in whom such tumors
are found an autosite, while the tumor or fcetal germ itself is denomin-
ated parasite.  This distinction would seem to apply to their actual
condition when discovered, during some  period of extra-uterine life,
either at birth or afterwards.
   What  the condition of such  union is during intra-uterine  life,
however, or at the commencement of it  in the ovarium is another
question.  The Archives' editors consider that there must have been
at first, either two distinct and isolated (and, at the time, perfect, as
we suppose) germs, that  one has  penetrated into  the other, or that
both  germs were originally united in the same ovule, i. e. as we in-
terpret the editors, were contained in  distinct ova and both ova  in-
cluded in one of Graefe's ovules, for example.  In either case,  how-
ever, it is clear that  one has been arrested in its development, and
that the  organization of the other  has  predominated over the last at
some period of intra-uterine existence.  But if we suppose distinct
or separate or isolated  existences from the beginning,  ab ovo, we
must, to  carry out the principle, suppose two embryos either in  the
state of twins united in  separate ova, or  together  in one ovum, and
yet each, in this latter, having an independent existence, so to speak.
In the Siamese twins the presumption is, that  if  distinct ova existed,
as must  have been the fact, these ova were indissolubly united from
the very first moment that the spark of organic life was infused into 
CASTRATION.
763
them.   It wrouId seem, in such  cases, that the two  organizations,
however, though united by a vinculum, must  be external to and iso-
lated from  each other.   Therefore, in the remarkable case under
consideration, it is impossible for us to resist the conclusion that the
ovum of the perfect individual must have originally contained within
itself by a species of involution, the ovum of the being whose devel-
opment was  arrested and, as it  were, crushed in embryo.   If the
latter was a parasite it was of the entozootic kind.   When both com-
menced their existence with the punctum saliens, both may have been
of equal development or  power, though  of unequal dimensions, as
one was within  the other.  At all  events, it is  to us clear that the
one which now exhibited  itself only under the aspect  of  an obscure
vegetative  life,  in  imperfect  portions  of a  foetus, was contained
throughout  the  whole  of its organization,  completely within  the
other: in other words, was at first  an ovum within an ovum, i. e.  an
ovum in ovo, or  an imperium  in  imperio.   Without, however,  pur-
suing this inquiry farther, and which  falls  more directly within the
province of embryology, obstetrics, and pathological surgery than it
does within the divisions embraced in this work, it may be observed
that the perfect authenticity of the facts in the  case of AI. Arelpeau,
and the interpretation we have ventured  to  give  in relation  to the
primitive condition of the individual and of his tumor  during intra-
uterine existence, are calculated to impart some degree of  proba-
bility to a  narration referred to in the Archives, (loc. cit.) hitherto
deemed fabulous, and  which asserts, on  the authority  of  Gabriel
Clauderius, (see  Pauli Observationes rara, selecta et curiosa, Lipsias,
1760, p. 85,) that in the year 1762 the wife of a miller  gave birth to
a  strong and healthy female child with a belly of  extraordinary
dimensions, which infant  some days  after its birth was also seized
with violent  pains and  convulsions, and flow of blood from  the va-
gina, from which, shortly after, there was expelled another perfectly
formed and living  female foetus  followed by a placenta!    The
two infants were baptised together and died  the day after.  For
ourselves we conceive this to  be  scarcely, in any respect, more mar-
vellous than  the detritus of a foetus within the scrotum of a healthy
full grown living male subject.
   The  fatal influence also which  the removal of this apparently inert
and insensible mass, had upon the  individual  in whom  it lived,  goes
still farther to corroborate, that there then existed and had previously
been established a primordial and indissoluble organic union between
both.   The  result also would  go to show, though the cases  are not
parallel, that an  attempt to divide asunder the vinculum which unites
the Siamese twins would, as many surgeons  have  conjectured, spee-
dily prove fatal  to one or both.
   Scrotal Tumor,—An irregular, oblong, lobulated, adipose  tumor,
eight inches by six in dimensions, situated in the left side of the scro-
tum of a patient forty-three years of age, and  which first made  its
appearance in 1842, and the true  diagnosis of which  from hernia em-
barrassed even MM. Lawrence,  Brodie and  Travers,  was removed
in April, 1815, by Air. Lawrence with perfect success.  Mr. Curling,
in remarking upon this case and the deception caused by the swelling
of the tumor just before stool and when the patient was in an erect 
764          NEW  ELEMENTS  OF OPERATIVE SURGERY.
position, explains it very naturally by the accumulation of blood  in
the parts, from the interruption made by the fceces  in the colon  to
the return of the sanguineous circulation from the tumor  and sper-
matic veins. (Provincial Med. and Surg. Journ., June 25,1845.) T. 1

              Article  V.—Diseases  of the Penis.

                         §  I.—Phymosis.

  A.  Varieties.—The contraction of the prepuce is a disease which
presents itself to the operator under three principal forms:  1st.  The
congenital variety is in  no other way annoying except in presenting
an obstacle to the flow of the urine, or in occasioning, in adult age, the
pains which result from it in the efforts of coition ; 2d. That which is
the effect of inflammation, more or less acute, may give rise to acci-
dents of quite a severe character; 3d.  In the accidental but chronic
form, the  entire prepuce  may be  indurated  and thickened in such
manner as to form a hard indistensible  and, as it were, lardaceous
or elephantine shell, which encases and goes beyond the entire glans
penis.
  I. If the congenital phymosis is caused, particularly as happens in
infants, by the excessive elongation of the  integuments,  no other
operation is required than that which is known and performed in the
East by the Jews, according to the precepts  of their religion, under
the name  of circumcision, and which AI. Brueck, (Journ.  Univtrs.
des Sc. Med., X. VIIL, p. 185,) does not hesitate also to recommend
as a preventive of phymosis and chancres!
  II.  Nor does that form of phymosis which is produced by an acute
inflammation,  chancres, venereal lesions or any other cause, require
the employment of instruments, except it should constitute too great
a difficulty in the treatment of the  principal  malady, or that we
should have found ourselves unable to subdue it by means  of  topical
applications, injections and other appropriate remedies.
  III. The third variety has been but rarely met with.  When  it is
ancient and has proceeded to such degree as to render the emission  of
the urine  difficult, it admits scarcely of any other remedy than the
division of the contracted periphery.  If it were only an elephantine
transformation, compression  perhaps might be found to answer, and
a patient whom I treated in this manner did exceedingly  well.   In
other cases we are obliged to extirpate the entire shell.  Under such
circumstances  M.  Kerst first divides  the   frenum  ;  he   then,  by
means of two vertical  incisions,  lays  open the prepuce  into two
halves, which  he removes separately in the following manner: the
prepuce is  to be divided by the bistoury down to its inner  layer; the
surgeon, then  drawing  upon this, incises it with the  scissors as near
as possible to the root of the glans penis.  By dividing in this man-
ner the tegumentary layers  of the prepuce to an unequal extent, we
avoid the constant tendency which the inner one has  to become turn-
ed outwards when both are  cut to the same point.
  B.  Operation.—It is to be remarked, moreover, that in performing
the operation  upon a  prepuce having ulcerations  upon  its inner
surface,  we  incur the risk of having the  wound itself undergo 
DISEASES OF THE  PENIS.
765
ulceration, and  that  in  such circumstances we must not omit  the
employment of anti-syphilitic remedies  both local and general.
  I.  The Dorsal Incision.—The operation for phymosis, which is one
of the most simple in surgery, requires no other articles than a  straight
bistoury, scissors, a director without any lip, a dressing and a ligature
forceps, a plumasseau of lint besmeared with cerate, two or three fine
compresses and a narrow  band about a  yard long.   The concealed
bistoury of Bienaise, which was employed by Lapeyronie, as well as
other special instruments designed for this purpose, are wholly useless.
  a.  Ordinary  Process.—The patient is seated on a chair, unless he
should prefer the bed.  The surgeon  glides the director under  the
prepuce as far down as to the root of the glans penis.  The assistant
who  holds the penis, takes care at the same  time to keep  the director
and  skin properly  adjusted to  each  other.  The  bistoury,  guided
upon the groove of the director, reaches to the base of the cutaneous
fold.    The  point  of the  instrument  is  then  immediately  turned
towards the skin, in order to perforate  the prepuce from within out-
wards, and then to  incise it rapidly  from  behind forwards.  The
incision, by means of a puncture from  the deep-seated parts towards
the skin, possesses this advantage, that the  patient  in drawing back
terminates the operation, so to  speak, himself, instead of disturbing
the operator.
  b.  Some persons, in order to  dispense  with the director,  introduce
the bistoury after the recommendation of Sabatier, flatwise between
the glans penis and its envelope, proceeding in other  respects in  the
manner just described.   There are others also, who in order to avoid
wounding the  parts  upon  which we wish  to glide  the  instrument,
place a small ball of wax besmeared with oil  or cerate, on the point
of the instrument, which latter having once reached the bottom of the
cul de sac, passes without difficulty through the wax at the same time
that it perforates the tissues which are to be divided.
  c.  The scissors are scarcely any longer ever used at  present. Being
compelled to act upon parts that are very soft, and'difficult to  be held
steady, they rarely make a sufficient division  at the first cut.  They
are consequently not  employed except for  regularizing  the  incision
made by the bistoury, when this incision has not divided  uniformly
both  layers of the  prepuce,  or when we wish to give it a some-
what greater length.
  d.  Some surgeons consider it advisable  to adopt  other and still
more minute precautions,  with the view of preventing the  wound
from extending too  far either  inwards  or  outwards.   M.  Ricord,
(Journ.  Hebdom., X.  XL, p. 297,) for example, recommends, when
we do not decide upon circumcision, that the tegumentary fold should
be seized by means of two, or even three  dressing-forceps,  from its
free  border down  to its root, upon three  different  points,  in such
manner  as  to enable  us to  stretch it sufficiently to  allow the bis-
toury or scissors to cut through it without  the fear  of making  the
layers which compose it slip over each other.  Besides the embar-
rassment of so great a  multiplicity of instruments, which exact,
moreover, an equal number  of assistants, this  method would have
the disadvantage of being but rarely  applicable; when the  prepuce
is so  contracted as to require the operation for phymosis, it would 
V66           NEW ELEMENTS OF  OPERATIVE SURGERY.
not admit of the simultaneous  employment of three forceps and a
cutting instrument.
   e. M. Lisfranc, (Alargot, Revue Med.,  1838, t. I.,)  in order to
avoid the angular projections  of the wound, proposes that we should
confine ourselves to  the  excision of a semilunar flap, from  the an-
tero-dorsal  border of the part,  which excision he perforins bv means
of scissors,  curved on  their flat,  and which he repeats on  several
points of the membranous contour, should the first  notch not seem
to be sufficient.
  /. This process might be replaced by the removal of a triangular
flap from the contracted circle, should an actual loss of substance be
deemed advantageous.  This last  mode of excision, moreover, would
in some respects  become indispensable  if we had to operate for a
phymosis from chronic induration, as I have done in one instance at
the hospital  of St. Antoine, in a  man who had the entire sheath of
the glans penis transformed  into an actual  fibro-cartilaginous shell.
M. Roux has seen a  similar case.   A  stony cap (calotte) lined the
interior of a prepuce thus degenerated in the  patient of AI. Sper,
(Lancette Franc., X. L, p.  377.)  In such cases it might be even ad-
vantageous to adopt  the process of M. Kerst, and to extirpate the
prepuce entire.   I would, nevertheless, remark that a  patient who
was in  the  same  state as mine, and whom AL Voisin, (These, No.
205, Paris, 1832,) operated upon, died  thirty hours afterwards from
urinary resorption. But in another case the same practitioner obtained
complete success, though the tumor had become prolonged under the
urethra, (Gaz. Med., 1839, p. 89.)   A case of elephantine phymosis
successfully operated  upon by means of the dorsal incision, occurred
in 1838  in  the  hospital service of M. Liston, (Encyclogr.  des Sc.
Mid., 1839, p. 234.)
  II.  The Urethral Incision.—In adopting the dorsal region  for the
incision in phymosis,  we incur the risk  of  the  sides of  the  wound
being drawn back and separated apart, so as to give rise to the for-
mation of a  border which is sometimes very annoying.  The exci-
sion of the free angles of  the division, is but a very imperfect rem-
edy for the inconvenience in question.
  a. The process devised by Guillemeau, (De la Nourrit. de I'Enfan,
chap, xxxvii., p.  438,  in 8°,) who  had a special instrument for this
purpose, or  the  method of  M.  Cloquet,  (Bull,  de Fer.,  X. VIIL,  p.
206,) is  infinitely less  calculated  to produce  this difficulty.   It con-
sists in  performing the operation  at the lower part  of the prepuce.
The bistoury is to be  directed upon one of the sides of the frenum,
which itself is to be divided  immediately afterwards, should it ap-
pear  to be  too  much prolonged  forward.   Besides that there are
fewer vessels in  this direction than in the first, the wound in  conse-
quence of the retraction of its lips,  becomes transversal only, and thus
co-operates exclusively  in continuity with the opening, which it was
our intention to enlarge, without leaving, as  in the preceding  case, a
deformity almost as embarrassing  as the  original disease.  It would
appear, moreover, that the ancients adopted the same  course, for
Celsus, in speaking of phymosis  says, "  .  .  .  . subter a  summd
ord cutis inciditur rectd lined usque ad frenum, atque ita superius
tergus relaxatum cedere retro potest."  I have  frequently used this 
DISEASES OF THE  PENIS.
767
process, and everything induces me to believe that it will ultimately
be substituted for the other.
  b. The excision of the  frenum by means of a V section from  the
prepuce, as proposed by Taxil, (Arch. Gen. de Mid., 2e ser., t. XL,
p. 230,) is referable to the same principle.
  c. Instead of placing the incision upon the median line, either
above or below, we are sometimes obliged by the presence of vene-
real ulcers or tubercles, to make it on the side, or even on both sides
of the organ; but before this could be necessary,  the prepuce must
have been profoundly altered at the part which, under such circum-
stances would become the place of necessity, for these  lateral divi-
sions usually produce, whatever M. Malapert, who  has  endeavored
to popularize this process says to  the contrary, a very great degree
of deformity.
  d. Process of M. Begin.—M. Begin having grasped the prepuce
with the forefinger  and thumb  of the left hand, makes, by introdu-
cing into this  opening one of the branches of a scissors curved flat-
wise, an oblique incision from the  part nearest to the frenum to  the
middle of its dorsal surface ; then bringing the instrument back to
this point, he carries it as far as on the opposite  side.  The  integu-
ments being afterwards pushed back, the inner lining of the prepuce,
which remains upon the glans penis, is incised upon the median  line
as far as to the  fold which forms its base.   If the preputial  ring is
too narrow to allow of the  introduction of the  scissors, M.  Begin,
(Elem. de Chir., 2nd edit., t. I., p. 550,) uses a bistoury surmounted
with a ball of wax and lays open the prepuce from about the middle
point  of its length  up to its free  border.   The two angles of  the
wound are then trimmed, with the scissors, and the  inner membrane
is longitudinally incised in a third stage ■ of the  operation down to
the base ofthe glans.  No accident ensues from  this operation and
its result, according to the author, is to leave no deformity in the part.
  e. In whatever way we proceed, it is  possible and even very ad-
vantageous when the coarctation exists to a great degree, to plunge
the point of the bistoury guided upon the sound through  the skin, or
from without inwards as is recommended by MM. Heurtaut  (These
de Paris, 1811)  and Tavernier, instead of making the puncture from
the interior to the exterior.   A  good rule also, laid down by M. Tav-
ernier, (Bull, de Therap., X.  I., p. 147,)  with the view of not deceiv-
ing ourselves in respect to the  relative extent of the incision of  the
organic tissues, is the  following: the sound being properly placed,
its beak is to be  moderately pushed forward ; the surgeon then draws
back the integuments until  the rosy border of the mucous lining
shows itself.  The parts being  held in this manner by an assistant or
the surgeon himself, we shall be certain that the instrument  perfo-
rating by a puncture either from the skin towards the sound or from
the sound towards the skin, and brought forward from the root of the
prepuce to its free border, will make a section as neat and as uniform
as possible.  [This process  I  have successfully  followed in about
20 cases.  T.]
 /.  As soon  as the operation is terminated  the  cutaneous  fold
mounts upwards behind the  gland.  A  plumasseau is applied upon
the wound, which is to  be  surrounded  with one  fine and two long 
768           NEW ELEMENTS OF OPERATIVE SURGERY.
compresses, or by a Maltese cross.  To terminate  the dressing, the
extremity of the bandage is to be brought to the root of the penis,
thence carried forward  by circular turns to the anterior extremity
of this organ and afterwards carried  back again where it is to be
finally attached.  A suspensory previously applied, would enable us
to keep up this small  dressing much better still, and would render it
less liable to be displaced.  Finally it is advisable to make use of one
or two  turns of bandage or a cravat  passed around  the loins, by
which means we are enabled  to keep all the parts turned  back in
front of the pubes.   The dressing is not to be renewed until the end
of two or three days, unless it has become loose, and as soon as the
solution of continuity begins to suppurate it is reduced, in fact, to so
simple an affair that it is useless to speak of it more in detail.
  g. In order that the wound  may remain as  narrow as possible in
the antero-posterior  direction,  and that it may not be too long in
closing, there will be an advantage especially to begin at the first
dressing  in placing the turns of the bandage  upon the  body of the
penis, by proceeding from behind forwards, and  then in making use,
as AL Tavernier recommends, of a Maltese cross, having a hole in its
middle portion, in order that it may leave the glans penis uncovered,
while at  the  same time it pushes the divided prepuce from before
backwards.  The dressing being  thus  adjusted, is found  to be more
solid and all the tissues to be pushed against each other, in place of
having a tendency to be separated apart, as  frequently happens
when we do not  adopt this precaution.  At a subsequent period I
have  found it  advantageous  to  draw forward  the callous border
which the borders  of the division will  form  for a considerable
length of time, in order to  make  some compression upon it and to
favor its resolution.
   h.  Process of the  Author.—The following process has  afforded
me excellent results.  I introduce three or four nooses of thread
on each side of the frenum,  at three lines apart from each other, and
then immediately detach  the frenum with a good pair  of  scissors.
The point of a bistoury plunged  in at  the root of this wound on the
median line, then lays open the prepuce, as in the process of AL Clo-
quet.   Having divided the nooses of thread at their middle portion,
I instantly knot them separately, and in this manner obtain the same
number  of points of suture, which immediately close  up  the two
sides of the wound.  In this manner there is no need of any dressing.
and the cure may take place in three  or four days.

                      § II.—Paraphymosis.

   A.  If compresses wet with cold  water, or containing ice, which pos-
sess the virtue, by diminishing the afflux of fluids, of reducing the size
of the corpora cavernosa, of putting a term to the strangulation, and
enabling us to  bring the  prepuce  forward, should not  be found to
answer or cannot be employed, and should the inflammation or pain-
ful condition of the parts present in other respects no objections, we
have still another resource to  make trial of before proceeding to the
operation, properly so called, which is  used in paraphymosis.
   B.  This resource is compression.  Some do this in the same way 
DISEASES OF THE PENIS.
769
as in  applying a roller bandage,  the  pressure  made by  which is
gradually augmented until the reduction of the glans  penis  can be
effected; others make use of the fingers, and in such manner that in
most cases we are enabled to relieve the patient immediately.  The
surgeon then grasps the penis with the fore and middle finger of each
hand,  crossing them behind the engorged border; his two thumbs
remaining free, are to rest against the sides ofthe glans penis, in such
manner that by acting in concert with the fingers, but in an inverse
direction, they may  crowd the glans backwards, while the prepuce
is  brought forcibly  forwards as if for the  purpose of covering the
thumbs, which will then be found to be lodged in its interior.  In order
that the fingers may not slip upon the skin, it is advisable to separate
them from it by means of a fine piece of linen, which has the  advan-
tage, also, of rendering the operation a little less painful. We should
be wrong to reject this process merely  because the disease has ex-
isted for 12 or 15 hours, and that the parts have already become in-
flamed and painful.  I have made use of it in several instances with
entire success at the expiration  of 24 hours, or of 3 or 5 days with-
out any inconveniences on that  account, although the front part of
the penis was extremely sensitive, and that there were many chinks
upon the sides of the preputial border.   It is an operation calculated
to succeed in the majority of cases if it is well  performed, and the
steps  of which it is  unnecessary to point out more in  detail to those
persons who are sufficiently  well instructed to know how to execute
it in the manner required.
   C. In case however it should not answer the expectations of the
surgeon, and that circular compression should not be practicable, we
should proceed then to the cutting instrument.
   I. While an assistant stretches the  penis at its two extremities and
gives  a moderate curvature to its lower side,  the operator glides a
narrow bistoury flatwise between the dorsal surface of the glans
penis or corpora cavernosa, and its envelopes as far as to the point
of strangulation, then turns the edge of the instrument upwards to-
wards the skin, if he is Certain of having penetrated underneath the
constriction, or in the contrary case, towards the side of the penis, and
then immediately makes the incision, depressing the wrist in the first
case, and raising  it a little in  the second.   If a first incision should not
appear  to answer, we immediately make one or two more  in the
same manner.
   II.  Processes of the author.—In place of digging away in this man-
ner in  the tissues in order to reach down to the bridle, and instead
of first incising the skin posteriorly, and inserting through that open-
ing a grooved director to guide the bistoury under the strangulation,
as recommended by Richter, would it not  be  better to make the in-
cision directly on its external surface ?   I know of no circumstances
scarcely which could render an incision of this kind wholly imprac-
ticable.  By causing the skin to be drawn  back towards  the pubis,
while  an assistant endeavors to reverse  the diseased  border in front
we generally succeed in exposing to  view the  base of the circle
which  causes the accident.   Nothing is then easier than to direct
perpendicularly upon this border the point of a straight bistoury held
as a writipg pen, and to make on one or several points, by means of
                              49 
770           NEW  ELEMENTS  OF OPERATIVE SURGERY.

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

               § III.—Strangulation ofthe  Penis.

  Since Morand drew attention to this subject, all practitioners have
related cases of individuals who mechanically, and from depravity, or
inadvertence, have got their penis incarcerated in certain cords or rings
from which they could not afterwards withdraw it.  This sometimes has
been produced by  a  circle or ring of iron,  copper, silver, gold, or any
metallic cylinder whatever; at  other times merely by a packthread
or common thread, &c, or by the socket of a candlestick, as  has
been seen by Dupuytren.   Sometimes, finally, it has been effected by
means of a steel ellipse, known under  the name of briquet, which
persons have imprudently placed around their penis, occasionally em-
bracing with  it even the scrotum also.  The parts soon react upon
such obstructions, which latter subsequently become concealed at the
bottom of a groove of more or  less depth, and  consequently by the
swelling which they occasion speedily bring  about a perforation of
the urethra, or of the fibrous envelope of the corpora cavernosa, even
if they should not go to the extent of producing a gangrene of these
parts.   Bands of thread, cord, or ribbon, will never produce any se-
rious embarrassment to a surgeon ; the point  of a bistoury or a sharp-
pointed scissors, will always promptly divide  them, without any great
difficulty.  The same remark nearly, would apply to a circle of wil-
low, bulrush,  or wood.  To divide a ring of ebony, ivory, or horn,
it would become necessary to use a very  strong  pair of scissors, or
cutting pliers ; while for metallic bodies, the  file or saw would  fre-
quently become indispensable.   In such  cases,  a cutting diamond
would  be a valuable resource  if  it could  be  commanded.   Unless it
should have a  great degree of  thickness, the  hardest  circle would
probably yield to the application of two  small  hand-vices if it were
practicable to grasp it.  Should there  be  too great a degree of en-
gorgement, this is  to be  in the first place diminished by means of 
DISEASES OF THE PENIS.
771
bird-peck punctures and scarifications.  Afterwards, the edges of the
groove are to be separated  as much as possible, in  order  to insert
when it can be done, a piece of wood, metal or linen, under the con-
stricting body, to protect the parts against the action of the instru-
ments.   Aloreover, the saw and file should be directed almost trans-
versely to the penis, much more than in the direction of its length, while
the employment of the other means will be sufficiently understood in
themselves without the necessity of entering into further details.  A
boy 7 years of age, in order to prevent his any more  wetting his bed,
undertook to tie the middle of his penis with a thread.  The mother,
who did not find it out until  the 7th day, brought him to  consult me
at the Hospital.  The skin cut through by the thread, had cicatrized
over it, and the ligature  was no longer  visible except by the extremi-
ties of its knot.   After having divided it, I effected its extraction and
on the following day no further difficulties remained.  The urethra
had not been divided.

                §  IV.—Division of the Frenum.

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

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

  The inner surface of  the  prepuce sometimes adheres very closely
to the  glans.   When this  infirmity is  not accompanied with  co-
arctation, it  does not in general  involve any  particular  inconve- 
772          NEW ELEMENTS OF OPERATIVE SURGERY.

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

               § VI.—Destruction  of the Prepuce.

  The prepuce in place of being too long and adherent to the glans,
may be too short.   Celsus, who  had   already devised a mode of de-
stroying this defect  of conformation, advises that we  should make
on the  body of the penis  a circular  division of the skin at a certain
distance from the glans,  then to  draw the integuments forwards and
fix  them by  means of threads  beyond  the free extremity of  the
organ.   At the present day we know, and can no longer doubt, that
an operation of this kind is unnecessary, and that the cicatrix scarce-
ly  ever fails to draw the  skin gradually backwards  again, and thus
re-establish the  defect in its  original condition; but it is probable
that we should succeed better by detaching the  anterior portion of
the penis, from its envelopes  to  the  extent of one or two inches, in
such manner, as to be enabled to bring them as far as to the  front of
the meatus urinarius, under the  form of an artificial sheath.  Only
we should then have to adopt precautions  to prevent the adhesions
of this new encasement from being prolonged too far upon the body of
the glans penis itself.  If the  prepuce had lost only a small quantity
of its periphery, and it should be  found impossible  to  remove  this
notch  in proceeding in  the manner of  harelip, we should  have to
dissect to a greater or less extent the two sides ofthe division, in or- 
DISEASES OF THE  PENIS.
773
der afterwards, when we had  abraded its edges, to approximate and
unite  them by suture.  In conclusion, it is evident that posdeplasty
would present  in fact as many modifications  as cheiloplasty.   M.
Dieffenbach, moreover, has shown that Sabatier as well as J. L.
Petit, were under an error in proscribing as impracticable those dif-
ferent species of restorations applicable to the virile member.  (See
Anaplasty, Vol. I.)

               § VII.—Amputation of the Penis.

  A.  From the mobility and the extreme distensibility of the envel-
opes of the penis, it will happen that  tumors of the prepuce for ex-
ample, will gradually push back the glans and corpora cavernosa in
such manner as to  appear to  occupy the place of the body of the
penis itself,  when,  in fact, there are no  other than its coverings
that are affected; from this, without doubt, originated  the error of
certain ancient  authors, who imagined that the penis was capable of
being reproduced, and that it has been seen to grow again, after hav-
ing been amputated.  We may, in fact, remove a very considerable
extent of parts  and  nevertheless not reach as far back as the meatus
urinarius.   The tissues  which  have  been in this manner crowded
forward by the tumor or the swelling, are elongated in such cases to
so great an extent as to impose readily upon those who are already
predisposed to  error.   Cancer  is not the only malady which may
cause this illusion, for all other kinds of degenerescences are calcu-
lated  to produce the same effect.  Even  acute inflammations have
sometimes given rise to this deception.  In 1824 there was admitted
into the hospital of Perfectionnement, a robust man about forty years
of age, in  whom the penis, which was enormously swollen, became
gangrenous, in twenty-four hours, down to two  inches from its root.
Precautions were adopted to save what might remain of the glans or
of the corpora cavernosa in the midst of this putrilage, but they were
found, intact, behind  the  sphacelus, and  were without any lesion
except some slight excoriations  on their front part.
  B. Amputation ofthe penis maybe either partial or total;  partial
whenever  the cancer does not occupy its entire substance, and in the
contrary case total.  Those descriptions of cancer of the penis which
commence on the skin, either at the prepuce or elsewhere, do not in
general reach to its fibrous envelope or  spongy tissue until after
the lapse of a very  long period of time; we should therefore com-
mence their extirpation in the same way as if to preserve the prin-
cipal organ, but so  as  to keep in view nevertheless1 our power to
sacrifice it when it  shall be found to be actually altered.   The  pre-
cept of removing only the degenerated tissues,  one which so many
ancient authors insisted upon,  and to which Callisen so  frequently
reverts when speaking of operations to be performed on the genital
organs, has been  too  frequently overlooked.   The  suggestion  also
made by M. Earle, (PI. Portal, Clin. Chir., X. L, p.  57, 1836,) that
we should remove only the cutaneous or superficial layers when the
cancer of the penis  does not appear to have involved the cavernous
tissue, deserves to be adopted.  We  should  rigorously adhere to it
therefore especially  in cases where, like that related by M. Gendrin, 
774           NEW ELEMENTS OF OPERATIVE SURGERY.
there was a well-defined hematic tumor, or one that  was sebaceous
or lipomatous, or any whatever that was cutaneous or sub-cutaneous,
as has frequently occurred to me in my practice.
  C.  Besides the peculiarities connected with  the envelopes of the
virile member, amputation of this organ requires that  we should not
lose sight of the arrangement of its own appropriate elements.   The
fibrous encasement  which forms its covering, and  the spongy tissue
whose meshes  all  communicate with each other, cause it to be
elongated or shortened immediately after the operation, according as
the tumor should have previously crowded it back or drawn it for-
ward.  The cavernous arteries enclosed in its  interior, one on each
side,  being  but  slightly  adherent, protrude at the  surface of  the
wound if the stump has retracted to a considerable degree; on  the
contrary they will  appear  to be embedded in its tissues if it has
undergone  an elongation.   The  urethra  being applied  against its
lower surface and also in immediate contact with  the  skin, presents
moreover this remarkable peculiarity, that its free wall attaches itself
with great facility to that which is adherent; so that it almost always
conceals itself at the circumference of the wound  immediately after
the amputation.   The osseous septum noticed between the corpora
cavernosa by M. McLelland, (The Lancet, vol.  L,  p.  714, 1828;
Arch.  Gen.  de Med., X.  XVIL, p.  272;  Journ. des  Prog., X. IX.,
p. 243,) could not have been extirpated without compromising the
life of the patient or the functions of the penis.   I refused to operate
in any manner whatever in a patient who had this singular deformity,
and in another in whom  an osseous prolongation, fifteen lines  long,
was sent out from the pubis  on the left side of the penis.
  I.  Ligature.—The fear of hemorrhage induced some  ancient au-
thors  not to make use ofthe cutting instrument to amputate the penis,
which they thought it more  advisable to  strangulate by means of a
ligature.   Ruysch cites a successful result obtained  by him in this
manner.  Nor have Heister, Bertrandi, M. Graefe (Alichaelis,  Bull.
de Fer., X. XX.,  p. 210) and M. Binet (Revue  Med., 1828, t. III., p.
70) thought this  method  unworthy of employment.   To perform it
we should at least previously introduce into the  bladder a catheter to
prevent the ligature from closing up the urethra.  If we should have
any apprehension of causing too much  pain by applying the liga-
ture immediately upon the skin, nothing would prevent our adopting
the recommendation which  we still find  in  Sabatier,  to incise the
tegumentary  covering circularly before  applying the thread; but
this incision, which is as painful as amputation,  properly so called, is
precisely that which deters  certain timid  patients  from undergoing
excision, and which induces  them to prefer strangulation.
  II.  Ablation.—The patient is to be placed in  a horizontal position.
An assistant grasps  the root  of the organ and draws back the skin to
a greater or less extent towards the pubis, according  as the disease
appears to have drawn  it more or less forwards.  The surgeon im-
mediately siezes the tumor, which has  been wrapped in linen, and
holds  it firmly with  his left  hand ; with a bistoury or small  knife in
his right hand he then divides with one cut the body  of the penis a
little beyond the limits of the disease, and  perpendicularly and either
from above downwards or from below upwards.  A previous divis- 
DISEASES OF THE  PENIS.
775
ion of the skin a little in advance of the place where the corpora
cavernosa are to be divided, would add but little to the length of the
operation and would always enable us  to adjust the section of the
penis exactly upon a line with the retracted integuments.   This pro-
cess, therefore, which Boyer recommends, when the disease extends
nearly as far as the scrotum, appears to me to deserve the preference
in all cases.   The arteries which are to  be closed up are sometimes
six in number or even seven, viz., two  dorsal, two cavernous, the ex-
tremity of the two superficial  arteries of the perineum below, and
also those ofthe septum on the lower median line.   The four princi-
pal ones, however, are the dorsal and  the cavernous arteries.  The
very loose tissue which  encloses the  first would render their isola-
tion  and torsion an easy matter, should a ligature  upon them be
attended with the slightest inconvenience.  The same remark nearly
would  apply to the  second named  arteries; but as we are not to
attempt immediate  reunion  in a wound of this description, it is a
matter of very little importance that  the vessels should be twisted
rather than tied.
  III. Process of Barthelemy.—Before proceeding to the dressing, a
catheter must be introduced into the urethra.  Some persons having
alleged that it would be difficult in  some cases to find again the ori-
fice of this canal at the bottom of the wound, a military surgeon, M.
Barthelemy, (Journ. Hebdom., X. XIIL, p. 41.) has  proposed that we
should insert the sound before commencing the operation, and to cut
through it at the same time with the penis, in order that it  might be
thus found placed in a natural position  by the same stroke.  This is a
modification which may  be adopted or rejected almost indifferently,
did it not incur the risk of the posterior portion of the tube escaping
into the bladder, or if the section of this instrument did not render
that of the remainder of  the penis somewhat more difficult.   To a
person possessed  of any anatomical knowledge, the finding of the
urethra, notwithstanding what M. Barthelemy may say, would never
be a circumstance of any great  difficulty.  Beclard  of  Strasbourg,
and MM. Poirson and Bedor, however, have made trial  of this pro-
cess with success.
  IV. The method of M. Schroeger, (Rust's Handb. der Chir., vol.
I., p. 667,) wiiich consists in dividing the penis, layer  by layer, from
above downwards, in order to tie the vessels in proportion as they are
cut, is of no value.   The noose of thread passed through the corpora
cavernosa to prevent their retraction and tie the vessels without dan-
ger, as recommended by AL Langenbeck, (Ibid.,) would only be use-
ful in cases where, as in that of AL  Hall, (Gaz. Med., 1836, p. 748,)
we were obliged  to carry the  bistoury as far down as under the
pubis.
  V. If the skin should  have been  crowded back  too far, it  would
of itself spontaneously cover over the wound, and might in this man-
ner produce some trouble.  When, on the contrary, it has not been
crowded back sufficiently, it is seen to retract towards the  pubis,
thus leaving bare the fibrous envelope  of the corpora cavernosa.  As
there  is no remedy to this last inconvenience, and as in  the other
method we always have it in our  power to excise the superfluous
portion of integuments, it is in fact  better to draw back the  tissues 
776           NEW  ELEMENTS  OF OPERATIVE SURGERY.
 towards the mons veneris, while we are amputating the penis.  Nor
 would there still, though we were obliged to operate near the pelvis,
 be any argument for giving the preference to the ligature over ex-
 cision.   The vessels at  this place cannot present any great decree
 of embarrassment; cauterization, moreover, with the red hot iron, or
 caustics, recommended as a general remedy by  so many  authors
 would constitute a last resource, which  would be found sufficient to
 put an end to the hemorrhage.  Compelled by a return of  the dis-
 ease to repeat the operation three times, M. Hall, who  went as far
 as to the pelvis, nevertheless effected the cure of his patient.  But
 what shall we  say  to M. Ogier, (Gaz. Med.,  1836, p. 7 is,)  who
 states that though he amputated the middle of the body  ofthe penis,
 he nevertheless  reagglutinated and preserved the glans !
   VI.  Dressing.—After  the catheter is once fixed  in  the  urethra,
 all that we have to do is  to apply a Maltese cross perforated by this
 catheter, over the wound.  Plumasseaux, two long compresses, and a
 narrow bandage, which supports them on the remainder of the penis,
 and afterwards passes once or twice around the  pelvis, constitute all
 the pieces of the dressing, unless we should prefer, as after the  ope-
 ration of phymosis, the employment of  a suspensory or  T bandage,
 upon which should be fastened the small bandage  or the extremity
 of the two long compresses which  have  been crossed over the bleed-
 ing surface.  As the catheter in these cases has no other object  than
 that of allowing the urine to escape without touching the wound, and
 that of preventing the closing up of the urethra, we may object to its
 use from the fact that the passage of the urine over the wound,' far
 from being injurious, is sometimes  advantageous.  The proof of this
 lies in the fact  that in former  times the urine  was frequently em-
 ployed to favor the cure of wounds.
   VII. It is the  opinion of some  persons that the urine expelled from
 the bladder would serve as a sufficient obstacle to the obliteration
 of the meatus, and moreover from  the urethra being lined by a mu-
 cous membrane, that there could be little reasonable apprehension of
 its obliteration.   I saw in 1823 a fact calculated to  confirm this opin-
 ion.  An old man had the penis amputated  by AL Bougon for a  can-
 cer ; the catheter was placed and the  dressing applied according to
 the usual rules.   But this man, destitute of every faculty of reason,
 was unwilling at any hazard whatever to sustain the slightest dress-
ing.  On the  second day, he removed the  catheter and  the  rest of
 the dressing.  I  reapplied them several times, and was never  enabled
 to induce him to keep them on.  Finally, it was  given up, not how-
 ever without serious apprehensions of the danger  that might result
 from this omission.   The wound however  cicatrized  regularly, and
 the urethra preserved as good dimensions as could  be desired.
  VIIL A catheter therefore is not indispensable.—As  its presence
therefore is  not  unattended with inconvenience,  we might, if we
 did not wish to dispense with  it entirely, make use of it,  at least
only during the first days, in order to prevent immediate reunion,
 and at  the termination ofthe treatment as recommended by LeDran
for the  purpose of preventing secondary  coarctation.   We might,
moreover, wholly  dispense with it by  adopting the  precaution of
uniting the mucous membrane of the  urethra to the skin by means 
                     TUMORS OF  THE VULVA.                  777

of three points of suture, according to the process which I have
pointed out in speaking of cancer of the lips, and which, according to
M. Rorbye, (communicated by the author, 1838,) he has heard recom-
mended in Germany.
  IX. I cannot terminate without remarking that amputation of the
penis, simple as it appears to be, rarely fails, notwithstanding, to be
followed by  consequences  of quite a serious  character.   Though
patients who undergo this operation almost constantly recover at the
expiration of fifteen, twenty, or thirty days, a considerable portion of
them soon become a prey to the most melancholy reflections, and  to
a deep-seated depression of mind that nothing  can remove; to such
degree that some ultimately destroy themselves, while others, in a
number of instances, succumb  to  their  mental despondency at the
very moment when it was least  suspected.   If the glans penis alone
is removed, it is shown by a fact in Scultetus,  and another of M.
Buret, that sterility is not the inevitable consequence.  In every other
other case could the result be other than this ?
                        CHAPTER  II.

                THE SEXUAL ORGANS IN WOMAN.

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

             Article  I.—Tumors  of the Vulva.

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

             §  I.—Labia Majora and Mons Veneris.

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

 the mucous  portion of the labia majora, and in the direction of the
 perineum rather than in that of the mons veneris.
   B.  Hematic tumors and sanguineous cysts are also  frequently de-
 veloped in the tissues of the same organs, either in consequence of falls
 blows, or accidental external violence, or from frictions made-during
 coition or from the effects  of pregnancy, or parturition. Having else^
 where treated, (Art des Accouch., X.  IL, 1835,)  of these tumors°under
 the title of thrombus of the vulva, and having related there the prin-
 cipal  examples of this kind which science possesses, to which might
 be added the six instances related  by  MM.  Riecke  and Elsasser
 (Arch. Gen.  de Med., 2e ser., t. V.,  p. 608,) I  will not dwell again
 upon  their history in  this place.   Their treatment, moreover, is  the
 same as that for hematic tumors  in  general, and it is only in their
 connections with  pregnancy or  parturition that they could present
 any peculiar features.
   C.  Sero-mucous Cysts.—There exist in scientific collections, and
 there are still daily seen in  practice,  numerous examples of sero-mu-
 cous cysts developed in the  tissues  of the  labia majora.  These tu-
 mors, whose  existence has  been pointed out by Pottier, (Bonet, Corps
 de  Med., X.  IV., p. 492,) Mauriceau, (Mai. des Femmes Enceintes,
 p. 152,) Denman, Watson, and Davison,  (Denman, Traite des Ac-
 couch., X. I., p. 168,) which I  myself  have seen  in a great number of
 instances, and which rarely exceed the size of the fist or a pullet's
 egg, usually contain a glairy, mucilaginous, and synovial, or purely
 serous matter.  I have already said  that they appear to  me to have
 been often confounded under the name of hydrocele, with infra-pubic
 serous tumors in  women.   I will add that in  most cases we may
 trace  their origin to some ancient injury to the  part, or to the conse-
 quences of an infiltration or effusion  of blood.   It would appear also
 that a predisposing cause to these tumors is found  in the species of
 bursa-mucosa which frequently exists  in the centre of each labium
 majus.  Puncture and iodine injections, when  they are of large size
 and tense, are the best  means to apply to them.   In the contrary
 case, it is better to lay them open largely or excise their free portion
 to induce the sac to suppurate, than to treat them by simple incision.
 It would  be advisable, moreover, to have recourse to the same means
 that I  have mentioned under the article of sero-mucous cysts in general.
   D.  The mons veneris  is  liable, like all  other regions of the body
 in women, to the development  of  various descriptions of tumors.
 M. Faneau (Precis Med. d'Indre et  Loire,  &c, 1821,) has met here
with a fibrous mass ofthe size ofthe head, and  which he successfully
extirpated.  I have in two  instances  seen here  an enormous varicose
 mass  which ascended up as high as  the umbilicus ;  I have no need
of remarking that abscesses, thrombi  and sanguineous tumors are also
 very frequently met with in this  region.  Operative surgery, more-
over,  possesses no peculiar resources which can be enumerated with
any advantage, in treating  of these tumors.
   E.  The vulva,  which  is  naturally supplied with numerous vessels,
and whose lips, in old women especially, are transformed sometimes
into Urge varicose or erectile tumors, is also liable to all the varieties
 of sanguineous fungous tumors from the tenderest age  of childhood.
In a little girl, three years of age, I  found the middle third of the left 
TUMORS OF THE  VULVA.
779
labium majus occupied  by an accurately  defined  arterial  erectile
tumor, which might have been extirpated without any danger.   An
erectile  tumor which was situated upon the left labium majus  of a
woman  29 years of age, was successfully extirpated by M. Portal,
(Clin. Ch'ir. &c, p. 142.)   It is readily understood, moreover, that
what has been said of erectile tumors in general, (see Vol. II.,) must
be applicable in every respect to erectile tumors  of the vulva in
particular.
  [An Encysted Tumor in the left labium  majus,  of the size  of a
goose-egg, and which led to the supposition of a hernia, from its dis-
appearing on pressure, was removed by Mr. Syme, (Cormack's Jour-
nal, Feb., 1846, pp. 83, 84,) from a woman aged  35,  by  a cautious
dissection of the sac, and  especially its posterior  adhesions.   The
woman  speedily recovered.   Mr. Syme had never before met with
an encysted tumor in the labium, but has removed one of  the size of
a pigeon's egg from the prepuce of the clitoris.  T.]

                 § II.—Tumors of the Clitoris.

  The clitoris, which is a sort of rudimentary penis,  is susceptible of
all kinds of degenerations.  The ancients, who frequently  amputated
it, had scarcely any other object in  view in these cases, than to mode-
rate the too great degree of lasciviousness in women.  Perhaps ex-
cision of the clitoris  considered in this point of view, has been  too
positively rejected for more than a century past.  Certain it is, that
a young girl, reduced  to marasmus by masturbation, was radically
cured of her vicious propensities, after M. Robert (communicated by
the author, 1839,) had amputated her clitoris.   The operation then
would be so simple, and so entirely exempt from  dangers, that we
should, I think, decide upon it without hesitation.  The  clitoris, more-
over, has been frequently amputated  for large sized tumors.   Wels-
chius  (Bonet, t. III., p. 309—t. IV., p. 309,) says that Molinetti extir-
pated one weighing 9 pounds.  Rougemont (Bibl.  Chir.  du Nord,
X. I., p. 132,) quotes from Kremer an instance of a clitoris  of the size
of three fingers, and which had become transformed into  a  sort of
cauliflower, and was amputated with success.  In a woman, who had
menstruated by the urethra, the clitoris, which had grown  into an
enormous tumor, was also successfully amputated  by M. E. Coste,
(Journ. des Conn. Med., X. III., pp. 205 and 276.)  M. Syme, (Edinb.
Surg, and Med. Journ., vol. 137, p. 387,)  who states that  he had oc-
casion to excise a tumor of the clitoris, in a girl 8 years of age, was
also placed under the necessity of extirpating a large cyst, developed
in the same organ in an adult  woman.  But the  most curious case of
this kind is, that described and figured by M. Schoenfeld, (Encyclog.
des Sc. Med., 1837,  p. 188.)    The tumor, which  included also  the
nymphas, and presented a granular aspect, weighed 3 ounces.   The
extirpation, which in other  respects  was easy,  occasioned a hemor-
rhage, which was arrested by cauterization, and  the patient was soon
restored.  A case nearly similar had been  already related by AL
MacFarlan, (Arch. Gin. de  Med., 2d ser., t. IL, p. 281.)   What I
have already said of processes relating to the amputation of the penis,
might be repeated under the head of tumors  of the clitoris.   The 
 780          NEW ELEMENTS OF  OPERATIVE SURGERY.

 operation,  nevertheless, whatever may be its  modification, is  still
 more easy here, and less  dangerous than at the penis.   As there
 is no large sized artery in the pedicle  of the organ, and  no urethra
 to be respected, I see no reason which could  induce us  to make
 use of the ligature rather than the cutting  instrument.  By means
 of the bistoury the  tumor may be  removed in a second  of time,
 and should a hemorrhage supervene, it could be soon put a stop to
 by the ligature, compression or caustics.  Caustics would  not be ad-
 missible  in tumors of the  clitoris, except for  those degenerescences
 which were flattened, diffused, and destitute of a pedicle, or in such
 patients as persisted in refusing every other kind of medical resource.
 The ligature in its turn would  not be applicable except  in timid
 persons, or in cases  of tumors with a slender pedicle, or where we
 had reason to  apprehend  the existence  of numerous large sized
 vessels in  the  root of the clitoris itself.

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

   Excision of the nymphas, which was formerly so frequently had
 recourse to, is scarcely ever practised  at the present day.   As these
 folds do not acquire large  dimensions in our  climate except in rare
 instances, they  do not excite the attention of women unless  they  ac-
 tually become diseased.  Whether the  pretended apron of the Hot-
 tentots be nothing more, as M. Larrey maintains (Clin. Chir., X. III.,
 p. 87,) than an elephantine degenerescence of  the labia minora, or
 whether it belongs to another order of hypertrophy or degeneres-
 cence, certain it is,  that the  wife of a Fellah, whom  our celebra-
 ted military surgeon  saw at  Cairo, had on  the labia  minora  an
 elephantine tumor in every  respect  analogous  to  that which is
 seen in the scrotum.   In  the women  mentioned by Kramer and
 M. MacFarlan, one  of the labia  minora,  or both,  had acquired a
 considerable  volume  at the same time that there existed as extra-
 ordinary a development of the  clitoris.   M.  Prieger, (Journ.  des
 Conn.  Mid., X.  I., p. 90,) who  has seen the nymphas acquire an
 enormous volume, applied  the ligature to them on both sides. One
 of the  tumors  became  detached  on the 8th  day, and the other on
 the 10th.   There supervened  an inflammation, accompanied with de-
 lirium, which was met by the antiphlogistic treatment,  and which
 did not prevent the radical cure of the patient.  Should the nymphas
 be merely hypertrophied,  the way would  be to excise them either
 with the bistoury or  with a good  pair of curved scissors.  A suffi-
 cient number of threads previously passed through their root, would en-
 able us after the excision to unite the two borders of the wound by first
 intention, by means ofthe suture, and in this manner to cure the patient
 operated upon in the space of a week.   The same process would be
 still applicable,  however extensive or of whatever nature the tumor
 might be, provided the latter comprised the whole length of the fold,
 without having its root  too much  widened.   Otherwise it would be
 advisable to divide its pedicle after it had been properly isolated, or
 in other cases to dissect it carefully,  and that  according to the rules
 laid down in the article on Fibrous  Tumors  in  general, or on hie.
phantiasis of the Scrotum. 
TUMORS  OF THE VULVA.
781
              § IV.—Elephantiasis of the Vulva.

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

              § V.—Tumors of the Vaginal Septa.

  The walls of the vagina are  also quite frequently the  seat  of va-
rious tumors, which  are seen sometimes in the interior of the canal 
782
NEW ELEMENTS OF OPERATIVE SURGERY.
itself, and at other times have their root in the tissues of the organic
layers of which it is composed, or upon its external surface.  Thus
there have  been noticed in the vagina sanguineous collections, ab-
scesses, cysts of every  description, and  schirrous  and encephaloid
tumors.
  A. One of those that have been most anciently known was noticed
by Pelletan; it was situated in the left wall of the vagina.   Dupuy-
tren (Lemazurier, Gaz. Med.,  1835, p. 544,) supposed it a hernia, but
Pelletan, (Arch. Gen. de Med., X. XVIL, p. 300,)  by laying it open
freely, demonstrated  that  it  was a cyst.  AL Roux met with one
which projected at  the same time into the rectum and vagina.  Al-
though it was  of considerable size  he  extirpated it and  cured his
patient.  In another woman,  attended by AL Recamier, (Lancette
Franc., X. V., p. 92,) who had a tumor between  the rectum and
upper  part of the vagina, it  made its  way into and was evacuated
through this last canal.   The  case, according to  every appearance,
was one of an hematic  collection.  We are indebted  to  AL Voilot
(Gaz.  Med., 1835, p. 702,) for the history  of a very large sized
tumor, which  was situated on the  anterior  wall of the vagina or
under the urethra, and which concealed the clitoris, and contained  a
milky liquid, while at the same time there was another tumor situated
lower down, and which was filled with a dark colored matter.  They
were successfully excised, and it would  seem, also, that these were
cases of a degenerate hematic deposite.  A concrete tumor which was
situated in the vesico-vaginal septum, was successfully extirpated by
M.  A. Berard,  (Ibid., p. 384.)   The  one treated  by AL  Lisfranc
(Ibid.,—Sonier Moret, Arch., 2e ser., t. VII., p.  213,)  was situated
in the recto-vaginal septum,  to  which it was adherent  only by  a
pedicle.  Moreover, it must be that this surgeon  operated upon two
cases, for the patient mentioned in the Gazette was cured, while that
cited by M. Moret  died in consequence of the operation.   A tumor
of the size of a small egg, which was situated  in the vesico-vaginal
septum, and which  M. Sanson (Ibid., p. 543,)  removed, was also  a
cyst of an hematic character.   I operated myself in 1833, at the hos-
pital of La Pitie, on  a woman who had an encephaloid tumor of the
size of a small egg about the middle ofthe recto-vaginal septum, and
I saw in 1838, at the hospital of La Charite, another  woman  who
had one of the size of the fist  in  the same place, or a little nearer to
the vulva.   I do not speak here of syphilitic vegetations, which are
so frequently  seen  at the entrance of the  vagina, nor  of hernias
either of the perineum or of  the  labia majora ; but I ought to men-
tion that tumors proceeding from the abdomen or pelvis, sometimes
become lodged to a considerable depth in  the recto-uterine cul de
sac, so as to make  a marked prominence upon  the interior of the
vagina.  I have noticed there a  number of times the apex of puru-
lent and sanguineous collections, that of serous  cysts and of cysts
of the ovary and of fecundation, as I have  also seen there fibrous
tumors or the  fundus of the uterus itself distended and reversed.
  B. All these tumors which  I have just spoken of, may lead to em-
barrassment in respect  to their diagnosis;  before  attacking them
with a cutting  instrument, however, it is a matter ofthe greatest im-
portance to ascertain if they are altogether  local, or if they do not 
TUMORS OF THE VULVA.
783
communicate in  some way or another with the interior of the peri-
toneal cavity or  rectum posteriorly, or with  the bladder or urethra
in front.  It is readily understood, in fact, that  if the source  of the
disease was either an intestinal hernia or that of any other  viscus, or
an ulceration or  perforation either of the urinary passages or  of the
peritoneum or intestine, the operation  to  be performed would  be
very different from that for a tumor purely vaginal.   All  that  is
necessary, however, to enable us to avoid any error, and to apply to
each disease the  operation  most suitable to it, is to be  apprised be-
forehand of the various lesions which may take place in that region.
  I.  In cases of cysts, whether serous, purulent,  or hematic, the ope-
ration is  easy and  attended with but little  danger.   The process
most advisable to follow is that of excision.  Having secured the tu-
mor by means of an erigne, we extirpate  all its projecting portion
either by means ofthe bistoury or a good pair of scissors.  Injections
which are  at  first emollient, then detergent, and  afterwards  resol-
vent, will be found sufficient to effect the cleansing and cicatrization
of the surface.   It rarely becomes  necessary to cauterize or  to un-
dertake to extirpate the adherent wall of the cyst, which it is  better
to leave in its place, and which ultimately becomes a part of the cor-
responding wall of the organ.
  II. Should the tumor be very large and greatly attenuated,  or the
matter contained in it consist of serosity or fluid blood, we  might
puncture it, throw up an  iodine injection, and treat  it  in every re-
spect like a hydrocele.  Should it on the contrary  be small, with
thick or well nourished walls, we might undertake its cure  by  a sim-
ple incision, and  treat it as an ordinary abscess.
  III. When the cases under consideration are those  of  abscesses
and cysts developed and established in  the recto-vaginal cavity, we
must not forget that arterial branches of considerable size  may pos-
sibly be found there, and that  by plunging in  the bistoury  in  this
part, we moreover necessarily divide the peritoneum.   I have, how-
ever, by  plunging  a straight bistoury into this  cul de  sac, cured a
lady of an enormous sanguineous collection, and also a number of
other patients, who afterwards discharged a considerable quantity
of pus through this passage.  I ought to add, however, that  in per-
forming the same operation for extra-uterine productions in two dif-
ferent cases, it did not succeed.  I have moreover, in another work,
treated in detail  of this division of the subject.  (Art des  Accouch.,
t. I., 1835, et Diet, de Med., art. Grossesse extra-uterine, 2d edit.)
  C. In respect to solid tumors, I have in several instances met with
those which might have been extracted through the upper part of the
vagina.   I have  even been on the point of undertaking that  opera-
tion which has, I believe, been performed  in one or two instances in
France;  but I was  ultimately dissuaded from  it by the age  of the
patient and the size of the tumor.
  I.  In the walls of the vagina itself, concrete tumors should  be ex-
tirpated entire when  we have decided upon operating upon them.
As they are situated upon thin irregular septa, their dissection would
be so much the more delicate, inasmuch as we should incur the risk,
should we penetrate into the bladder or rectum, of leaving disgust-
ing fistulas, which would be found very difficult to cure, at the same 
784           NEW  ELEMENTS  OF OPERATIVE SURGERY.
time that we should be  liable, higher  up,  to  perforate  the  peri-
toneum, which would also be  attended with  its dangers.  We
should  therefore be  careful to protect  ourselves by the necessary
precautions.
   A. In operating on the posterior wall, the woman should be placed
in the same way as for lithotomy.  The surgeon secures the tumor
at its most elevated portion, by means of an  erigne, which he imme-
diately  confides to an assistant.   Then introducing his left forefinger
into the rectum, as a guide and sentinel, he  commences by circum-
scribing the mass with an elliptical incision,  by means of a straight
bistoury, while the assistant gently draws it forward.  Continuing to
dissect  the parts upon his  finger, he will find  himself enabled in this
manner to proceed without danger down to  the  mucous membrane
of the intestine, and to separate from  one side to the other, now  to
the right and now to the  left, and from  above downwards, the dis-
eased parts from the sound tissues. The arteries  divided during this
operation are usually  so small as not to require either a ligature, tor-
sion or cauterization.  Gentle  tamponing will suffice to check their
hemorrhage.  The dressing is so simple that  there is no need of de-
scribing it, and we treat the  wound like all  those which are to be
cicatrized by second intention.
  B. If the tumor were sufficiently movable  to enable us, by draw-
ing upon  it with one or two erignes, to elongate its base in  the form
of a fold, three  ligatures  passed through the tissues which compose
it, by means of a  curved  needle, while the finger protects the inte-
rior of  the rectum, would enable us to excise it rapidly  in front, and
to reunite the wound  immediately by the suture.
  C. Tumors of the vesico-vaginal septum are still more difficult of
removal than the  preceding; for it is not possible to introduce the
finger into the urethra or  bladder as in the rectum.   It is  better  to
place the patient on the belly and on the edge of the bed,  with the
thighs flexed, than  upon her back or side.  A silver sound is  then
introduced into the bladder through the urethra; the tumor is secured
as in the preceding case and is circumscribed by the same  kind of
incision.  But we  must  afterwards  take care  to  dissect it with
extreme caution and not  penetrate into  the tissues of the vaginal
wall deeper than  is  absolutely necessary.   The sound, which the
assistant causes by an oscillatory movement to project on the side of
the vagina, serves as a guide to the finger, which should always be
kept at  the bottom of the incision to direct  the  cutting edge of the
bistoury.  As soon as the sides and  apex of the tumor are isolated
we should, while detaching it as in dissecting flaps of integuments
from a cyst which we do  not intend to open,  let the danger fall, that
is to say, direct the cutting edge of the instrument rather towards
the tumor than towards the vesical septum.
  D. The previous threads which I have just spoken of could not,
under such circumstances, be introduced with sufficient security to
authorize  me to venture to recommend them.   Their  employment
however ought to be taken into consideration should the tumor com-
prise the entire thickness of the septum, or should it be decided upon
that, notwithstanding  the  necessity of perforating the  bladder, the
diseased mass must nevertheless be extirpated. 
                 IMPERFORATION OF THE  VULVA               785

  E. On the sides of the vagina tumors would not incur the risk of
these dangers.  In that region there is no important part to wound
so long as it is unnecessary for us to go beyond the thickness of the
canal.  If we were obliged to  go beyond that point, the operation
would be unattended with danger except in relation to the vessels in
the  neighborhood, and to  the  purulent  inflammation which, if once
established in the peri-vaginal tissue, might  take on a serious character
by  becoming effused  into  the  pelvis  and  peritoneal  cavity.  This
would be an objection here to our undertaking union by the first in-
tention, and an argument for confining ourselves to simple dressing.

          Article II.—Imperforation of the Vulva.

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



  If, as  in the  cases noticed by  M. Fristo, (communicated by the
author, 1838,) those  by M. Coley, (Arch. Gen. de Med., 2e ser.,
t. IL, p. 585,) and M. Kulman, (Ibid., X. V., p. 143,) and those which
I have elsewhere related, (Traite d'Accouch., X. I., p. 108, 2d edit.,)
the  vagina is  closed only by a  membrane,  nothing more is required
for  its destruction than to  plunge through  it the point of a straight
bistoury, incise it freely from before backwards and then transversely,
and afterwards to excise its four angles.   We then keep the opening
properly distended by means of lint or portions  of sponge shaped in
the  form of a tent.   Three young girls whom I  treated in this man-
ner  recovered  perfectly.   If,  before  the  period  of marriage, the
employment of dilating means is not persevered in until the cicatri-
zation of the wound is complete, we would incur the risk  of its clos-
ing  up again, or at least contracting considerably, as happened in a
young girl six years of age, in whom one of our confreres confined
himself to a longitudinal division of the hymen, and as happened in one
instance  also to myself.   It is altogether useless to make at first a
puncture through the membrane by means of the trochar, or to have
                            50 
786
NEW ELEMENTS OF OPERATIVE SURGERY.
 recourse to the canulated sound to guide the bistoury, or to any other
 special instrument.  The perforation  being made,  the forceps or
 scissors  curved flatwise, or even the ordinary bistoury, will always
 be found sufficient for the excision of the flaps.

                               §11.

   In adult age we are not usually called upon to perform  this ope-
 ration, except in women who suffer  under symptoms to a certain ex-
 tent similar to those of pregnancy, and who have  the belly volumi-
 nous, &c, and this in  consequence of the catamenia  having no ex-
 ternal issue.   If the hymen alone  closes  the passage, it is found pro-
 truding and tense, and in some cases even of a bluish  or dark tinge,
 caused by  the blood which is endeavoring to force it outwards.  In
 such cases the opening into it is still less complicated than in the pre-
 ceding circumstances.  Any surgeon may perform it without danger.
 Except that the sudden evacuation of so large a quantity of liquid,
 and the impossibility for  the wOmb and other organs, that have been
 previously distended, to  immediately resume their normal  position,
 render this operation in some cases quite dangerous, from the visce-
 ral inflammations and fever of a bad character, which it might give
 rise to.   Perhaps  in such cases it  would be better not to make use
 of any effort or  pressure to aid the escape of the liquid, but  to aban-
 don its  expulsion  to the  natural  contractility of the cavities where
 it  has been for  so long  a time confined.   By this means we leave
 no void in  the collection which we  have  perforated.   The air can-
 not be introduced  or  become stagnated there, nor react either on
 the  morbid liquid or walls  of the  cyst,  by giving  rise to those
 accidents which are  generally imputed to it.   Injections, moreover,
 either emollient, detergent, slightly  resolvent, or  even antiseptic,
 should they be indicated, are  not to be omitted.   Should there be
 ever so little fever, heat, or pain,  in the lower belly,  the patient is
 immediately to be  put upon the severest regimen, and under an anti-
 phlogistic treatment, corresponding in energy to the intensity indica-
 ted by the  symptoms.  Should the vagina, be closed up to a certain
 distance from  the external orifice, the operation is naturally attended
 with more  difficulty ; in the first place  because we can  scarcely as-
 certain beforehand what  is the length of the obliterated portion, un-
 less there be a sort of diaphragm or septum, which constitutes the
 obstacle to be  destroyed ; in the second place especially, because we
 have to insert  the  instruments between two important organs, viz.,
 the rectum and the bladder.   Before  commencing,  therefore, we
ought by passing a sound into the urethra, and one or two fingers
into the rectum,  assure ourselves under such circumstances, that there
is  still remaining  a certain  degree of thickness of tissue  between
those organs, that  the womb exists and occupies its natural  position,
and that the vagina in every portion of it is not entirely obliterated;
in  this  last case  it  might  be bazardous to  undertake  its restitution.
Though M. Langenbeck, (Bull, de Ferr., X. XIII., p.  364,) in opera-
ting upon a woman who was probably destitute  of a uterus, may
have succeeded  in  rendering  the  vagina permeable, AL AlacFarlan,
 (Arch. Gen. de  Med., 2e ser., t. IL, p.  202,) had the  misfortune to 
                 IMPERFORATION  OF THE VULVA.                787

fail completely.  Nevertheless, if the  existence of the woman was
endangered by the accumulation of the menstrual fluid, and that there
existed the slightest hope of reaching the uterus by making a passage
between the intestine and the bladder, we ought, in my opinion, to
surmount all fears, and not shrink before the difficulties.   Should the
surgeon, in fine, decide upon operating, the  patient is to be placed in
the same way as for  lithotomy.   If the difficulty in question is  a sep-
tum or diaphragm, it is to be perforated by a puncture with the bistoury
or trochar.   Jt will be an easy matter afterwards to enlarge the open-
ing by repeated incisions, or by a kind of process of debridement with
the bistoury, conducted upon the finger or upon a'grooved sound, if not
upon a gorget.  M. G. Baehm, (Arch. Gin. de Med., 2e ser., t. XII.,
p. 442,) succeeded in the case of a young woman twenty-six years of
age,  by making use of a dilating  cylinder after the puncture.   A
mulatto in Brazils, (Rev. Mid.. 1832, t.  IL, p.  473,) was perfectly
cured by means of a simple incision.  The patient of M. William,
(Ibid., 1833, t. IV., p. 451,) who cites  similar facts from Haughton,
Simpson, and Richardson, also got well after passing through divers
accidents.  AL Fristo, (communicated by the author, 1837,) though
obliged to incise in this manner four successive contractions in a wo-
man who had an imperforate hymen, was no less fortunate.  The mul-
tiple debridement also succeeded in the case whose history is given by
M. Bouchacourt, (Bull, de Therap.,  X.  XIV., p. 285.)   While his  left
forefinger remains in the rectum, and the assistant is holding  a  ca-
theter in the bladder, and  taking care to push its beak towards the  hy-
pogastrium, the surgeon, if operating for the removal of an obliteration.
properly  so called,  plunges in  the direction  towards  the  vagina,
either a long bistoury with a narrow blade, or a trochar armed with
its canula.
   The absence of resistance and the freedom with which he may
turn the point of his instrument in different directions, soon indicate
to him that he has passed beyond the point  ofthe disease.   He then
enlarges the wound  a little throughout its whole  length while with-
drawing  the bistoury, the cutting edge  of which should  even be
directed upon the  opposite side and  afterwards in front and  behind,
should he feel sufficiently secure of not wounding the surrounding
organs.   When we have made use of  the trochar and there  escapes
through the canula a dark  colored  viscous liquid, a grooved sound
may  be necessary to enable us to enlarge to a sufficient extent  the
perforation we have  made.  The introduction  of the  finger would
enable us to ascertain if the division is sufficiently large, and  in the
contrary  case to increase  its extent in the  direction  that  may be
deemed most advisable.   Though the vagina, after an operation of
this kind, usually  preserves its permeability, prudence nevertheless
suggests that we should  adopt  the necessary precautions to  prevent
it from closing up again.  A tube  either of metal or  gum-elastic,
dilated in the manner of a spindle or spread out externally like  a
funnel in such manner  as  to  be  enabled of itself to remain in
place, and gradually  increased up  to a  certain  size, would, in  my
opinion, be  the  best means  to  be adopted  to attain this result,
although  meches  of lint or linen daily  renewed after making the
injections, might also answer.   Scientific works contain so  great a 
788           NEW ELEMENTS OF OPERATIVE  SURGERY.
 number of operations of this  description, that  it would be superflu-
 ous at the present time to describe any of them  in detail.  Every day
 moreover we find  still published additional cases ;  to those which
 have been described by MM. Ventura, Cabaret, Delpech, De.sn-ranfTes
 Williaume,  Flamant,  Renauldin, and many others  which I  have
 cited, (Traite d'Accouch., &c, t. L, pp. 109,110, 111 and 239; t. II.,
 pp. 210, 211, 212,)  we may also  add those of  MAI.  Keates, (Journ.
 des Prog., X. XIIL,  p. 273,) Jefferson,  (Med.-Chir. Reviem,vo\. II., p.
 193,) Coste, (Journ. des Conn. Med.,  t. III., pp. 105 and 27(5,) Amus-
 sat (Journ. Hebdom., 1834, t. I., p. 70; Gaz. Med., 1835, .p. 785,) and
 Fristo,  (communicated by the author,  1837,)  which are the  most
 remarkable of all.  Though  almost  all those operations, as well  as
 those of MM. Rossi (Gaz. Med., 1838, p. 682,) and Toulmouche, and
 those which  M. Roux witnessed in  Germany, were followed  with
 complete success, it is nevertheless not to be forgotten, that in a case
 related by Morgagni, the woman died after the expiration of a few
 days, and that in examining the dead body, the bladder was found
 extensively laid  open, at  the  same time that  one of the  fallopian
 tubes dilated by the blood had  burst into  the cavity ofthe abdo-
 men ; nor must we forget that Dupuytren has  frequently seen acci-
 dents of an extremely dangerous character result from this operation.
 In a patient of  M. Morisson, (Bull, de Fer.. X. XIIL, p. 364,) there
 resulted from this operation an abscess in the  iliac fossa which ulti-
 mately opened into the intestine.   The  patient  of M. Langenbeck
 (Arch. Gen. de Med., 2d ser., t. IL, p. 102) died of enteritis.   M. Mac-
 Farlan, (Journ. des Prog., X. IV., p. 116,) who, as I have said, opera-
 ted in a case  in which there was  no uterus, also  lost his patient.  I
 will add that M. Jefferson was obliged to penetrate in his dissection
 to the depth of five  inches before  finding the retained liquid ;  that in
 one of the cases of M. Fristo he found it necessary from the vagina
 having been transformed  into a cord, to  reconstruct  it entire by dis-
 secting upon his finger the tissues,  layer by  layer ; and that AL
 Amussat, operating in a case full as difficult, detached and tore the
 laminas of the recto-vesical septum  by means of his  finger directed
 from below upwards, to a much greater extent than he divided them
 with a cutting instrument.  M. E. Coste Went farther.  The vagina
 was opened into  the bladder ; having laid open the urethra and after-
 wards adjusted a cylinder  of lint in the bottom  of the wound on the
 side towards the rectum, he  ultimately constructed there an entirely
 new vagina.
   [Vaginal occlusion from traumatic lesion.—Mr. J. W. Square,
 surgeon of the hospital at  Plymouth,  (Eng.) was  called to a case of
 cicatrized  vagina in 1843,  aged thirty-four years,  caused, as it would
 seem, by the use of the forceps with her  first child three months pre-
vious.  The vagina was quite closed at an inch from its orifice, and
 emitted a purulent  discharge.  The  partition,  however, was pene-
 trated  by a probe, and for weeks bougies, catheters, and sponge
 tents were introduced, but produced only intolerable  pain.  The sur-
geon determined upon an operation, which was effectually performed,
by pressing the  rectum with the forefinger introduced against the
sacrum, and then by means of a concealed bistoury  passed through
the perforation already made with  the probe, &c, dilating the par- 
PUNCTURE OF THE UTERUS.                789
tition freely in a lateral  direction, first to the  left  and then to the
right side.  A large quantity of grumous blood  gushed out, probably
menstrual,—which had been retained in the upper part of the vagina,
which latter organ had been  thereby distended into a large oval
sac, having, however, a healthy os uteri at its upper part.   First
a plug of lint, oiled, was used  to keep the passage dilated, but being
difficult  to be maintained  in place, a wooden plug was substituted
and kept up by a  bandage.   This last, which was, as we  think, in-
judicious practice,  caused  much irritation  and  was, very prudently,
soon replaced by a gum-elastic rectum  bougie.
  Dr. Mott, who has performed a considerable number of these ope-
rations, both where there was total or only partial  occlusion, and
with unvarying success, and with most satisfactory results to  such
particularly as had had effectual sexual intercourse and utero-gesta-
tion completely suspended by this occlusion for years, gives a decided
preference to a plug of proper  length, rotundity  and  shape, composed
of a portion of sponge nicely adjusted within  a cylindrical sac of
suitable  size,  made of thick goldbeater's  skin,, or  thin caoutchouc
cloth tissue, kept constantly  oiled when applied, and  to be renewed
by washing the bag and  inserting a fresh, clean, and  dry portion of
sponge as often as  it  becomes  infiltrated with the utero-vaginal dis-
charges.
  The passage should be also, occasionally, say once a day or oftener,
cleansed out with  an  injection of tepid weak soap and water, until
ciaatrization is completed.
  Imperforate Vagina.— Dr. W.  Shuttice  of  Mathews,  Virginia,
(Amer.  Journ. of  the Med. Sc, new series, vol. VII., Phil., 1844, p.
243, 244,) in a case  of imperforate hymen in  a young lady  aged
eighteen, who had  never menstruated, and who, in consequence, had
her abdomen so distended  as to give rise to the  suspicion of a tumor
or of pregnancy, successfully relieved his  patient by puncturing the
tense partition, which gave the patient  immediate relief, and as sud-
denly reduced the  swelling by the loss  of no less than six pounds of
dark, tarry, grumous, uncoagulated, retained catamenial blood.  The
discharge continued for several days, and  the surgeon supposed the
patient lost altogether, at  the  operation  and in this  interval, some
eight pounds of menstrual blood.   The cure was, of course, accom-
plished in this manner at once.  All such  cases show the necessity
of surgeons themselves making a close examination per vaginam, as
false delicacy  of young ladies  or their relatives often piocrastinate
relief until it is too  late.  T.]

           Article III.—Puncture of the Uterus.

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

  The neck of the uterus, like the vagina, may never have had an
external opening, or it may have been closed up by accident.   This
however is quite a rare occurrence, and one which many practitioners
have supposed they had met with, where in fact it did not exist.   It is
evident,  for example, that  the neck of the  womb was not obliterated
in  the case quoted by M. F. Hatin, (Journ. des Conn. Med.-Chir., 
790
NEW ELEMENTS OF OPERATIVE SURGERY.
1839, p.  111.)   The  error, moreover, would  be so natural in  such
cases that M. Galopin, (Gaz. Med., 1838,  p.  714,) who, under the
supposition that there was an obliteration of the neck of the uterus,
performed the vaginal Caesarean operation successfully, both for the
mother and infant, and who adds that his confrere, AL Lannelongue,
witnessed the fact, might also have  readily committed a mistake of
this kind.  Nor is it scarcely probable that the occlusion was com-
plete in the patient operated upon by M. Stoll, (Ibid., 1839, p. 185.)
M. Pacoud, (communicated by the author, April, 1839,) who, out of
more than 100,000  accouchements, of which we have an enumera-
tion in his school, had not yet met with one instance of this disease,
nevertheless appears to have finally encountered a very decided  case
of occlusion.  The first thing to  be  done after we have ascertained
the imperforation of the uterus and its  distension  by any liquid,  is to
endeavor to find by means of the finger, some trace of the neck in
the place where it ought to exist, and should it be found to endeavor to
introduce into it an ordinary sound, in order to remove the impedi-
ment.  Otherwise we must proceed to its perforation, which has now
been performed a great number of times, with various sorts of instru-
ments.   Some recommend that we should first make a puncture by
means of the trochar; others that we should prefer the straight bis-
toury wrapped in a small band to within some lines from its point.
Even the pharyngotome has  had  its partisans.   Dance relates  that
Barre used a  long  canula, including a spear-shaped  stilette, which
latter had a groove upon its concavity.  In this matter each may fol-
low his own pleasure  and  select the instrument which is most  agree-
able to him.  It is evident, moreover, that a  bistoury of some length,
concave  and wrapped in  linen, and  guided  upon the left forefinger,
would fulfil all the indications, and that the  sound with its spear
stilette, (sonde a dard,) or any trochar  whatever, or the pharyngo-
tome, would equally attain the object in view.   However this may
be, the trochar and the bistoury  are in my opinion the two  instru-
ments which ought to be preferred.   All that is necessary is to make
an opening sufficiently large for the liquid to escape, and not to ven-
ture too far towards the bladder or rectum.   As in  the case of the
vagina, we must also be on our guard  against a return of the difficulty,
and do all in our power to prevent the opening we have made from
closing up again, unless the natural neck of the uterus has ultimately
become re-established.  We should  therefore  endeavor to introduce
into the uterus the end of  a gum-elastic sound, in order to keep the
wound open.   In  the operation which  AL Hervez de Chegoin  per-
formed with success, he  had recourse to a trochar whose  canula
served for the introduction of a bougie, which in its turn  was used
as the  conductor for  the  end of  a sound destined to remain in the
wound, and  which was subsequently replaced by a female catheter.
This is the most  prudent course of treatment we  can adopt, and
which almost  all practitioners  have deemed it advisable  to pursue,
whether  they have used  the trochar, bistoury or any other  instru-
ment.  Having  spoken in  detail in  another  work  (Traite d'Ac-
couch., X. IL, p. 216) of the obliteration of the neck of the  uterus
during pregnancy and of  the remedies it requires, there is no neces-
sity of my dwelling upon  it any longer in this place. 
PUNCTURE OF THE UTERUS.
791
                      § II.—Retroversion.

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

            Article  IV.—Reversion of the  Vagina.

                § I.—Excision of the Integuments.

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

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

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

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

   Since the first publication of the preceding portion of the  text, the
method of contracting the vagina as  a  remedy for prolapsus of the 
PROLAPSUS OF  THE UTERUS.
793
uterus,  has been introduced into  practice  under various  forms.
Some have proposed for  this purpose cauterization, or scarification
of the tissues, while others have recommended to slough off flaps
from the vagina by means of the suture.  There are those again, in
fine, who restrict themselves to the contraction of the vulva.

                      § I.—Cauterization.

  It is in France that the general method originated under two prin-
cipal points of view.   In 1823,  M. A. Gerardin transmitted to  the
Medical Society of Metz, a memoir, which he also addressed in 1824
to the  Royal  Academy of Aledicine, and upon which M. Beaude-
loque (Arch. Gen. de Mid., X. VIIL, p. 132)  was appointed to make
a report.  In  this treatise, which I have read in  manuscript, the  au-
thor proposes as  a remedy for prolapsus of the womb, that we should
contract or obliterate the vagina by cauterizing its interior.   Since
that time this recommendation has been adopted in various hospitals.
In 1833, AI. Laugier attempted to cure  one or two  women in  this
manner, by making use of the nitrate acid of mercury.  Being my-
self also desirous of ascertaining  what virtue  it  might  possess, I
treated, by means  of cauterization  with the  red hot iron in 1835, at
the hospital of La Charite, a woman who had been for a long time
afflicted with a prolapsus of the uterus, and  I have understood that
an attempt with cauterization  had  also been made use  of for the
same purpose, but without success, at the Hospital of St.  Louis.  It
has been considered that to obtain success, it would be necessary to
cauterize either by means of chemical substances, or the red hot iron,
several lines upon the vaginal cavity to such degree as to cause them
to  mortify to a sufficient  depth,  and to become transformed into
an eschar, from the neighborhood of the neck of the uterus as far as to
the vulva.  Considered in itself, the operation is exceedingly simple ;
having inserted  into the organs a jointed speculum, or that of Duges
or M. Ricque, or any other, we apply a pencil charged with  caustic
matter, or the reed-shaped cautery, either upon the two sides  or the
posterior median line, or upon some other intermediate spaces of the
vagina, in such manner as to destroy their vitality.
   It is important not to forget, while we are proceeding in this man-
ner, that the bladder and urethra are in front, the rectum behind, and
the  cul de sac  of the neighboring peritoneal  cavity  very near the
posterior lip of the neck of the uterus.  During the time the eschars
are  being exfoliated, we confine ourselves to  emollient injections,
general baths  and antiphlogistic treatment.  At  a  subsequent period
we promote the cleansing and cicatrization of the wounds, by deter-
gent, and afterwards resolvent injections, and place the patient on a
more substantial diet.  Having now established in this region wounds
with loss of substance, the surgeon  has re-ason to expect that after
their cicatrization the vagina will necessarily be contracted by them,
and that being intermingled with inodular seams, they will  be capa-
ble of presenting an obstacle to the descent of the uterus.   Doubt-
less, we cannot  assert that success would never crown  an attempt
of this kind.   The bridles, septa, and coarctations of every descrip-
tion, which are  sometimes  accidentally formed in the vagina, and 
 794           NEWr ELEMENTS OF OPERATIVE SURGERY.

 which I have  spoken of  above, are  a sufficient evidence that the
 uterus is, under such  circumstances, compelled  in some cases to re-
 main above the vulva.   A  neck which did not allow  of the in-
 troduction of the little finger, and which was found in  the vagina, at
 the depth  of two inches and a half in a lady whom I saw with AI.
 Berigny de Aleulan, perfectly fulfilled in that part the function ofthe
 best constructed pessary.  A semilunar septum, situated an inch higher
 up, performed  the same office in a lady whom I saw with AI. Andral,
 the father.   I have already spoken of a patient of AL Gerardin, who
 after having had a  pessary for several years successively, imprisoned
 in these parts,  found herself after the  extraction of this body,  cured
 of her prolapsus by means of a circular  contraction formed on the
 middle  portion of the vagina.  It is, nevertheless, true that these co-
 arctations  are not effected without difficulty, that the women treated
 in this manner  by AI. Laugier, have had their prolapsus return, and
 that the disease was  also  reproduced  in the woman operated upon
 by me at the Hospital of La Charite, though I  had cauterized to a
 considerable depth  four radiating lines on the vagina.  The  pliancy
 and distensibility of the tissues, and  the  quantity  of fluids  which
 readily accumulate in these parts, all present an obstacle to our pro-
 curing  in this  region, at pleasure, a  solid and  durable contraction.
 As it is an operation, moreover, which would not be unattended with
 danger,  it  does not consequently, in my opinion, deserve to be re-
 tained in practice.

                         § II.—Excision.

  Contraction  effected by means of excision, first attempted by AI.
 Heming, (Gaz. Med., 1832, p. 32,) and afterwards  by AL Ireland, in
 1834, and  by AL A. Berard and myself, in  1835, already enhances
 several  modifications.   AI. Berard has followed in every respect the
 process of AI.  Ireland ;  that is to say, that after having excised from
 each side of the vagina  a strip near  an inch wide, and from two to
 three inches long, he has reunited the wound by means of the suture.
 The patients, who  at first  appeared to have  been effectually cured,
 have, nevertheless, had their infirmity return upon them shortly after.
 Inasmuch as the walls of the vagina are under  such circumstances
 very much thickened, or as it were hypertrophied, and  that there is
 almost always  existing at the same time a reversion of the bladder
 or rectum,  that is, a cystocele or rectocele, I  have deemed  it better to
 make the incision of the tissues in front and behind rather than on the
 sides.  Desirous, moreover, of rendering both the incision and suture
 more easy, I have commenced by placing  the  threads through the
 base of the fold which is to be removed.  Afterwards detaching the
 entire organic  strip, I have  found it exceedingly easy to unite the
 borders of the wound, by knotting each of the threads, and thus com-
 pleting the  suture.  For  this purpose I place the woman on her back;
 I then secure by means of  an erigne, and as high up as possible, the
 median  posterior crest of the  vagina, while an assistant, in the  same
 manner,  raises  up  its  perineal extremity.  Immediately consigning
the two erignes to the assistant, I introduce  the forefinger of the left
hand into the rectum, in  order to protect the movement of the curved 
PROLAPSUS OF  THE UTERUS.
795
needle, which latter, conducted by the right hand, is to pass three or
four double threads through the base of the vaginal fold, taking care
to commence with the one which  is  to be  highest up, and to termi-
nate  with that  which is nearest  to the  vulva.   Another assistant
holds all these threads stretched out, while the surgeon provided with
a good bistoury, divides the  tissues on  one  side, and then on the
other, and finally from  above downwards, at the distance of three
lines inside of each point of suture.   The same manipulation is to
be made use of upon the anterior  median line,  after which nothing
is easier than to reunite  the wound by knotting  each of the threads
on one of its sides.  Having cut near the knot one of the halves
of each ligature, the  surgeon gathers the  remainder together, and
brings  them into the  fold of the  groin, where he fastens them un-
der a piece of adhesive plaster.  The ligatures  rarely come  away
until after the expiration  of from six  to ten days.  Sometimes, in
fact, they  do not cut  through the tissues,  but seem to  be relaxed,
and would soon act in  the same manner as a seton, if we did not
take the  precaution to cut them.   A patient whom I operated upon
in this manner,  in  1835,  and who  appeared to be cured during
nearly three months that she remained in the wards of the hospital,
had  when she resumed her labors, a few weeks after, a  return of
her prolapsus.   I operated upon another woman, in 1838, with a com-
plication of rectocele, and who  died three  months subsequently of
an ulcerous enteritis, the prolapsus in her case also having begun to
reappear.   But it is proper to add,  that in  this last case the projec-
tion from the vagina was  prolonged into the pelvis, by means of  a
plain, soft cylinder of a vascular and fleshy appearance, three to
four inches long, and of the size  of a child's fist, and which termi-
nated on a line with the fundus of the uterus,  by a kind of globular dila-
tation of a venous, or  as it were fibro-muscular texture, possessing
some analogy to that  of the uterus.   Do these facts  suffice to  prove
that  the process of excision does not yet  constitute the efficaceous
remedy for prolapsus of the uterus or vagina ?   In answering  in the
affirmative, I have too much fear  that future  experience will not re-
verse my verdict.

                         § III.—Suture.

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

                §  IV.—Contraction of the Vulva.

  The idea of contracting the vulva for prolapsus of  the vagina, and
which originated from  the practice  of Dupuytren for reversions of
the rectum as applied  to prolapsus of the womb, appears  to present 
796          NEW ELEMENTS OF OPERATIVE SURGERY.

some few advantages over the preceding mode.  Certain it is that
made  trial  of by different  surgeons,  it has always  procured,  if
we receive  in  the  literal acceptation what  they "say of it,  very
encouraging results.   M. Fricke, who performs it by a  new process,
wrote to me in 1835, that at  that period he had  already used  it in
twelve instances, and always with success.  This surgeon proceeds
nearly in the same manner as for suture of the perineum; that  is to
say, that he  abrades the two posterior thirds of the vulva by excision
of the tissues, and then reunites the sides of the wound by three or
four points of simple suture.  The perineum is in this manner found
to be  prolonged  an inch or two in front, in such manner as to close
up all egress  to the  neck of the womb.   Taking care to leave  an
aperture behind  and to preserve a portion of the  vulva in front, AI.
Fricke (Ann. de Chir. de  Hambourg, 1833; Gaz. Med., 1835, pp.
249, 268) in this  manner guards  against accumulation  of liquids in
the vagina,  and  is enabled subsequently to  re-establish the sexual
functions.   M. Knorre (Gaz.  Med.,  1839, p. 185)  states that he has
succeeded with this  operation in one instance.   The same was the
case with M. Loscher, (Ibid.,) but though it did not fail in the hands
of AL Fricke at Hamburg, I am compelled  to state that a patient
operated upon by him in my department at La Charite, in 1837, was
not cured;  that M. Plath,  (Ibid., 1837, p. 13.) in  making trial  of it
upon another woman was not more fortunate, and that one of the two
patients also upon whom I made use of it did not derive any benefit
from  it.  It is nevertheless certain  that  this process,  denominated
Episioraphy by M. Fricke, ought to succeed  more frequently  than
those  which have been mentioned above.   The ruptures of the
fourchette and perineum, and the enlargement of the Vulva from any
circumstance whatever, are, it cannot be denied,  the most common
predisposing causes  of prolapsus of the uterus.  It  is readily  con-
ceived, therefore, that an operation which replaces the parts in  their
original condition, and which  even has the effect to diminish the nor-
mal dimensions ofthe vulva, must hold up the uterus in such manner as
to efface the two lowest portions of its prolapsus.  As to the operative
process, it is moreover precisely the  same as that which will be men-
tioned under the head of suture of the perineum.  The  same weight
which is felt from the womb at the fundament, after an  operation  of
this kind, is  also found in women who wear a pessary.   This dif-
ficulty moreover could be remedied in this as in any other case,  by
means of a  hypogastric girdle, provided with its infra-crural band-
age and its accompanying perineal cushion.
  [A  complete prolapsus both ofthe uterus  and vagina, has.  been
stated in one recent instance at least, to have not prevented the safe
delivery even of twins !  M.  Rathman, (Med. Zeitung von Preussen,
1842,  No.  33—Arch. Gen.  de Med. de  Paris, 4e ser.,  t. IL, p. 231,
&c.,)  relates a case of this kind in a woman who had had incomplete
prolapsus of the parts in question from the age of sixteen, and  who,
when she was arrived  at the age of twenty-two,  was on February
17, 1842, delivered by him of two well formed twins at  the full term,
but dead, by means  ofthe  forceps; not, however, without much
difficulty and  laceration of the  parts.   The woman, however,  re-
covered.  T.] 
REDUCTION  OF THE WOMB  AND VAGINA.
797
      Article VI.—Reduction of the  Womb  and  Vagina.

                              §1-

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

                             § II.

  If the case is one  of retroversion, it sometimes becomes necessary
 to vary the position of  the patient, who in the preceding  cases may
 remain in a horizontal position, at the same time that her  limbs and
 all her muscles are kept in a state of relaxation.   The first thing  to
 be done to straighten  the uterus, when it has become retroverted
 in the pelvis,  is  to  secure, by means of the fore and middle fin-
 ger of one of the hands, the periphery of the os tineas (le museau
 de tanche,) which usually is found to have become lodged behind or
 above the pubes.  If this does not  answer, we introduce some  of
 the fingers of the other hand into  the rectum, in order to push  the
fundus of  the organ upwards and forwards, while on the other hand
we endeavor to make its neck descend.  But wThen these attempts do
not succeed, it is  recommended to place the woman upon her knees
and  elbows, in order  that,  the abdominal viscera, by their weight, may 
 798          NEW ELEMENTS of  operative surgery.

 assist in drawing the womb towards the umbilicus, at the  same time
 that the surgeon is endeavoring to dislodge it.  If all these resources
 fail, we may, should it be practicable, imitate Dusaussov, who, intro-
 ducing  the entire hand into the intestine, was enabled to  overcome
 difficulties which  no other means could remove but that.  Finally,
 if the finger could not get a sufficient hold upon the neck, we should,
 after the manner of AL Bellanger, introduce into the bladder through
 the urethra, the flat catheter of Segrot, or any other of the same
 form, or as I have done in two instances with advantage, an ordinary
 male sound, which could be afterwards  used as a hook by  turning its
 concavity backwards.  I have no  necessity of remarking, that for
 simple displacements ofthe uterus in the pelvis, and in all circumstan-
 ces where it is practicable in other cases, we should begin by empty-
 ing the  bladder by means of the catheter, nor that in certain cases
 we may very conveniently grasp the organs to be  reduced by means
 of the fingers directly, without the necessity of covering the parts with
 linen.   Repose, the horizontal position, the proper kinds of injections,
 one bleeding,  and the  antiphlogistic regimen in general, are  applicable
 to the sequelae of this operation, as to those of most  others, for the pur-
 pose of  calming the irritation which must have  been produced, and
for enabling the tissues to resume their customary  functions

                   Article VII.—Pessaries.

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

                  §  I.—Pessary ofthe Vagina.

  Among the  pessaries which are still used at the  present  day, there
are some whose object is to keep reduced the hernias which have pro-
truded through the walls of the vagina, or to prevent the prolapsus
 and eversion of this organ itself; while others are exclusively design-
ed to prevent  the  descent  and deviations of the uterus.  The firsl
 class may be divided into  two orders.   Some consist of a  hollow
cylinder about four inches long, and of a sufficient diameter to fill up
 the whole organ ; these are called bung pessaries,  (pessaires en bon-
don.)  The others, contrived by M. J.  Cloquet, differ from the pre-
 ceding  in this respect, that they are somewhat flattened, and also
 concave in front, slightly dilated at their extremities, and having only
 quite a  small  canal in their centre.  The name of elytroidal pessary,
 by which this professor has designated them, would be more applica-
 ble as it is seen to the pessaries en bondon, since the  former  merely
 signifies a pessary in  the form of a sheath ; but the name is a matter
 of little importance  so  long  as we understand their construction. 
PESSARIES.
799
Both are introduced  in the  same  manner.   The woman is placed
upon her back, while  holding her thighs and legs moderately flexed
and kept apart.   The pessary being besmeared with cerate, is intro-
duced at its smallest extremity, like a speculum, into the entrance of
the vagina, and then pushed into the cavity of this organ from below
upwards, and from before backwards.   The elytroidal pessary, from
having a greater  breadth  in one direction  than in the other,  is to be
introduced flatwise to the great diameter ofthe vulva, in such a man-
ner that  its posterior angle being the first lodged in the vaginal open-
ing, may serve to depress the rectum as well as  the entire thickness
of the perineum with a certain degree of force; the  other angle of
the same extremity is then depressed little  by little as it glides under
the pubic arch, after which there is no longer any difficulty in  making
the instrument penetrate into the vulvo-uterine passage.  As  soon as
it has entered into this part, we give it a movement of rotation, which
places its convexity towards the intestine, its concavity forwards, its
upper extremity under the neck of  the womb, and its lower extrem-
ity, which is the  largest, transversely  above  the ossa ischia.  The
bung pessary, from its forming  only a sort of tube, whose walls are
very thin, may in general be introduced with greater  facility  ; but as
it is straight, and  makes but little resistance, the organs soon  change
its form, so that its presence soon ceases to afford any benefit.

                 §  II.—Pessaries of the Uterus.

  A. The pessaries ofthe second order have varied much more in their
form and composition, than those which I have just described.  The an-
cients constructed them of an oval  elliptical  plate, of wood or cork,
which they afterwards covered with a layer of wax ;  they  had them
also of gold, silver, copper, lead, and even of tin, and of all kinds of
forms.   Those which are  called gimblet-shaped, are either perfectly
circular  or slightly notched in front and behind, like a figure  of 8, or
depressed at the same time upon the four extremities of their princi-
pal diameters, or  they are merely elliptical  and flattened, and perfo-
rated in the centre. In England, they frequently employ pessaries of
a globe form, sometimes hollow, at other times solid and perforated
or not in their middle portion, and this is the  usual practice also
adopted  in America.   Wax and cork have been long since rejected
in practice, since  they readily become changed in the organs, and do
not possess a sufficient degree of suppleness.   The same remark ap-
plies to the employment of ebony, ivory and silver, unprotected, be-
cause of their hardness or weight.   Pomarest, (Bonet, Corps de Med.,
t. III. and t. IV.,  p. 103,) however, states that he kept up a  prolapsed
uterus for the space of ten years, by means of a ball of wax.  At  the
present day they  are made almost exclusively of gum elastic ; except
that this substance is occasionally protected by linen, hair, felt, or
wool, silk tissue, &c. ; in order  to have them as solid and  light as
possible, Mdme. Rondet, who makes use of a steel ring, well  temper-
ed, and wrapped  in hair and caoutchouc itself, has  contrived others,
the entire circle of which is hollow and filled with air.  M. Houin,  a
manufacturer of instruments, has prepared  some which have the form
almost of a solid  bung, and which are made out of pure caoutchouc. 
800           NEW ELEMENTS OF OPERATIVE SURGERY.
Those of M. Tanchou are flexible, and represent the periphery of a
funnel which is  very flaring,  to receive the neck, and with a very
short  conical beak, to hinder them from turning over.   M. Rognetta
has proposed some which have still another form.
  B.  AL Hervez de  Chegoin (Mem. de FAcad. Roy. de Med., t.  IL,
p. 319) having remarked that the uterus in its descent almost always
is inclined outside of the axes  of the pelvis, has shown  that the form
of the pessary ought in some  respects to be different for every wo-
man.   According to this idea,  we  require sometimes a ball dilated
in front, behind,  or on its side, sometimes a bilboquet, bung, gimblet,
or cap, whose border depressed in one direction and  raised up in
another,  may  be placed  between the neck of the uterus and the
wall  of the vagina  against which it is  reversed.  In this manner
we prevent the anteversion or retroversion, and also the anteflexion
and  retroflexion, as well as at the same time  the  descent  of the
uterus.
  C.  Ivory, which  has been rendered flexible by the  processes  of
AI. D'Arcet and M. Charriere, that  is to say, by means  of hydro-
chloric acid and tannin, being more  easy to work with, is infinitely
better calculated to fulfil these indications than any other substance.
With this preparation the pessaries retain their  elasticity and flexi-
bility ; they cause but little irritation to  the  organs, less readily un-
dergo alteration than most of the others, and may be constructed of
the shape desired, and almost immediately.
  D.  Physick still continued to use pessaries of gold or silver.  His
are globular, like those of the time of Denman or Clark,  and are com-
posed of two capsules united at their base.  Those moreover which
have  a little more breadth transversely than from before backwards,
possess the advantage of being introduced with more facility, and of
occasioning less  disturbance to the functions ofthe rectum and blad-
der.  They are introduced even with more facility than pessaries of
the vagina.  The important point is to  make them reach into this
passage by means of the precautions above mentioned.   By means
of the finger introduced  into their ring or upon some part of their
circumference, we are always  enabled by that means  to give them
their  proper position, that is to say, to impart  a vibratory movement
to them, which places them horizontally in the pelvis, with one of
their  borders  posteriorly and  the other in  front, and with their  ex-
tremities towards the ossa ischia; in such manner in  fact, that  the
extremity  of the os tineas may rest on the upper cavity of the open-
ing, which traverses its whole  substance.
   E. Women who have had their perineum lacerated, or in whom
the vulvar orifice of the vagina is  very large, scarcely derive any
benefit from  pessaries  of the gimblet or-globular  shape, which
in general  they  cannot keep up; so that we are soon obliged to find
others which are more  perfect, and which may be substituted  for
 them.
   F. Those described by Bauhin, and which have received the name
 of bilboquet  pessaries, are formed of an ivory or wooden ring, sup-
 ported by three branches, and terminated by  a root some inches
 long, which is  perforated at  its free extremity with  three or lour
 holes.  The cup of  this instrument,  which is intended  to receive the 
PESSARIES.
801
neck of the  womb, has  sufficient depth to enable the menstrual or
other discharges from the uterine cavity to escape with facility be-
tween the three roots  of its support.   The  cords that are passed
through the lower openings  of this  pivot,  enable  us  to fasten it in
front and behind upon a girdle which the woman is to wear constant-
ly.  Desormeaux having remarked that notwithstanding the notches
which are found between the circle ofthe bilboquet and its tail, fluids
sometimes accumulate  below the neck of the  womb, and acquire
there irritating properties, proposed to transform the  stem of the in-
strument into an actual  canal, and to give to the cup itself the form
of a shallow funnel; but in spite of these precautions, matters will
still occasionally become lodged between  the orifice of  the  uterus
and the  instrument, so that there is not  in  fact any good  reason  for
giving a preference of this new pessary over the ancient one.  If, as
some  practitioners recommend, and Desormeaux  among them,  we
should confine ourselves to adjusting the beak of the bilboquet above
the os coccygis, and in  the interior of the  vagina, rather than to at-
tach it  by means of cords to a body  bandage, there would be too
much danger of perforating the rectum to  justify me in recommend-
ing it, even though it should include a cork-screw  spring in its pivot,
as recommended by M.  Recamier.
   G. Some  persons, with a view to remedy the continual vascilla-
tions and disturbances to which the  instrument is  exposed while the
woman  is walking, have constructed those  which have at their lower
extremity a plate  about four inches long, concave  above, pierced
with a large opening behind opposite to the anus, and with two slits
in front, in such manner that the cords attached to  the four angles of
this plate, enable it to embrace with sufficient  accuracy the  whole
extent of the perineum from before  backwards, and to keep the bil-
boquet almost immovable in the position we  have judged proper to
give to  it.        *
   H.  Saviard, dissatisfied  with the pessaries which  had been used
up to his time, undertook to  keep up the uterus by means of a small
apparatus which is composed of a curved  spring, adjusted upon the
hypogastrium  by one of its extremities, while the  other entered into
the vagina to make compression there upon a tampon arranged in a
proper manner.  The one recommended by AI. Villerme is based up-
on the same  principle.  Its stem represents a large arc, the concavity
of which when it is fixed in its situation is intended to embrace the
anterior half of the pelvis.   It is a kind of a  hook, the tail of which
being fixed upon the  hypogastrium enables its head, inserted in the
vagina, to support or suspend the entire uterus.  M. Deleau proposes
another which, so  to speak, occupies a middle place  between the
bilboquet and gimblet.   It is composed of an elastic spring surround-
ed with caoutchouc and turned into  spirals, so that the  apex or  first
ring is  fixed, while the last or  base remains free, in order that it
may be  tightened or enlarged  as required. When we wish to  ad-
just it, we fix it upon the head of a species of bottle brush or piston,
after having contracted its  circle to the proper dimensions.   After-
wards left to itself in the vagina with its point upwards, it accommo-
dates itself by its elasticity to the dimensions of the organ and runs
no risk of being displaced.   Preuner (These de Haller, French trans.,
                              51 
802           NEW ELEMENTS OF OPERATIVE SURGERY.

t. IL, p. 393) describes one which is almost in every respect similar
in its form, but I am very apprehensive that its advantages, in fact,
are much more apparent than real.
  I.  Whatever may be the pessary we employ, we must not neglect
the precaution of withdrawing it from  time to  time, in order to
cleanse it.   Unless this were done it might become encrusted with
calcareous matters and ulcerate the vagina, and ultimately give rise to
serious accidents, too many examples of which are on record.   Wo-
men moreover soon learn to perform this little manipulation them-
selves, and to renew the pessary at the proper time, without  having
occasion of any person to assist them.  On  its  first application it is
advantageous to  keep the patient for some days in bed; otherwise
she might be liable to a degree of weight upon the fundament and to
various kinds  of irritation, which would be  much  less to be appre-
hended when  we'have given  an opportunity to the organs to become
accustomed to the presence of the foreign body and to adapt them-
selves  in some respect to it.
  J. Appreciation.—A question  immediately presents itself.   Are
pessaries in reality of any advantage ?  There can be no doubt that
they may occasion much inconvenience and quite a number of acci-
dents,  and that many women even  are wholly  unable to support
them.  The pressure which they make upon the rectum and bladder
is itself an obstacle to the functions of those two viscera.  The neck
of the  uterus itself, irritated by the contact of a body of this descrip-
tion, becomes lodged and strangulated in the opening  of the pessary,
which  latter in its turn ultimately excoriates and perforates the walls
of the  vagina, if it does not also the coats of the intestine or bladder.
Many  examples of this kind of strangulation have been published,
(Bibl.  Mid., t. XVIL, p. 259; Journ. Gen.  de Mid., 1826;  Gaz.
Med.,  1834, p. 536.)   If we make use of  the  bilboquet, in whatever
manner we apply it, it inclines more in one direction than in another,
and  ultimately after a certain length  of time depresses the vagina
rather  than the os tineas, or at the same time with it.   The gimblet
itself almost always turns over either in front or behind, and also fur-
nishes  but a very poor support to the neck of the uterus.   As to the
bung pessary, the opening at its two extremities, which is thin and
almost of a cutting edge, also very readily wounds the parts.  The
elytroidal pessary, adapting  itself to the  vagina and   filling up this
passage with a certain degree of accuracy, is less liable to be dis-
placed, keeps up the parts  more perfectly, requires less assistance to
be maintained in its place, and  from these considerations possesses
much  fewer inconveniences than  any of the others.  But as it forms
a more  considerable bulk and occupies  the totality of the organ,
many  women find themselves on this account very  much incom-
moded by it and it is difficult to keep it in place.  Since these instru-
ments  then are so far from being  innocuous, why should they be
continued in practice ?  It is at least certain that they  should be pro-
scribed in a number of cases in which they are had recourse to.  In
a case of simple  reversion, for-example, or in that of the reduction
of a prolapsus or retroversion,  pledgets  and bags made astringent
by being saturated with red wine in which roses  have been boiled,
or by  oxycrat or decoction of bark or diluted solution of sulphate of 
            FOREIGN BODIES IN THE GENITAL ORGANS.         803

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

    Article  VIIL—Foreign Bodies  in the Genital Organs.

                     § I.—In the Vagina.

  The foreign bodies that  we are called  upon to extract from the
vagina are sometimes pessaries  or portions of pessaries which have
been destroyed.  Some other substances, however, have  been found
there.  Dupuytren met  there with  a pomatum cup, the  opening of
which was downwards.   In the two women mentioned by M. Grenier,
(These No. 7, Paris, 1834,)  it was a case filled with needles,  which
had been introduced closed, and become opened in the vagina.  In the
cases cited by MM. A. Cooper and Capuron they were portions of
sponge,  which had been  neglected and  left there, and which had be-
come the nucleus of hard bodies.  Any person, moreover, may compre-
hend the varieties  of form  or substance which foreign bodies  may
have that  have got introduced by chance,  or by the volition of the
woman into this passage, as well as the kind of accidents which  they
may occasion.  There have been found here pessaries that had been
buried, as it were, for the space of 10, 15, 20 or 40 years,  and which,
after having  become encrusted with calcareous matters  and under-
gone corrosion, or even become imbedded with fungous vegetations,
have produced pains, inflammations, and the most formidable array
of symptoms.  In a woman cured by  M.  J. Cloquet, so great an
alteration ofthe vagina was produced that it was taken for a cancer.
Ordinarily they ulcerate, and perforate either the bladder or rectum,
and even sometimes both those organs at once.  A woman desiring
to withdraw her bilboquet  broke its stem, and finally forgot that she
left its ring in the  vagina ; at the expiration of a long period of years
she was  seized with symptoms which obliged her to solicit the ex-
traction  of this foreign body.   Dupuytren was  then   enabled  to
ascertain (Bull, de la Fac. de Mid., X. VIL, p. 136,) that it made  a
projection  at  the  same  time into the rectum and the bladder.   M.
Berard has published a still more  remarkable case, and  to which I
myself was witness.  The woman,  who wTas very advanced in  age. 
804           NEW ELEMENTS OF OPERATIVE SURGERY.
had quite forgotten her pessary since she had broken its stem twenty-"
five years before.   It could be felt naked  in the bladder by means
of the sound, and very distinctly in the rectum with the finger.  The
vagina, which was  almost completely obliterated below, formed  no
longer anything more than a species of cul de  sac  having  a small
aperture in  its upper part.  In the case communicated  by AI. Lar-
roche to M. J. Cloquet, (These de Concours, 1831,  p. 100,) the  stem
pessary had  perforated the rectum, where its  cup had  become the
nucleus of a stercoral calculus, while its pivot occupied the centre of
a urinary calculus in the interior of the bladder.  As the operation
which is to  be performed  under  such circumstances must vary ac-
cording to the cases which require it, it could scarcely be submitted
to any special rules.  If the pessary still  continued to be free and
nothing more was required than  to subdue the irritation which it
produced, the forefinger introduced into its ring or on one of its bor-
ders, would  be quite frequently found sufficient  to  effect its  extrac-
tion.  If it were otherwise, a long  polypus forceps could be  advan-
tageously substituted for the fingers, or we might try to succeed bet-
ter with  a blunt hook guided and  protected by the forefinger of the
left hand.  When it projects  into the rectum and cannot be with-
drawn through the vagina, we endeavor  to grasp it and  bring it out
in the same manner through the anus.   In cases where its size is an
obstacle to the success of the operation, it may be found  useful  to
break it up into fragments.  If it is of ivory or wood, or any fragile
substance- whatever, we may do  this quite readily by means  of a
strong cutting  pliers or solid pair of forceps.   The same cannot be
said of metallic pessaries.  In such cases we have no other resource
than to make use of the file, which of itself would  be of but very little
advantage, or of a small saw  introduced into the  rectum  and  pro-
tected by a suitable canula, while we held the foreign body by means
of a forceps in as complete a state of immobility as  possible.  It was
with the saw that Dupuytren  effected his  object in the case which
has just  been mentioned.  In a patient whom I saw at La Pitie, M.
Lisfranc began by incising the front part of the anus and a portion
of the perineum, in order  to  obtain a  wider entrance.  He  then
grasped the  pessary without any great degree of  difficulty, and
effected its extraction by a forceps held in  the right hand, while the
fore and middle fingers of the left hand  regulated the movements of
the instrument at the bottom ofthe parts.  In operating since on two
similar cases, one at the hospital of La Charite, and the other a pa-
tient of M. R. Gerardin, I did not find it necessary to incise the peri-
neum.   The  position of the woman and  the precautions necessary,
before and after the operation, are the same as those for all the other
processes which we  have been describing  in the preceding articles.
If a  tumbler or vessel, either earthen or  of wood, should produce
accidents in the vagina, it  would become  necessary after having  in
vain endeavored to place them in the most suitable position  and  to
extract them  entire, to break them in  their  place and to remove
them  by piecemeal.   Moreover, the intelligence of the surgeon will
know how to supply the deficiencies to  which books are necessarily
reduced on this subject.  The  consequences ofthe operation are usu-
ally very simple, unless the intestine or bladder has  been  perforated. 
POLYPI OF THE  UTERUS.
805
It is remarked, that even in such cases fistulas soon become conside-
rably reduced, and frequently even finally close up entirely of them
selves.  Another peculiarity, no less remarkable, is this, that after the
pessary has been extracted, the descent of the uterus, in a consider-
able number of cases, does not  again take place.  The vagina, which
has become indurated  and contracted, and occasionally transformed
into inodular tissue below the cul de sac, which had been long occu-
pied  by the foreign body* contracts  still  more when this latter  is
removed, and to so great  a degree as to present an obstacle to the
womb and to retain it above.  The woman  whom I operated  upon
in  1838 with M. Gerardin, presented  a fine example  of this modifi-
cation.
                     § II.—In the  Uterus.

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

             Article  IX.—Polypi of the Uterus.

  There  is  no  method  of treatment recommended for polypi in
general, or those of the nasal fossas in particular, which has not been 
806           NEW elements of  operative surgery.

applied to uterine polypi.  These  last nevertheless have not, in this
respect, excited the genius and invention of surgeons to so great an
extent as the first.  Cauterization,  which seems  to be alluded to by
Celsus, and which was still  eulogized  by Verduc, Volter, &c, and
also  scarifications and  the use  of desiccants, as mentioned in the
work of Aetius and that of  Moschion, have been long since aban-
doned.  On the other hand the tearing of them out merely or making
use of torsion with this, would be  applicable only in a small number
of cases. If, moreover, the treatment of these diseases should appear,
according to Sabatier and many of the moderns, to have  been so
much  neglected  by the ancients,  the reason lies in this, that until
quite a recent epoch they have been  designated in medical works
under the name of affections which are exceedingly different.  Phi-
lotenus, (Peyrilhe, Hist, de la Med., p. 115, in 4to,) for example, evi-
dently confounded them with cancer, and Moschion with varices of
the uterus.  We  can  no longer entertain  any doubt on this subject,
when  we  see the  mysterious Aspasia describing hemorrhoidal tu-
mors which sometimes originate on the neck, sometimes at the fun-
dus of the womb,  but  rarely on the external genital  organs;  tumors
which are  to be excised without any hesitation when they are hard
and white, which  are to be tied when they have a great tendency to
bleed, and  among which some are found which resist every remedy.

                         §  I.—Varieties.

   In order to comprehend the relative value of the operative pro-
cesses applied to  uterine polvpi, and to reconcile  the different writers
who have  treated of them, it becomes indispensable to say a word
respecting their origin and nature.  It can longer be disputed at the
present day that there may be developed in the uterus tumors which
differ very materially from each other.
   A.  The small polypus mentioned by Z. Lusitanus, and the excision
of which was accompanied with so copious a  hemorrhage, may be
compared to the vascular or vivacious polypi which are so frequently
observed in the nasal  fossas.
   B.  M. H. Berard has noticed  in  the neck of the uterus soft polypi,
which were almost entirely mucous, or to  a  great extent similar to
those of the nose.  I have  seen in  three instances  in the uterus ol
women, used in dissections at the Ecole Pratique, tubercles of varia-
ble volume, containing small vessels, and which were continuous with
the tissue ofthe organ and yet without any pedicle.
   C.  Dance, M. Berard and M. Cruveilhier, as well as MM. Mayer
and  Meisner have, like myself, met  with those which appeared to
have been the result of an actual  partial  hypertrophy, either of the
body or neck of the uterus ;  that is to say, that they were continuous
without any line of demarcation with  the fibres of this viscus, from
the structure of which, moreover, they differed in no respect what-
ever.  I published, in 1825, a case of this kind, the morbid specimen
of which I have preserved in alcohol.
   D. There are others  which are  also continuous with the tissue of
the uterus, but which are evidently a degenerescence or transforma-
tion of this organ.  These  last are  hard, elastic, and of a greyish 
polypi of the uterus.
807
color.  When they are cut  into, they present •the appearance of a
lardaceous, semi-cartilaginous, homogeneous white  substance, desti-
tute of vessels, and in which it is impossible to recognize the slightest
appearance of fibres.  I have had occasion to excise some  of this
description, and  in which all these characters existed  in the  most
marked degree.
  E.  The  most  common, by far, are nevertheless those  which,
since the labors of Bayle, M. Roux and Dupuytren, are designated
under the name of fibrous bodies, and which are primitively developed
between the layers, and in the tissue of the uterus itself.  The three
cases of carcinoma  of the uterus  related  by Pottier, (Bonet, Corps
de Med., X. III., p. 492, and t. IV., p. 492,)  who, after having tied and
drawn, and  depressed the tumor to the vulva, effected its excision,
also the cases of fungus of the uterus extirpated by Ollulaire, (Ibid.,
X. IV., pp. 29. 31,) in two different  women,  and the enormous sarcoma
extracted from  the  vagina,  by Behrens,  (Theses de Haller,  Sous-
Vater,X. IL, p. 179, 1718, French  trans.,) are evidently to be classed
with these fibrous bodies.  Certain facts induce  me  to  believe that
these last mentioned  tumors  quite frequently result from an effusion
of blood  or from a fibrinous concretion*  which has  been  scarcely
organized, but continued to retain its vitality, and to  grow by imbibi-
tion in the midst of  the  surrounding parts.  Exhibiting always a
tissue of fibres,  intercussated in  various  directions, and  grey  or
whitish, as in the preceding  species, these also do not  contain any
vessels, and are covered over with a layer  from the  uterus, which is
sO much the more attenuated in proportion as they are larger in di-
mensions, and which may be so much the  more easily recognized in
proportion as we approximate to their pedicle.
  F. Fibrinous Polypi.—A  woman, 32 years of age, sought my ad-
vice, at the Hospital  of Saint  Antoine, in  1828.  For  a month she had
occasionally observed a slight discharge.  Upon introducing the finger,
I found a mass of the size of a small egg, somewhat swollen, of quite
a firm consistence, and which was prolonged by a distinct pedicle as
far as to the upper part of the neck.  I supposed it  to be a polypus,
and the  patient was placed  in  a  bath,  and underwent during the
space of  three days, preparation for the operation.   Having  intro-
duced my finger into the part, I again encountered  the  mass which
I had at  first recognized ; but in endeavoring to reach its pedicle, I
caused it  to fall  into the  vagina, and thus extracted it.  It was  a
fibrinous  concretion, or simple  clot of indurated blood.  Thus we
have a new variety of polypus, in other words, fibrinous polypi.  A
sanguineous concretion, resulting from the catamenia, or some dis-
charge of blood,  engrafts itself upon the neck of the uterus, and ulti-
mately becomes organized there.   I have  now seen four  examples
of this kind at different degrees of organization.  Did not the poly-
pus in the  form of a cyst,  with  a long pedicle, as noticed by M.
Arnott, (Encyclogr. des Sc. Med., 1836, p. 315,) and which originated
on the anterior lip of the neck, belong to this species ?
  G. Cancerous Polypi.—Schirrous or encephaloid tumors developed
in the tissues of the walls, or  in the cavity of the womb, may descend
and dilate the neck,  and present themselves in the vagina, under the
form of a polypus.  Three women were  seen in  this  state at La 
808
new elements of operative  surgery.
Charite, in 1836, 1887 and 1838.  I saw a fourth instance with MM.
Roux, Alarjolin and Sanson.  A surgeon exhibited to the  Academy
of Afedicine, under the name of a polypus,  a tumor which he had
extirpated  in a patient whom I subsequently saw with AI. Magistel,
and who in reality was affected with a cancer.  In  the case of AI.
Arnott, (Encyclog.  des  Sc. Med.. 1836, p.  315,) this description of
cancer caused an inversion of the uterus.
  H.  True polypi may in  their  turn be mistaken for tumors of an-
other character.  In  1823  MM. Richerand and J. Cloquet removed
one of the  size of a child's head, which  had hung for  a great num-
ber of years to the  vulva of a woman, and which they supposed
to be the extirpated uterus itself.   This body when laid open pre-
sented a cavity in  its centre, and  almost  all the other characters
of a uterus to so great a degree, that it was considered of a nature
to demonstrate  beyond  dispute, the  practicability of an amputation
of the organ.  The patient died, and the  uterus was  found entire
in its natural position—notning more had  been removed  than  an
enormous polypus !  A woman from the country,  who  came to the
hospital of Perfectionnement in 1821, in order to have reduced, what
she called a. falling down of the uterus, had at  the vulva a  conical
tumor with  a small transverse cleft  at its top, which she had kept up
for a long time by means of a pessary, and which I  readily pushed
back into the vagina and supported with a  bilboquet.  This woman
having returned home, after the expiration of a few days was seized
with  pains in the  abdomen, which induced her to come back to the
wards of the hospital, where she died the next day but one of a peri-
tonitis.  The tumor which I had reduced was a polypus attached  by
means of a pedicle of  the size of a finger to the  fundus of the uterus,
which latter had been inverted !
  I.  The point of insertion of uterine polypi varies greatly.  Those
on the fundus of the uterus, if their pedicle is somewhat large, rarely
descend into the vagina  without giving to the neck of the womb the
appearance of a simple ring, which might readily lead to the suppo-
sition  of an inversion of the organ.   A woman who was sent  to me
by M. Villette de Compiegne, and who died before being  operated
upon, was in this condition.  I have seen two polypi with long  pedi-
cles originating at the  summit of the neck, one from the anterior and
the other from the posterior lip.  M. Arnott mentions a similar case.
In the interior of the neck as well as in the cavity of the womb, the
pedicle is almost always found external to the median  line, and  al-
lows of the finger or probe being passed along its  side or  above it.
In a young woman, however,  upon whom I operated successfully, it
adhered throughout its whole circumference, though the dilated por-
tion of the  tumor was scarcely larger in size than a nut.
  J. Polypi of  the uterus, whatever  may  be  their species,  vary
scarcely less in  their  form than in  their point  of insertion.   In the
case of a lady the polypus was globular, half  the  size of a nut, and
adherent in the manner of a projection against the  fundus of the or-
gan.  I have seen  those  that were fibrous,  cancerous, fleshy, and
mucous,  of much  larger  size, and which  retained this  form,  or
where one of the halves was imbedded in the natural tissues, while
the other projected in  the  shape of a bump upon the interior of the 
POLYPI of the uterus.
809
 jterus, or of its neck.  It would neither be easy or prudent to attack
 those of this description.   Though isolated, they continue to be glob-
 ular, and are not elongated into the shape of a pear so long as they
 are entirely included in the uterine cavity ; it is only when  they ar-
 rive in the vagina that they become pyriform. In a lady whom I saw
 with M. Lacournere, the polypus, which had its root in  the uterus,
 extended itself under the form of  a cylinder or  penis as far as  two
 inches  outside of the  vulva.   An analogous fact was noticed  by
 Gaches, (Soc Med. de Montpellier, X. 33, p. 31,) and the same modi-
 fications have been seen in polypi of the vagina, properly so called.
 Frequently there exists several polypi at the same time.  Cancerous,
 fibrous, and  mucous polypi, are those which especially multiply in
 this manner.  In 1838 I operated upon  a woman who thus had four
 granular pediculated polypi, of the size of an almond or raisin-seed,
 in the cavity, and on the lips of the neck of the uterus.

                 § II.—Spontaneous separation.

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

                             §  III.

   It was this spontaneous separation of certain polypi which must
 have suggested the first idea of the method of arrachement, which
 had already  been employed by  Dionis, Juncker  and Heister,  and
 which Lapeyronie and Boudou have not hesitated again seriously to
 recommend.   These authors at the same time advise torsion of the
 pedicle, in order either to tear out  the polypus with more facility, or
 to protect ourselves  with  greater  certainty against hemorrhage.
 Torsion, combined with simple tractions, being calculated to become
 dangerous by drawing upon the tissue of the uterus, Hevin under-
 took, at  the schools of surgery, in 1753, tb  sustain a thesis wherein
 he showed, that by holding the root of the tumor by means of a for-
 ceps at its upper part, while at the same  time we turned it upon it-
 self, this danger would  no longer exist.  M. Pecot, (Arch. Gen. de
 Med., 3d ser., t. IL, p. 382,) who recommends  this for soft polypi
 after parturition, alleges that he has derived decided advantages from
 it.  M. Sanson (Bull, de  I'Acad. Roy.  de Med., X. L, p. 877)  also
 used this method in one instance with success, in a woman who had
 been delivered, and in  whom there was  a fibrous polypus in the
womb  as large as the fist.   A  similar instance was met with by M. 
810          NEW ELEMENTS OF  OPERATIVE SURGERY.

Breon, who showed me the tumor in  1835.   M. Magistel was as-
tonished to find in a woman whom he had just delivered, a mass in
the uterus  larger than  the  fist.  We found after death, which re-
sulted from peritonitis, that the  case in question was one of  an enor-
mous fibrous polypus.  Many  of these polypi, moreover, are very
easily extracted.  A lady of Alans, whom  I had  seen, went to con-
sult M. Recamier, who removed  her polypus with his finger nail.
In another case, the polypus, which was of the size  of a large  nut,
and situated in the interior of the neck, was detached  by means of
tractions and simple frictions with the speculum. I have torn them out
in several instances, even  from  the cavity of the womb, by means of
my finger.  In a woman who had just been delivered for the fifth time,
M. Stoll (Gaz. Med., 1839, p. 186) found in the vagina a polypus ten
inches long, and  weighing a pound, and which he  was enabled to
detach from the uterus  by means  of  his nails. In  the mother of a
young physician, I  was enabled  by means of my finger to detach
and remove a polypus as large  as  the half of an egg, though it was
situated in the cavity of the  uterus  itself.   To effect the  arrache-
ment, we grasp the body of the polypus with the forceps of  Museux,
with the ordinary tenaculum, or with the  fingers if it is  not very
large, or with a straight or curved forceps.   We then make regular
tractions, either simple, or combined, with slight movements of rota-
tion, until  we  have brought the tumor  outside.   It  is scarcely ex-
cept at this stage that it would be practicable to make use of the
precaution  of Hevin,  but there would  be  no longer any object in
doing so, for if we did not at this  moment wish to have recourse to
pure and simple excision, nothing  would be more easy than  to apply
a ligature on the most contracted part of the morbid mass, and then
to excise the latter immediately  below it.   I  have been enabled in
three instances to tear out small mucous polypi, situated in  the neck
of the  uterus, by means of the polypus tenacula, guided upon  two
fingers of the right hand.

                              § IV.

  M. Recamier, who considers that these  bodies  may be destroyed
not only by arrachement, but also by breaking them, up (broiement),
has published two cases in support of his assertion.  In one the poly-
pus, which was of the size of the great toe, was implanted into the
upper part of the neck, apd projected into the vagina.  Having made
strong  pressure  upon it with the  forefinger of his right hand,  this
physician succeeded in dividing and reducing it into a pulp,  and  was
enabled to accomplish its extraction in less  than two  minutes; in the
other, finding it impossible either to tie or extract the tumor, it  was
ruthlessly  broken up by means  of the erigne forceps or fingers, and
reduced into a  sort of packthread, the filaments of which constantly
slipped between the prongs  of  the instrument.  I cannot understand
the advantages of a process of this kind, and have no remark to make
upon it.
                              § V.
   The ligature  to  uterine  polypi is  a  much  more  ancient process
than Levret has alleged.  It is evident that Aetius and Aloschion were 
POLYPI OF THE UTERUS.                  811
acquainted with it, and Philotenus before them.   It must be admitted,
however, that we are indebted to Levret for  having introduced it
into practice in modern times, by demonstrating that it is applicable
not  only to  polypi that protrude  from the vulva,  but also to those
which are placed at the highest point in the genital cavity.  Numer-
ous  instruments have been contrived for  performing this operation.
All  those used for tying polypi of the nose are applicable to it.  The
two tubes united in  the form of a forceps, and which in  the  begin-
ning were much extolled by Levret, also those that Theden had con-
structed upon the same model almost, together  with the instrument
of Lecat and that of Herbiniaux are now abandoned, nor do  I think
that the ligature-holding and knot-tightening forceps of M. J. Cloquet,
which scarcely differs from that of Theden, will continue to be any lon-
ger used.  Nor has the double canula ofthe  first named author been any
longer retained in practice.  The two separated canulas of Desault
or the catheters of Niessen have been substituted for these.   Every
thing  leads  us to believe that the modifications  proposed by Clarke,
Laugier, Loeffler and Cullerier, as well as a great  number of others
mentioned in the treatise  of M. Meisner, will also be rejected from
practice.
  A.  Operative Process.—The instruments being  prepared, the fol-
lowing is the manner in which we should proceed.
  I. The operator having  ascertained the position  of the polypus
and the dimensions of its  pedicle as correctly as possible, adjusts the
ligature whicn he intends to use, which should  be of fine silver,
according to the notions of Levret, but which is now more generally
made of silk or linen thread, taking care only that  it shall have suffi-
cient  strength.   If we make use of  the two canulas of Levret, we
adjust the thread in such manner that it may form a noose on one end,
and be fastened at the  other upon the ring  which is found external
to the shoulder of each canula.  One or two fingers of the left hand,
introduced as high up as  possible, will serve to  guide the whole to
the pedicle  ofthe polypus.  The surgeon  then immediately takes one
of the canulas in each hand ; fixes  at the same point the one on which
the ligature is fastened below ;  then makes the other pass around the
circumference of the pedicle until he has been enabled to cross them ;
then twists and turns them together on their axis ;  detaches the liga-
ture from them ; withdraws them ;  and  then  passes the two united
extremities  of the ligature through another tube, which is called the
knot-tightener, and which enables him to  strangulate the tissues with
all  the force required.
  II.  The instruments of Desault differ from those of Levret in this,
that the two ligature-holders are separated and  free, like those of
David, and  also in one of them when  shut containing a sort of forceps
which terminates in a beak or bird's eye.  Half the ligature is  first
passed into  the simple canula  and fastened below on its ring; the
other half is then embraced by the forceps, which is  closed by with-
drawing  it  into its canula,  and which latter has on  its lower part a
notch to  secure  the second end of the ligature.   The  apparatus is
then introduced in the same manner  as before at the  part which pre-
sents  the least resistance.  Having reached the pedicle, the operator
with his left h  d holds the simple canula immovable, grasps the for- 
812           NEW  ELEMENTS OF OPERATIVE SURGERY.

ceps-holding canula with his right  hand, makes it pass around the
entire circumference of the tumor, and brings it back on a line with
the other in such manner that  the  ligature  forms a complete circle
upon the pedicle which is to be strangulated.  The forceps pushed
through its canula opens and lets the  thread out, and may be removed
without displacing  it.   The extremities of this ligature united into
a single cord, are then inserted through the opening of another me-
tallic piece some inches long and cleft at its external  extremity, and
the head of which,  which has an eye, is bent almost at a right angle
upon the body of the instrument.  This knot-tightener enables us to
regulate the constriction in such manner as may be desirable, and to
augment or diminish it according to the indication presented.  It is
then to  be finally attached by means of a  thread upon one of the
sides of the vulva, after having protected the instrument with lint or
linen.
  III. The apparatus of M. Niessen is composed of two long curv-
ed silver canulas, which may be flexed or  straightened at pleasure,
and which serve as  the ligature holder.   When they have arrived at
the polypus, they are both inserted  into a third  canula, which latter
is divided into two tubes by a partition, and is only an  inch or two
long.  This last, which seems to be  nothing more than a portion of
the double tube of Levret, is  conducted as high up as possible, from
below upwards,  first by means of the fingers, and then with the ex-
tremity  of a hook sound.  Its object is  to strangulate gradually the
pedicle of the tumor, by forcing the  upper extremities of the two first
canulas  to approximate  each other  without losing their parallel di-
rection.
  IV. We can scarcely understand at first sight, what advantage there
would be in  giving the  preference to these instruments over those
of the French practitioners.   The canulas of the German author be-
ing no other  than  those of  Levret  slightly elongated  and curved,
might possess some advantage perhaps, when we have  to penetrate
to a great depth  ; but the double tube intended to approximate them,
appears to me infinitely less adapted to attain this object than the knot-
tightener contrived  by Desault.  If,  moreover, we wished to modify
this last part of the apparatus, the  chaplet of M. Mayor would be
decidedly preferable, and  better even than for the nose.   If, in order
to strangulate the polypus by means of this  chaplet, we  could not
command the mechanical addition of the winch which the  author
uses, nor the little instrument of the  same kind, invented by AL Le-
vannier, (Arch. Gen. de Med., X. XL, p. 467,) we might succeed very
well by  tightening the two halves of the ligature upon a piece  ol
cork,  or any other solid substance.  The jointed  knot-tightener,
which Bichat was desirous of substituting for the forceps-canula of
Desault, as it is incapable of carrying out the intentions of the author,
except in a few rare cases, is worthy of no further remark.  Nor do
I think that the knot-tightener of Ansiaux,  (Clin. Chir., 2nd edit., p.
285,) or the speculum of M. Guillon, as modified by AL P. Dubois, so
as to serve as a ligature holder, nor  the seven pieces which enter into
the instrument of M. Lasserre,  (Arch.  Gen. de Mid., 2nd ser., t. V.,
p. 153,) are calculated to throw into oblivion the apparatus ofthe an-
cient surgeon of the Hotel Dieu, which is so simple and  ingenious. 
POLYPI OF THE UTERUS.
813
  V. When the ligature is properly applied, the circulation and vital-
 ity of the part below it soon cease.   While the mortification of the
 polypus is going on, the ligature little by little cuts through the pedi-
 cle.  It is easily conceived, moreover, that the ligature will divide
 the root so much the more  speedily, according to the force of con-
 striction employed, and the  density,  resistance and volume of the tis-
 sues.  So long as the pedicle does not exceed in thickness the  diam-
 eter of an inch, a single ligature properly tightened will suffice  to cut
 through it in the space of a few days ; but it has been  considered
 when it exceeds this diameter, that it would be advantageous to per-
 forate it by means of a needle with a  double  ligature,  in order to
 strangulate its two  halves separately.  This is a  principle to which
 in the first place,  two objections  may be made:  1. Those polypi
 which may be brought out to the vulva, and which are the only ones
 which are adapted  to this process, rarely have a  root so large as to
 require this precaution.  2. Those  which  have  a larger  pedicle,
 whether  they may be brought  out  or  not, are all of them fibrous
 bodies, which are to be detached by means of the cutting instrument,
 or they are vegetations of a bad character, which are not to be med-
 dled with.  Enormous polypi, however, have been removed by means
 ofthe ligature.  Richter, of Moscow, (Synopsis Obstet., &c, p. 114,)
 has succeeded by this means, though the tumor weighed four pounds
 and a half.
  B. Among the ligature-holding instruments which have been pro-
 posed, those of M. Mayor appear to me  to be especially worthy of
 being made trial of.  These consist  of two elastic steel rods,  or even
 of whalebone, should we not have time to procure those of metal, and
 are terminated in crabs' claws.  The ligature is adjusted in the same
 way as in the forceps  of Desault, and is  to be applied  around  the
 polypus with the same precautions.  All that is required to disengage
 it, is to draw with some force upon the conducting instrument, as soon
 as the knot-tightener has reached near the pedicle to be strangulated.
 With the double tube of Levret, the two portions of the ligature  are
 brought too near the polypus, to allow of its sliding with ease  when
 we wish to augment the constriction.  The same remark nearly  ap-
 plies to all the knot-tighteners.   To  introduce  the  ligature down to
 the root of the polypus, astraddle the left forefinger, while with  the
 right hand we bring its two  halves out in front, as  some person  (Gaz.
 Med., 1832. p. 720,) has recommended, would succeed only  in some
 rare exceptions.  Embarrassed, like so  many others,  by this incon-
 venience, AL G. Pelletan, with  a view to avoid it, has caused to be
 constructed an ingenious apparatus.   Being slightly separated apart,
 in the manner of a fork, to the distance of some lines, the two  branch-
 es which  terminate the inner extremity of his knot-tightener, are ap-
 plied on their concavity against the root of the  polypus, and scarcely
 deviate the  direction of the  thread, with the circle of which they are
 in some sort continuous.   A spring,  or kind of  steel band, curved in
 several directions in order to increase its elasticity, being placed at
 the outer  extremity of the instrument, receives the other end of the
 ligature, and constantly augments the constriction.  The elastic in-
strument moreover, may be combined with all the other contrivances,
and  among others with the  chaplet of M. Mayor.  As to  the  bifur- 
914           NEW ELEMENTS OF OPERATIVE SURGERY.
cation of the knot-tightener, it would  be  attended  with no inconve-
nience, unless we wished to turn it on its axis in order to twist the
ligature.
  C.  Before strangulating  a polypus which hangs outside, it is im-
portant to remark, that  its  pedicle might possibly  be formed by the
fundus of the everted uterus, and that it would be dangerous in that
case,  to place the ligature on too elevated a point of the tumor. The
decomposition of a polypus in the sexual organs, sometimes involves
consequences which we  should be fortunate if we could avoid.  Thus,
the offensive odor which attends it is exceedingly disagreeable, both
for the patient and for those who are  about her.  When the polypus
is of a very large size, and the temperature of the weather very ele-
vated, this odor in fact may be so excessive  as to  be insupportable.
The putrilage, moreover, which  results from it, irritates the vagina
and vulva, and may, if  it is absorbed, give rise to infection ofthe
whole system, or to a fever of bad  character.  Should it be found
impossible to bring  the tumor to the  outside, we must content our-
selves with  combatting  these  inconveniences  by means of the ordi-
nary  cleansing  resources,  by simple injections with mallows  or
sweetened barley water, those of decoction of bark, or what is better,
with solutions of the alkaline chlorurets; but  when the pedicle is very
low down, 01  when by  means of moderate tractions we can make it
descend without occasioning too much pain, it is more expeditious;
and certainly  less  dangerous, to excise the whole mass  below the
ligature than to leave it to itself.  M. Demaziere de Bergues, (com-
municated by the  author,  August 16, 1837,)  by  operating  in this
manner, after having made use of the forceps to depress a  polypus
of two pounds and  a half in weight, in a woman  41  years of age,
succeeded perfectly.
  D.  Levret has contended that after the ligature, the mortification
extends to the union of the polypus  with  the uterus, even though
the constriction may have been made a little below, and that these
tumors, when once strangulated, almost always become detached
at the same point  as the umbilical cord does in  the infant, what-
ever may be the  part at which the ligature has been applied.  This
idea appears dangerous to  Boyer.   In fact, if it were erroneous, it
might involve serious consequences  in practice.   If we adopted  it,
it would be a  matter of little  consequence whether we applied the
ligature exactly on the upper  part of the  pedicle or at  some dis-
tance  below.  Now, as  it is generally more easy to apply it lower
down than  higher  up,  and as  some persons, moreover, might be
fearful if they adjusted  it higher up,  that they might wound some
portion  of the tissue of the  uterus, the ligature would  in many
instances  be placed in  such manner  as  to  leave  a portion  of the
polypus in the organs.   If on the other hand it be true, as Boyer
affirms, that vitality does not  cease  in  the  tumor, except -in the
part below  that which  is embraced  by the ligature, this  latter,  if
we do not  wish  to run the rbk of  a return of the disease, ought
always  to be  applied upon the most elevated point of the morbid
production.  The opinion of Levret is based upon facts, and AL Gen-
seul has defended it by  adducing cases in support  of it.  Aloreover.
from  what we know of  the laws of the organism, there is no reason 
POLYPI OF THE UTERUS.
815
why this process may not be compared to what takes place at the time
ofthe separation of the umbilical cord.  All that is requisite is, to un-
derstand ourselves on this  point.   The mucous polypi, or those  in
which numerous vessels are distributed, and which are  evidently
continuous with the tissue  of  the  uterus  itself,  are not compatible
with  the theory of Levret, which in my opinion is applicable only to
those which constitute actual foreign bodies in the midst of the organs,
or still  more to those polypi which are purely fibrous or lardaceous,
and  which  are destitute of any appreciable vascular circulation.   I
have seen more than an inch of the root of a fibrous polypus come
away a long time  after the separation  of the ligature, and  putrefy
in two other  cases to a considerable  distance  beyond  the  point
where  it was excised.   This phenomenon is so much the less surpri-
sing, from the  fact, that certain polypi  dissolve, and ultimately dis-
appear spontaneously in the womb.  A fibrous body of the size of a
nut, which I had ascertained to exist in  the neck of the uterus, could
be no longer found at the expiration of six months, though  nothing
had been expelled from the genital organs.  If it should be objected,
that  I might have  been deceived  in  this case, I would  add, that in
a woman who  came into La Charite in  August,  1838, to be operated
upon, the polypus gradually disappeared under our eyes, and that the
patient having  died of- peritonitis, we were enabled by the autopsy
to detect the root in the body of the uterus itself.  Duges and Mdme.
BorVin, moreover, have noticed similar facts.

                       § VI.—Excision.

   The  ancients, more daring than surgeons of the last century, fre-
quently had recourse  to excision  of genital  polypi.   Philotenus,
Aetius, Moschion, &c, evidently had  reference to this method  when
they recommended the removal by means  of the cutting instrument,
of varicose or hemorrhoidal excrescences of the uterus.  F. ab Aqua-
pendente made use for this purpose of cutting hooks, which he has
greatly eulogized, and the extremity of which made in the manner
of scissors, exempted him from the necessity  of previously drawing
the polypus to  the outside.   Though the attention of practitionershas
been occasionally directed by authors to the subject of excision, and
that  Tulpius, (Bonet, Corps de  Med., X. IV., pp. 29, 31,)  Water and
Fronton, the latter cited by Levret, relate  cases in its favor, it has
nevertheless not yet succeeded in triumphing  over all prejudices.
Boyer,  who states that he employed it in one  instance with success,
and who does not appear to be disinclined  to yield it the preference,
does  not, however, venture to formally recommend  it as a general
method. The objection to it is that it exposes to hemorrhage  and  to the
danger of wounding the rectum, bladder, vagina, and even the womb,
and that it is a  more difficult process than the  ligature.   The wound
itself which it must necessarily occasion, has alarmed many surgeons,
who  apprehend that inflammation  may be thus produced in the
uterus,  or that  there may ensue a suppuration or an ulcer, which it
would be found difficult to cure.  The investigations and dissections
which I have had it in my power to make, and which are in accord-
ance  with those undertaken by  M. Hervez de  Chegoin, have  demon- 
816          NEW ELEMENTS OF  OPERATIVE SURGERY.

strated to my satisfaction that fibrous bodies, properly so called, may
be excised without the slightest inconvenience.   In no cases, in fact,
are they adherent to the uterus by a pedicle containing large  sized
vessels.  The layer  of the  uterus,  usually very attenuated, which
serves as their investment, is nothing more than a simple envelope,
which we have nothing more to do than to incise to effect the enu-
cleation ofthe pedicle with great ease, either by means ofthe fingers
or the handle of a scalpel, in the same way as if it were a lipoma or
sub-cutaneous cyst.   As  to homogeneous, hard  grayish tumors,
which are continuous with the  tissue of the uterus, the section  of
their pedicle  alsois not of a nature to give rise to any dangerous loss
of blood, if I may judge at least by those which I have met with in
the dead body, or which I have had occasion to remove during life.
Nor, in the third place, can I conceive why fibrous masses caused by
a partial hypertrophy of the organ, should be calculated to give rise
in this respect to  the slightest apprehension.   It is also  difficult  to
comprehend  how the  removal with  the cutting instrument of those
small mucous soft tumors mentioned by AL Berard, and which I
have several  times successfully extirpated, or how any other polypous
growth  which can be attacked  by the  ligature, could any more  in
reality give rise to a dread of this accident.  There are, therefore, no
other tumors than  those  reddish  bleeding vegetations, occasionally
painful, but rarely pediculated, and which have been mentioned above,
which might  render  excision improper;  but the ligature  to them
scarcely  answers  any better purpose,  for we have  to rank these
among those  unfortunate diseases which nothing can  relieve, and  to
which may be applied with too  much justice the designation of noli
me  tangere.   Dupuytren  excised  all the uterine polypous tumors
which he was called upon to treat, and in one case only did the  flow
of blood appear to him so considerable as to require some particular
attention:   M. Hervez de Chegoin relates numerous facts which are
full as conclusive.   AI. Villeneuve, AI. Lejeune, and a great number
of other practitioners  have also published various operations of the
same  kind, which have been no less  successful.  In Germany AIM.
Siebold  and  Mayer have  published  a memoir  which  proves  that
excision, which had been long since adopted by them in  the hospitals
of Arienna, has been  attended with  successful  results  of the  most
remarkable character.  Finally, I  may be permitted to add that out
of twenty operations  for  polypus, which  Up  to the present  time
(April, 1839)  I have had occasion to perform with the cutting instru-
ment, not one of them  has occasioned the slightest disturbing hemor-
rhage.
  A.  Operative Process.—The  articles consist  of one  of Museux's
long forceps, an ordinary bistoury or simple scalpel, together  with
lint, certain astringent preparations in case of necessity, and  also
linen  as in other capital operations.   If, however, the tumor should
be of large size other instruments might be required;  such, for ex-
ample, as  forceps, sharp hooks, or, as I have sometimes  used,  long
and strong double erignes, somewhat curved, in order to accommo-
date themselves to the form of the parts.
  I. In ordinary cases, the right  hand introduces the forceps, shut
up, into the vagina, and does not open  them to  grasp the tumor ex 
POLYPI OF THE UTERUS.
817
cept so far as the fingers of the left hand  protect and direct their
hooks.  By means of gentle tractions, judiciously made, the morbid
production is then gradually made to descend.  If the mobility of the
uterus is such as to enable us to bring out the pedicle with ease, its
section may then  be  readily made by means of any cutting  instru-
ment whatever, while an assistant carefully holds open the lips of the
vulva.  When, on the contrary, the polypus does not  yield, the sur-
geon, without allowing  it to ascend, must proceed with the point of
a straight bistoury, to divide it at its most contracted portion, always
following the instrument with  the fingers  of his left hand, which
should  be kept in  the vagina.  I had occasion, in a young lady, to
operate for a polypus as large as a turkey's egg,  which was planted
on the interior of  the neck,  and  which, after having got down as far
as into the vulva, appeared to be disinclined  to descend any more.
While AL Cottereau,  physician of the patient, retained  it  in the pel-
vic strait, I introduced the fore and middle finger of the left hand to
the os tineas, and then, with the right hand, I glided in,  as high as  the
upper part of the vagina, and  between the polypus and my fingers, a
bistoury wrapped  in linen, and by means of which I readily detached
the tumor.  Not a drop of blood flowed, and this lady might have re-
sumed  her usual occupations on the third day after.
  II. If the polypus,  on account of its size, should prevent  our pro-
ceeding in this  manner, we might make use  of a bistoury slightly
curved flatwise,  or a pair  of scissors of the same form.   In cases
where  it  might appear to be dangerous to  make tractions on the
womb, the species of forceps terminated by a strongly curved ex-
tremity and  slightly notched, and having  a cutting  edge like the
tenaculum of J. Fabricius, and which  has been used by Lobstein  in
more than one  instance, would prove a valuable resource.   It was
with the  same object in  view that M.  Mayer contrived long and
strong  scissors,  curved  in the shape of an S, by  means of which he
could  detach the  tumor at whatever height  it was situated.  The
scissors, however, made use of by Boyer and Dupuytren, which are
equally long  and very strong, and which have only a  simple conca-
vity on one of the sides of their blades, wTould accomplish the same
result full as  perfectly.  They  have, moreover, another advantage,
viz., that of detaching the polypus little by little from the walls of the
vagina when  it  has contracted adhesions with them, and before we
bring it down and divide its pedicle, as would have been required in
the case  noticed  by  M. Berard, (Arch. Gen.  de Med., X. IL,  p. 88,)
as the tumor here was attached to the vagina by  one of its roots and
to the interior ofthe uterus  by the other.
  III. If  the tumor should not be separated from the organic wall
upon which it has originated except by a groove, in place of having a
pedicle, and if this body were fibrous, we must not, on. that account,
suppose ourselves obliged  to  carry the instrument into the deepest
part of the groove.  In such cases, in  fact, provided we incise a
little  above the greatest diameter of the polypus, and can give a
certain extent to the  incision and  divide the entire layer of natural
tissue which  envelopes  the morbid production, nothing more is re-
quired to  enable us, by means of the fingers, the handle of the  instru-
ment or simple tractions, to detach the tumor in the same way that we
                              52 
818
NEW ELEMENTS OF OPERATIVE  SURGERY.
would separate a kernel of fruit from the parts which  envelope it.
The flaps which are left by this enucleation, either retract and cica-
trize by shrinking upon themselves, or are in part destroyed by means
ofthe suppuration.
  IV. Uterine  polypi  are sometimes of  so  large a size that they
completely fill  up the whole of the vagina, and even ascend as hi^h
as into the hypogastrium or iliac fossas.  Baudelocque states that he
saw one whose lower half occupied the pelvis, while the other made
a marked  projection above the  upper strait.  lie was enabled to
strangulate the first  portion; but when it had separated, Louis was
not willing that they should attempt  to reach the other with the for-
ceps.  The woman died, and Baudelocque asserts that it would have
been practicable to extract  the second portion of the foreign body
full as well as the first.
  It is for cases of this kind that the same author recommends the
use of the forceps, which Herbiniaux had employed before him with
entire success.  Since that period, it  has been used by M. Deneux,
Murat, and M.  Hervez de Chegoin, with all the benefit  that Baude-
loque had anticipated^ from  it.   At the present time, when we have
quite correct ideas on the nature of these large sized polypi, we could
undertake their extraction with so much the greater confidence, from
our not  feeling  ourselves any longer  under the necessity of having
recourse at the same time to the ligature.  After all, the forceps is
not the only instrument, nor is it always the best which would be
indicated in such cases.
  V. In  the  month  of  September, 1830, I  was sent for to Bergues,
by M. De Mazieres, to attend  a  lady who had an enormous fibrous
tumor of the  womb, and which made  a projection above  the pubis
and filled up the vagina.  Though resistant and very elastic, it could
be so easily depressed that the prongs of the forceps constantly tend-
ed to slip either in  front or behind.   I preferred  grasping its apex
with Aluseux's  long  forceps, and  then applying two strong  erignes
with double hooks above its thickest  portion, one on each side, and
plunging them  deep into its tissues.   Being thus grasped by four
points at  the same time, it was  gradually brought  down into  the
lower strait by means  of well regulated tractions.  The perineum,
which had to be incised posteriorly, resisted for a long  time,  but
finally, ascertaining with my forefinger that the pedicle of the poly-
pus was  powerfully stretched, I directed upon it a straight bistoury
wrapped  in  linen,  when an incision  of  a few  lines  enabled  the
elasticity  of  the parts  to complete  the operation; no hemorrhage
took place, and notwithstanding  the  marasmus and exhaustion  to
which the patient had been reduced,  her health has been completely
re-established.  I have operated with the  same success in a case in
every respect similar, and who was a  patient of AL E. Aloulin.  In an-
other woman the polypus was so voluminous that I could not.in any
way bring it to  the outside.  M. Chassaignac suggested to me the idea
of removing a thick cut  from it in the same way as we would a slice
of melon.  Having thus brought it down I detached it in the same
way as  in the  preceding cases.  There are  cases  however  where
the tumor is so  situated  that nothing  appears capable of depressing
it.  A woman 36 years of age, was sent into my department at the 
POLYPI OF THE  UTERUS.
819
 Hospital of St. Antoine, by M. Kapeler.  Her tumor filled up almost
 the entire  pelvis, and  formed  a considerable  projection above the
 strait.   AL Marjolin,  M. Kapeler and myself,  decided that we
 would endeavor  to extirpate it through the  natural passages.  I
 grasped it three times with an ordinary forceps, and three times my
 efforts to make it descend proved unavailing.  Being then apprehen-
 sive that I would unnecessarily aggravate her sufferings,  I deemed it
 advisable to abandon the patient to the natural consequences of her dis-
 ease.   She  died at the expiration of some months. At the autopsy, we
 found a fibrous body without any pedicle, and mostly transformed into
 putrilage, and having its root in the tissues of the left wall of the neck,
 from which moreover it could easily be detached after having incised
 its layer of natural tissue.   Another tumor, which was as large only as
 the two fists, and united at one of its sides with the preceding, occupied
 the right side of the uterus, and was also found enveloped by a thin
 layer of this organ. These two masses, whose base was almost as
 large as their greatest diameter, and which were of larger size above
 than below the strait,  could not  be  grasped  with sufficient firm-
 ness by the forceps  to enable us to  depress  and remove them; but
 the dissection  proved to  us, that notwithstanding  the apparent ex-
 tent of their adhesions,  their  excision  by enucleation would have
 been  practicable, if by any  means whatever we could have made
 them  descend to  the lower strait, or could have  applied the bis-
 toury upon any point of their circumference.
   VI.  As these descriptions  of polypi cannot be lacerated but  with
 much difficulty, it would be advantageous, when we have succeeded
 in making  them protrude at the vulva, to  insert through them, by
 means of a long curved needle, having a handle and pierced  near its
 point, a strong ligature of waxed thread, which should be shaped into
 a noose, and which would enable us to make traction  upon  them
 without causing as  much embarrassment as the other instruments.
 When the tumor is of an equivocal character, or when it should ap-
 pear practicable by  seizing it with a forceps to mak,e  it descend  so
 far as to enable us to pass our finger around  the pedicle, or when, as
 in the cases cited by Levret and Eschenbach, we perceive  arterial
 pulsations in this pedicle,  or when, notwithstanding what  I have said
 in the  remarks above, the hemorrhage  might  still be calculated to
 produce alarm, there would be nothing to prevent us from applying
 in the first place, before making the excision, a ligature as high up as
 possible, as  is  recommended  by M. Mayer,  and as has  been prac-
 tised by M. Demaziere.
  VII. If the tumor  is still entirely enclosed  in the womb, and if we
 have been enabled to satisfy  ourselves that it is alone and  that no
 others exist in  the tissues  of the organ, beyond the aid  of surgical re-
 sources, we may still quite frequently have it in our power  to reach it.
 To secure the  neck of the uterus by means of a number of Museux's
 forceps, to depress it. and to  enable us more readily  to explore, grasp,
 and remove the polypus, is a  pernicious practice, which would be not
 worthy of being mentioned, if  a surgeon of Paris had not conceived
 the idea of giving  it the preference  over  every  other.   It is infi-
nitely better in such  cases to imitate Bonnie,  and to dilate the parts
at first before disengaging the polypus, or even to effect the debride- 
820           NEW ELEMENTS OF OPERATIVE SURGERY.
ment of the neck on one or several points, as Dupuytren has done in
some instances.
  VIIL Process  of the  Author.—I feel moreover satisfied  that a
good pair  of erigne forceps,  guided by  the finger, will almost al-
ways succeed in  such cases without any great degree of difficulty,
in embracing  the head  of the  polypus,  whether the debridement
should  afterwards seem  to be indispensable, or whether  the finder
may in the first placereach the  root  of the tumor; I apply as  high
up as to this part, either the long curved scissors, or the blunt knife,
which is also curved.  Supporting the forceps with the finger, while
an assistant makes gentle traction upon them, I  am enabled  to  de-
tach the polypus without any difficulty.   I was enabled in this man-
ner, with M. Pailloux to assist me, to  remove in  1837, from a lady,
an enormous fibrous  mass which had passed into a state  of putrilage
in the uterus.  In adopting the same  method, I ^excised  without  dif-
ficulty at La Charite, in 1836, 1837, and 1838, a  sarcomatous poly-
pus of the  size of a nut, afterwards  a fibrous  polypus, which was
yet still less, and finally a polypus as large  as an egg. in three dif-
ferent women.  This is a  method, moreover, which I also apply to
polypi which have escaped from the neck, and which may be seized
in the vagina.   A patient of M.  Dufrenois, and several  patients of
the  hospital, were operated upon in this manner without the slightest
difficulty.   As we are  enabled by this process to avoid  all  tractions
upon the uterus, the operation is thereby evidently rendered less pain-
ful and less dangerous.
  B. Subsequent  treatment.—After the excision, the  treatment re-
quired by the patient is confined  to injections, which are  first  emolli-
ent, then detersive, and finally slightly desiccant.  If contrary to all
expectations a hemorrhage should  supervene, astringent injections or
pledgets of lint saturated with oxycrat,  eau de Rabel, or solution of
alum, or sprinkled with  colophane or any  other styptic powder,
would, as  I conceive, speedily arrest  it.  Tamponing also would  be
a last resource, which must not be  omitted after having in vain made
trial of other means.  The cure  is usually rapid, and  the woman is
sometimes re-established  in less than 15 days. But serious and even
fatal accidents may also result from the excision of a  polypus, how-
ever small it may be.  A lady had  one of the smallest description.
She was operated upon and death took place three days after.   As-
sisted by A/L Cartault, I excised  one which did not exceed the  size
of a cherry, but the patient nevertheless died of peritonitis in eight
days.  A fatal hemorrhage closely followed upon an operation of as
trivial a character in a case which has been related to me by AI.
Marjolin.   In two instances I have seen serious symptoms of phlebitis
or of suppuration in  the pelvis, after the removal  of a polypus  from
the  uterus.   As a general rule, however, it is one of those operations
in surgery  which succeed the  best.

                     [POLYPI  OF THE  UTERUS.

  One of the  most important circumstances connected with fibrous
polypi of the  uterus,  growing  upon the fundus  of the womb  and
within that organ, is the difficulty  attending its diagnosis from preg- 
POLYPI OF THE  UTERUS.
821
nancy, or prolapsus, or eversion of the uterus when the tumor is very
large.  It then, as is remarked by Dr. Bullen, in an excellent memoir
on Polypoid growths of the uterus, (Dublin Med. Journ., vol. XXV.,
1844, p. 407, &c.,) occupies the whole of the womb.   In a remarkable
case of this  kind in a woman  aged 50, labor  pains and hemorrhage
came on, and the  tumor having  descended into  the vagina was re-
turned by the midwife, on the supposition that it  was a prolapsus of
the uterus.  Its appearance, according  to  Dr. Bullen, was in many
respects similar to a prolapsed uterus.  It may be mistaken for a
prolapsed uterus when  the tumor has only partially descended  into
the vagina or to the vulva, because  not only its general  shape natu-
rally corresponds  to the  cavity which  it  fills, but also the mucous
membrane which  lines it, being continuous with  that of the  uterus,
presents in a morbid state the same aspect as the  latter.  For exam-
ple, it is extremely vascular, and several large  veins filled with blood
can be distinctly seen ramifying through it, while upon the surface
are irregularities, and also a marked indentation that give it quite the
appearance of the os tineas.  The deception,  moreover, of  an im-
pregnated uterus  will be added to this misapprehension when the
polypus is  replaced  in the vagina, as the tumor is then felt in the
hypogastrium above the pubis, of the size and  shape of the womb in
the sixth month of pregnancy.  But when  the polypus drags down
and inverts the uterus  by  its weight, that is, turns  the latter inside
out and brings  it  completely without the  vulva, a mistake  can no
longer exist, as  we should  think,  because then the counterfeit os
tinea still  remaining, would manifestly prove  that  the uterus itself
could not have prolapsed to so great an extent; while  the  attach-
ment of the polypus to the everted  fundus would also then be neces-
sarily defined in a clear manner.   To make a correct examination,
Dr. Bullen recommends Prof. Simpson's uterine bougie, to be passed
up between the uterus and tumor, taking  care  first to replace the
uterus in situ.
   The tumor in the case  in  question was  brought  as far as conve-
nient without the vulva, when a ligature was placed around its broad
base, close  to its  attachment to the fundus of the  womb.   Forty-
eight hours  afterwards, in consequence of the dangerous  reaction,
pain, abdominal tenderness, offensive discharges from the vagina, &c,
it  became  necessary to proceed immediately to  the delivery of the
tumor by Levret's forceps, and before the  ligature had had time to
cut its way through it.  To meet  this difficulty torsion was used
with the forceps to a very considerable extent, by which means the
polypus was brought away.  It was fibrous and larger than a child's
head, and  weighed nearly two pounds.  An  immense quantity of
fetid liquid, which had  been pent up, was thus also enabled to come
away, which gave great relief.  The ligature  on  the remaining neck
of the polypus came away two or  three days afterwards.   Though
it is not so stated, the inference is that this patient recovered.
   In remarking upon this case and treatment, Dr. Bullen judiciously
points out  the necessity of forcibly abstracting the tumor by torsion,
as above described,  as soon as  there are  any manifestations of the
dangerous  description mentioned.   The  retention of  the  natural
mucous  and  sanguineo-mucous discharges of the uterine  cavities 
822           NEW ELEMENTS OF OPERATIVE SURGERY.

and  passages, must necessarily endanger  their absorption, which is
the chief thing to be  dreaded,  and much more so than  the imme-
diate inflammation radiating from  the place of the  ligature.   Cases
in proof of this are given, and one (Provincial Journal, 1844) where
the polypus being left in the womb, caused engorgement  of  the fal-
lopian tubes with pus,  suppuration and  gangrene of the tissues near
the right ovary, sloughing of the uterus, adhesions of the peritoneum,
and, in  fact, all the local and constitutional phenomena  of typhoid
fever and uterine phlebitis  in their  most formidable shape.   The
polypous tumor was never abstracted, and  lay loose and detached
in the vagina, being the twelfth day from the operation.
   Dr. Bullen points out another very important circumstance  in con-
nection  with the difficulty ofthe diagnosis in these polypi.   Thus the
investing membrane ofthe tumor, by the deposition of coagulum lymph,
will  be found to have  become closely adherent to the lining mem-
brane of the dilated uterus itself, as well as to portions of the vagina,
with which it may be in contact.  This state of things may still more
strongly incline the surgeon to suppose at  first that the  disease in
question is  in fact a. prolapsed uterus ; and should the tumor slough
and separate, a more gross delusion may arise, and  lead to the sup-
position that it is the uterus itself which  has been  detached.  The
great purpose of the ligature  to  polypi  in the uterus, is, as we per-
ceive, not to wait for its action until it has cut through the enormous
pedicle, but in order to prevent hemorrhage when we proceed to ex-
tract the tumor by torsion.  As  an  evidence of the danger of  hemor-
rhage, in immediate excision  of uterine polypous tumors,  Dr. Bullen
instances several in which he has  seen it occur  after snipping off
merely those forms of  this tumor which are cystic, and united mere
ly by a  slender pedicle to some part of the lining membrane of the
cervix uteri, of which membrane these cystic polypi, which are filled
with a gelatinous fluid, appear to him to be nothing more than a sac-
culated  prolongation or hypertrophy.   The  actual cautery only, he
says, will arrest  the hemorrhage, but this is what will scarcely be
permitted by the patient.
   There is a third description of polypi of the uterus, which are ma-
lignant, and terminate fatally, and yet are not, in Dr. Bullen's opin-
ion, cancerous.  These are what he terms malignant, granular, or
tuberculous  polypi, sometimes called the  cauliflower polypus, and
which are distinguished by their great  vascularity and tendency to
profuse  hemorrhage,  producing great  exhaustion, but unaccompa-
nied with pain.  In their ultimate development, they assume all the
characters of Carmichael's malignant parasite.  Yet they are totally
distinct, Dr. Bullen  says, from true carcinoma of the uterus, in which
latter no one can  mistake the peculiar well-known acute, hot, and
lancinating pains, and  finally  the terrible, though slow destruction of
parts from the rat-bitten-like, jagged ulcerations, &c.  Nevertheless,
these cauliflower forms are frequently hereditary, or at least connect-
ed with a constitutional diathesis.  Thus he knew three married sis-
ters  of a highly respectable family near Cork, (Ireland,) who  all suc-
cessively died of this hemorrhagic  form of polypus, on reaching the
age  of 43 years.   Two ofthe three had children.
   In another, an extreme case of this kind, in a married  lady, aged 
POLYPI OF THE UTERUS.
823
30, Dr. Bullen, from the painful and distending pressure made by the
growth of the tumor, which finally filled up the entire uterine cavity,
and thus of itself arrested the  hemorrhagic discharges, was obliged
to have recourse to the silver wire ligature, applied through the can-
ula.  He thus brought away a basin full of the morbid growth, but
it was at the sacrifice of an immense and  dangerous loss of blood.
The surface of the substance was rough and granular, and  its tex-
ture very friable, and easily rubbed  down between the fingers, show-
ing a reticulated appearance like sponge.   It would be well,  as we
think, in such cases, always to  ligature a small portion at first, and
bring it  away, were  it only  to  aid  the  explorations and  diagnosis.
Dr. Bullen remarks that there were  also lobulated  aggregations of
small whitish opaque bodies, manifestly tubercular, thickly scattered
throughout the extent of this morbid mass, and interspersed with
distinct cavities containing transparent  hydatids.   The size  of the
masswTas greatly reduced  by its removal, showing that its great bulk
was chiefly owing  to the quantity of blood which it  contained.
However, this distressing disease again returned, and she sunk  from
loss of blood, both her mother and aunt having died with the  same
affection, before they reached the age of 40.  Whatever be the name
given, we cannot but look upon such forms of polypus, if that  gene-
ric designation in fact be admitted, as purely of Xhefungus hamatodes
character, such as are found in the breast and other regions.  The ap-
pearance of hydatid  cysts and encephaloid deposites in the so-called
cauliflower polypi, when they have reached their ultimate degeneres-
cence, does not make it necessary to exclude them from fungus he-
matodes, for however old fashioned this word, its import is well un-
derstood, and such bleeding, hypertrophied, and  almost painless tu-
mors, are much easier recognized by these  familiar epithets, than by
any presumed analogies to the more vague descriptions of disease
known under  the names of erectile  tumors, or vascular sarcoma.
Dr. Bullen, however, contends also  that these carcinomatous polypi
differ in toto, as they doubtless do, from  the florid warty vegetations,
which are often seen upon the  external lip of the  cervix uteri ac-
companying obstinate leucorrheas and certain forms of syphilis.  [Ra-
ther say, mercurialized syphilis. T.]   Dr. Bullen considers this form
of polypus as decidedly malignant, but as  not necessarily requiring
carcinomatoits ulceration or symptoms.of true cancer to make  them
fatal.   In the beginning, excision of the  neck of the uterus, as  this is
their special locality, might answer; but then the disease is so insi-
dious that it is completely marked  by (i. e., confounded  with) mo-
norrhagia.  In considering the point, whether in their advanced  stage
excision of the uterus would be justifiable, Dr. Bullen is  averse to it
under almost any circumstances, and naturally reverts to the fact of
the danger of such  an operation, and the growing aversion  to the
employment of the knife as a curative agent in any form of malignant
tumor.  Certainly  experience has given us too much reason  to dis-
trust its value under  such  circumstances, especially when we reflect
that daily accumulating observations go more and  more in confir-
mation of the ancient opinion, that malignant tumor depends  on  a
constitutional malignant diathesis, always existing, but developed at
a certain period; or as Dr. Bullen says," growths, essentially malignant 
824           NEW ELEMENTS OF OPERATIVE  SURGERY.
are malignant ab initio, or from their first development in the sys-
tem."  A fortiori, we would say to this surgeon, that we are car-
ried back for our  only refuge here, as well  as  in various other de-
partments of the art, to conservative surgery and the medical treat-
ment of local  as well as constitutional affections, hitherto deemed to
have been the monopoly of the scalpel.
  Dr. Bullen also quotes the recent report of Dr. Regnoli to the Sci-
entific Congress of Italy, to show that the average duration of life is
longer in such  cases, where they have been let alone, than where
extirpation  or the  knife has been appealed  to.  For out  of 250 in
whom cancerous  formations  had  been extirpated  by the  knife,
scarcely twenty had survived three years.
  The discussion on tumors at Paris, which we have elsewhere given
at length in  this volume, (see supra, under Tumors) also all resolves
itself into this one great conclusion, from which  there has  been  but
little dissent.  Of this result M. Cruveilhier, who first led off in this
important investigation, has much  reason to  be  proud, when he
reflects how great an acquisition this unanimity has already brought
to conservative surgery, and to the shielding of human  life from the
inhuman mutilations of the knife in the hands  of reckless and ig-
norant persons.
  Dr. Lever of London (Practical Treatise on Organic Diseases of
the  Uterus. Sec, which received the Fothergillian medal in 1843,) has
found, contrary to the general remark,  as many uterine  polypi that
were sensitive, as those that were not so.  He considers both polypi
and fibrous  tumors, which he makes distinct, more frequent  in  un-
married than in married persons.
  Mr.  H. Oldham  (Guy's Hospital Reports, April, 1844) has been
surprised to  find, that on injecting ordinary pediculated fibrous polypi
of the  uterus, the arteries were not  only of large  size, but far ex-
ceeded in their number that of the veins in the tumor.  The abundant
hemorrhages which such polypi frequently occasion, especially where
they are complicated with pregnancy, when  they may lead to dan-
gerous mistakes, is thus easily accounted for.  The  uterus  itself has
been ligatured for a large polypus, and thus  actually excised!  Mr.
Rigby informed Mr. Oldham of a case in which a fibrous polypus was
tied, when  on the  following morning  the surgeon  finding anothei
tumor  above his ligature, also tied that.  After the separation of this
supposed second tumor, a  cicatrix was found  above  at the upper part
of the vagina, but the womb was  gone !  Polypi consisting of small
cysts, containing viscous  matter, are, Mr.  Oldham  thinks, abnormal
developments ofthe ova of Naboth, or of uterine follicles.  To these
follicles in the neck  of the womb he also ascribes a new form of
uterine polypi, which he  calls canaliculated,  having a number of
elongated canals running  through their substance and  opening by
quite large orifices on their surface.  Most polypi he considers discon-
nected in their origin with organized clots of blood, but as growths
from the substance  of the uterus itself.   When  polypi in the womb,
by  their hemorrhage during parturition, give  rise  to apprehension,
they are to  be ligatured or exsected immediately.
  M. L. Boyer (Arch. Gen.,  Alay, 1844) recommends  a new knot-
tightener, or  rather sawing  ligature,  for exsecting polypi of the 
CANCERS OF THE NECK OF THE UTERUS.
825
uterus.   He calls the process sercision, (from serra,) and the  two
ends of the ligature, after this is adjusted, are drawn in such manner
in opposite directions by a  saw-like movement,  similar to certain
sports of boys, that the pedicle is rapidly cut through, and this tear-
ing process  (a species of torsion)  may, he thinks, even prevent as
much hemorrhage as in ordinary cases.
  A pediculated polypus  in the  womb,  to which  a part of the
placenta had become so  firmly adherent, with  perfect inosculation
of their respective  vessels,  that the  cord was  broken off in an
attempt  to  remove the secundines  after the birth of the child,  was
effectually detached by M. Aubinais, (Gazette Medicate, Paris, Sep.,
1844,) by  twisting  the polypus upon  itself, by which  means  this
foreign body, which  had  not it appears interfered with, but  rather
shared  in the process of utero-gestation, was immediately brought
away  together, with its  attached  placenta.  (See  also Cormack's
Monthly Journal, March, 1845, p. 243.)
  A large polypus of a fibrous character was recently expelled from
the uterus (Provincial Med. and Surg. Journ.;  also Edinb. Med.
and Surg. Journ., Oct. 1, 1845, p. 283)  by contractions ofthe organ
artificially brought on by ergot of rye.  T.]

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

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

                        § I.—Indications.

  The difficult point is to establish the indications clearly.   The
elongation of the neck from  simple hypertrophy, being an infirmity
rather than a disease, does not require it under  any circumstance.
Excoriations, ulcers, and syphilitic vegetations, not being  incurable 
826
NEW ELEMENTS OF  OPERATIVE SURGERY.
 in their nature, also, do not require it.  The# same remark applies  to
 indurations and  to lumps (bosselures) that 'are not  painful, whether
 they are accompanied or not with  chronic tumefaction, and which
 are  so frequently seen in women between the ages of 30  and 40
 years.  It is not  allowable, therefore, to have recourse to it except in
 clearly ascertained cases of cancerous degenerescence.  But it is pre*
 cisely  in this point that lies the difficulty ofthe question.   In fact,  so
 long as the cancer is not ulcerated, or does not  present itself under
 the  aspect of a tumefied mass in the upper part of the vagina, its
 diagnosis is extremely difficult.   The hardness, or natural consistence
 of the  neck, the varieties that it presents in size, prominence, density
 and form, according to the  age and various conditions under which
 the woman may have  been placed, exact  in the first place, a great
 deal of skill  to prevent  our sometimes apprehending  affections of
 which there is not the slightest trace.   Then again, how can  we be
 certain that we may not be deceived in  respect to  the nature of a
 lesion so profoundly situated in the midst  of a structure so compact,
 and  one  containing such  a variety  of elements ?   This is not all:
 though the presence of a cancer may  be unquestionable, we  have
 still  to determine  its limits.   Now it is rare that all doubts on this
 point are dispelled before the disease has advanced very far, and then
 we can scarcely ever be certain  that the  neck alone is affected, and
 that the  body of the  uterus is not already more or  less implicated.
 The surgeon therefore, is constantly placed between two difficulties:
 1. The fear of removing an organ which is not diseased, and of unne-
 cessarily performing a painful and dangerous operation; or, 2. That
 of removing only a portion of diseased structure, the remains of which
 will  inevitably result in death.  The natural conclusion from these
 remarks, is, that the formal proposition to amputate the apex of the
 womb, should be  rarely decided upon, and that it is not to be wonder-
 ed at that we  should still meet with intelligent practitioners who with
 Wenzel and Zang, seriously ask the question whether it can ever be
 advisable.  Since the question when this disease  exists in the breast,
has been deemed proper, what are the  advantages of extirpation,  it
 would  be difficult in fact that the same question should not be put when
the subject under consideration is the uterus.   The  reply, therefore,
that  may be made, is this, that while we admit  it to be reasonable to
extirpate external cancers, there  would be nothing  improper  in ap-
 plying  this operation to cancers of the genital organs when they are
under favorable conditions.   It is a consolation to know that in these
last cases the disease remains for a long  time local, and that it is in
 reality less liable  to repullulate on other points than in any other re-
 gion.  I do not, therefore, for my own part, consider that this opera-
 tion  ought to  be  absolutely proscribed.   Better undertake it than
 abandon  the woman to a certain  death, in  every case where the ex-
 tent  of the disease leaves  room to, hope that  we  may remove  it
 entire.

                              §11.

  The neck of the uterus may be attacked by three very different
descriptions of cancerous  degenerescence.  Sometimes the affection 
CANCERS OF  THE NECK OF THE  UTERUS.
827
proceeds by ulceration from its borders, or from its cavity towards the
substance  of its walls, and these ulcerations, which are sometimes
covered with vegetations and fungosities, penetrate quite frequently in-
to the interior of the womb,  and present the same symptoms nearly
as phagedenic (rongeant) cancer, and noli me tangere on the face or
mouth.  Sometimes, on the contrary, the  disease consists of an en-
cephaloid or scirrhous mass, which is developed in the  tissues of the
organ itself, near  its free portion, or on any other point of its tissue.
I have said above that  encephaloid masses, primitively developed at
the fundus of the  uterus, sometimes protrude through  the neck, and
show themselves  at the upper part of the vagina, under the form of
a polypus.

                      § III.—Cauterization.

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

                        §  IV.—Excision.

  In its natural state the free  portion of the neck  of the womb has
neither three, four, six nor eight lines in length, but in fact, sometimes
one and sometimes  another  of these dimensions, and without being
on that account diseased.   We may detach the vagina from the an-
terior lip to the extent  of more than half an inch, without incurring
the risk of opening into the peritoneal cul de sac, which separates it
from  the bladder; only, as  the bladder adheres quite  intimately to
its anterior surface, this  is the organ  which  may be then wounded
by the instrument.  Posteriorly the peritoneum not only lines the
corresponding  surface of the  uterus,  but descends down upon the
vagina to form the recto-genital cavity; in such manner, that in this
direction the bistoury  would only have to go to the  depth  of a  few
lines to open into it.  It must have been by inadvertence that M.
Avenel  (These, No. 80, Paris, 1828,) has said that there are but eight
lines of extent in  front,  and ten  behind,  between the apex of the
lips of the neck and the interior of the  abdominal serous membrane.
As this  is a  gross anatomical  error, I am surprised that  it should
have  been  again  committed  some years since,  (Gaz.  Med., 1833,
p. 21, and 1834, p. 387,) and that M.  Mury (These, No.  41, Paris,
1826,) should have  ascribed the  successes of M.  Lisfranc  to  this
discovery.
  A.  Operative Processes.—The mode of performing excision of the
uterus did not  suddenly reach  the degree of perfection to which we
find it at the  present day.
  I.  Osiander  began by passing two ligatures, by means of a curved
needle, through the  diseased organ, which latter he depressed  and
secured  in this manner, so as not to exsect it until  after having
brought  it  down  nearly to the vulva.   When he could not make it
descend, two fingers introduced into the rectum enabled him to ex-
cise it in its place; but the  invention of his hysterolome soon enabled
him to dispense with his ligature tractors.
  II.  Dupuytren, and  after him  most other operators, have substi-
tuted for the ligature of the surgeon of Gottingen, a very  long Mu-
seux forceps, the hooks of  which  are slightly curved, and by means
of which we are  enabled to embrace with facility the whole of the 
CANCERS OF  THE NECK  OF  tfHE UTERUS.
829
diseased portion.  As this forceps readily tears the tissues, and as it
is frequently useful to apply a second one, M. Colombat has had one
made with four  branches.   Others  have proposed to introduce into
the  womb,  through the opening  of the neck, an instrument which
might, in opening in  the  middle  of the organ, be transformed into
hooks, and  allow of our making  strong traction downwards.   The
most ingenious instrument of this kind is that of M. Guillon, (Soc. de
Mid, Prat., 1827, 1828, pp. 72, 73.)  Another, which is much more
complicated, has been proposed  by AL J. Hatin, and M. Recamier
has since invented a third.
  III. Speculum.—Osiander dispensed with the  employment of the
speculum.  With us, on the contrary, this instrument has almost al-
ways been made use of;  also a number of persons have endeavored
to improve it.  The one  which  AL  Recamier first proposed was a
simple  cone of tin.   Dupuytren  added a handle to it,  which  gives
more facility in its application.  The ancients had one which is found
figured  in the works  of  Pare, Joubert, Alanget, and Scultetus, and
which was composed of two valves which could be widened or ap-
proximated at pleasure.   That of Aladame Boivin, constructed upon
this principle, is formed of  two  halves of a cylinder, and has at its
large extremity a handle terminated by two rings, like a pair of for-
ceps.   It is introduced, shut up, in the vagina, and all that is neces-
sary is to act upon the two halves of its handle in an opposite direc-
tion, in order to open it in the manner of a scissors, and to dilate as
much as we desire the passage to be explored.  M. Lisfranc has had
one constructed which  differs from  the preceding only in this, that
its apex, which is somewhat flattened, is more elongated, also its
diameter greater and  its handle destitute of any rings.  In order to
keep it opened at such extent as we may desire, M. Guillon added to
it a stem or sort of slider, which,  being displaced by the finger when
judged necessary, immediately enables us to  shut it up  again.   The
same practitioner, with  a view to  avoid the pinching ofthe tissues, to
which we are more or less exposed with the ordinary jointed specu-
lum, has added  a third  piece when we have adjusted the instrument
in its place.  This piece is a plate which is glided from the base to
the point of the two principal halves of the instrument, upon a groove
which is found upon each of them on the inner face of their free bor-
der.  Not content with having a speculum with two branches, the
triple speculum, which  is also figured in the ancient works which I
have just mentioned,  has  been revived.   But as it  is the upper part
of the vagina, particularly, which we  have to  dilate,  MM  Bertze
and Colombat have contrived a speculum in  the form of a cone, the
base of  which is found  at the handle when it is shut up, and at the
other end, on the contrary, when it is open.  That of  M. Bertze is
composed of two  tubes enclosed one within the  other.   The inner
one, which  is divided into several rays in  its upper half, is disposed
in such manner  that its branches open  by their own proper spring,
as soon as we free them by drawing towards us the  piece which
serves, so to speak, as their sheath.   Eight pieces  compose that of
M. Colombat, and form in their ensemble a hollow cone, the point of
which is opened or contracted to a greater or less degree When the
instrument  is in its place, by means of quick screws placed at the 
830
NEW ELEMENTS OF OPERATIVE  SURGERY.
two extremities of one of the great diameters of its  base.  When
open this instrument represents a sort of grillage, the same as is seen
in the speculum of Duges or AI. Alayor, and which enables us to see
at the same time both the neck of the uterus and the interior of the
vagina.  Of all these  varieties of speculum, that which Alad. Boivin
suggested,  (Bull,  de  la Fac.de  Med., X. VIL, p. 349,) but which
has undergone remarkable improvements since, appears in my judg-
ment to  be the best.  The only inconvenience  which  I find in  it, is
that  of allowing  the  mucous membrane of the vagina to become
caught between its borders, and of exposing to the risk of pinching
it when it is shut  up.  But  this inconvenience, which the  proposed
modifications have as  yet but very imperfectly  remedied, exists to a
much  greater degree in the speculum with three branches of AI.
Hatin, in that of M. Colombat, and even in that of M. Bertze, all of
which, moreover, may wound the organs  by their point and are far
from  reflecting the light with as much advantage.  Under this last
point of view, the original  speculum or simple cylinder is still the
most commodious, without even excepting the cribriform or perforated
speculum contrived by AL  Ricque.   At the present  day  we have,
moreover, the speculum of AI. Galenzowski, (Journ. des Prog., X. V.,
p. 237.) which differs from the ordinary speculum only jn having a
cylinder  or cap of ebony, which is adjusted upon it in order to intro-
duce  it, and which speculum AI. Melier (Mem. de I'Acad. Roy. de
Chir.,) considers  as the best; also we have the speculum of Lair,
(Arch. Gen. de Med.,  t. XVIL, p. 141,) that of M. Jobert, the specu-
lum of M. Ricord,  that of M.  Sirhenry, those of M.  P. Dubois, (Ibid.,
t. XXIL, p. 278,)  M. Moreau, M. Clairat, and M. Charriere, without
counting the vibratory speculum of M. Duparcque.
  IV. As to the  cutting instrument, properly  so called, many de-
scriptions of these also have  been made use of.  Dupuytren, for ex-
ample, frequently made use  of a sort of scoop  or trowel, somewhat
concave, and  having a cutting edge  only on  its upper extremity,
which is  convex, and  of a semilunar  form.   By means of a circular
movement this blade will divide the neck at the bottom of the specu-
lum ; and it may even be made, if  necessary,  to penetrate into the
womb, so as to hollow out this organ in the manner of a cone.  M.
Hatin has applied  to  the stem of his principal  instrument, a forceps
terminated by two cutting extremities, like the spoon-shaped  forceps
of F. ab Aquapendente, or that of Lobstein.  The erigne forceps of
M. Colombat has  combined with it a  stem, upon  the  extremity of
which is situated  a small blade placed transversely, which may be
elevated or depressed by means of a particular apparatus, and which,
when turned upon  this stem, smoothly cuts the entire circumference
of the neck above the prongs of the  erigne.   The  hysterotome or
secator of M. Arrhonson, (Ibid., X. XXIL, p. 278,) would be at the same
time more simple and more convenient, if instruments of this kind could
be substituted for the bistoury in an operation of this description.
  V. Even the ligature, as mentioned by Lazzari, and which might
in fact be applied, has also had its advocates.  M.  Alayor thinks,
and  not  apparently without  reason, that  by introducing above the
disease a silk ligature with his conducting instruments, the neck of 
             CANCERS  OF THE  NECK OF  THE UTERUS.          831

the womb might afterwards be readily  strangulated by means of his
chaplet constrictor.
  VI. Finally, all these modifications ofthe operation may be classed
under two methods, One which consists in making the neck descend
as low as possible before excising it, and the other, which gives the
preference  to excising it in its  natural position.  This last at first
sight seems much more advantageous than the other in this respect,
that it protects us from all kinds of traction or laceration.   Never-
theless, it is less convenient, in the first place, because it does not al-
low us to ascertain with as much precision the condition ofthe parts,
nor to penetrate  as far or with as  much  security in  the direction
towards the womb, and in  the  last place, because it is from this
circumstance evidently more  difficult  of application.  It does  not
therefore deserve the preference, except in those cases in which the
uterus is too firmly fixed to enable us by the most judiciously direct-
ed tractions to make it descend  into the lower strait.  In the  first,
there can be no longer any question about the  threads of Osiander,
since we have known how to modify in a proper  manner the erigne
forceps.   The speculum also, of whatever description it may be, ap-
pears to me to be much more embarrassing than useful. _ The hooks
ofthe instrument, guided by the fingers ofthe left hand, may always
be placed around the neck without much difficulty.   If it should be-
come advisable  to  increase their number, in order to prevent any
laceration, it is better to imitate Dupuytren, and place a second Mu-
seux forceps above or upon the opposite side of that of the first.   As
the straight bistoury wrapped in a band may be  conducted to a suf-
ficiently great depth in the  vagina, it has appeared to  me to be as
useful as any other instrument.  I have no necessity of  remarking,
that  the tractor instruments which open themselves in the interior of
the parts, would in most cases be dangerous, and that they ought to
be absolutely rejected.  When we are  obliged to excise the neck of
the womb without displacing it, it is difficult to dispense with the
employment of the speculum.   As  we require  as much space and
freedom as possible, the jointed speculum is then the only one which
could fulfil the intentions of the surgeon.  It would be  in such cases
also  that we  might, if  necessary, make use of the scissors that are
slightly curved, the  cutting ring, the scoop of Dupuytren, or the bis-
toury which is concave on one of its flat sides near its extremity.
  VII. Operative Process.—The woman is placed in the same  way
as for cauterization.  One assistant supports her  head and arms, two
others attend to her lower limbs, and a fourth hands the instruments
as they may be required.
  a.  Introduction of the Speculum.—The surgeon placed in front of
the vulva, begins with the introduction  of the speculum, if he has de-
cided upon using this instrument.   After having besmeared it  with
cerate, he glides it gently into the axis  of the pelvis, resting it chiefly
upon the posterior commissure of the pudendum  at first, directs  it in
this manner to the seat of the disease, and  inclines it more or less in
front, posteriorly or to one side, according as the neck presents it-
self more or less perfectly at its extremity; and on  the  contrary
opens it  if it is jointed, in such manner as to dilate the vagina  com-
pletely, and to expose the whole extent of the mischief.  Upon the 
832           NEW ELEMENTS OF OPERATIVE SURGERY.

supposition that he wishes to leave it in its place to apply the forceps,
he immediately causes it to be held by an assistant until he has accu-
rately adjusted them.  He then withdraws  it, and it is at this mo-
ment particularly that the jointed speculum  possesses an  advantage,
by allowing the forceps to be readily  disengaged from it above.
  b.  If  the operator dispenses with the speculum, two fingers  of his
left hand are first introduced  into the bottom of the vagina, where
they are to remain, after having recognized the form  and extent of
the cancer.   He  then  conducts the forceps, shut up, upon their pal-
mar  surface, opens it on  reaching  the tumor, and applies it  as high
up as possible, in  such manner that its hooks may be implanted on a
sound portion of  the neck.   By means of this forceps, which should
be inserted by pushing rather than  by drawing upon it, he endeavors
to make the  organ descend  into the vulva.  In place of effecting
these tractions with the two hands, it is  better to employ the right
hand only, acting all the  while in the direction of the axes of the pel-
vis, and to make use of the  fingers of the  left hand to protect, without
ever  letting go their hold upon the hooks of the  instrument.  If he
perceives  that these hooks  have lost their hold,  or that the parts
embraced by them have  a tendency to become  lacerated,  he imme-
diately applies a second forceps on the opposite part of the diameter
of the neck, after having charged the  assistant to hold the first.
  c  When the parts are  brought out he  cautiously separates the
sides of the vulva ; gives the tractor instrument or  instruments to
one of the assistants, and having seized the bistoury which has been
prepared applies it first on  the right  side and always above the dis-
ease, brings it in  front and then to the left, or might also make the
section ofthe parts from behind forwards and from left to right.  If
the disease should not  appear to be accurately defined, he should
attend to the adhesions of the vagina and  destroy them, little by little,
in such manner as to remove not only the os tineas but also the upper
portion ofthe neck, and  to hollow out the lower part  of the womb
itself in the manner of a cone,  upon the  supposition that this should
be deemed necessary.
  d.  As soon as  the excision is completed, the fundus of the  organ
mounts  upwards and resumes its natural  position.  If any remnants
or tubercles of the cancer have been left behind, we must re-intro-
duce the speculum, grasp them with the forceps, and immediately ex-
cise  them, or we may destroy them by means of caustics.
  VIIL Subsequent Treatment.—When there is no hemorrhage, there
is no necessity of  any dressing.  We confine ourselves  during the
first  days  to injections of tepid  or cold water.   Nevertheless I could
see no inconvenience in  gliding in upon  the bleeding surface a fine
piece of  linen in the form  of a chemise, to be lightly filled  up
with small balls of lint.   If the blood  flowed in too great abundance,
this  chemise would give a great degree of facility to the tamponing,
and  would expose to no dangers which could not be immediately
remedied.
  The dangers  of excision of the uterus  arise from:  1.  Hemor-
rhage, which M. Pauly  (Malad. de F Uterus, pp. 446, 447, 448, 451,
453,454) has seen take place in seven instances out of thirteen cases,
and  result in death in  three  women  at  the end of a  few hours;  2. 
CANCERS OF  THE NECK  OF THE UTERUS.
833
Peritonitis, which  also frequently  occurs;  3. Phlebitis, which has
already been observed in several  instances ;  4.  Purulent inflamma-
tions in the pelvis ; 5. Perforation of the peritoneum, rectum or blad-
der ; 6. A return of the disease.
  IX.  Appreciation.—Up to the present time I have performed ex-
cision of the neck  in but eight  instances, and  for that purpose have
required nothing more than Museux's  forceps, a knife, curved scis-
sors, and a straight bistoury.    In the first woman the whole of the
neck was diseased, and the operation was prompt, easy and attended
with but little pain.  A certain quantity of blood was  discharged,
which  was checked by the use of simple  means.   She died, however,
on the third  day, but we  found, on opening the body, neither perito-
nitis nor other appreciable lesion.   The rest of the uterus was sound,
but there was a small cerebriform mass upon the  right of and behind
the vagina.   An opening also,  of two lines in extent, was found on
this wall of  the vulvo-uterine passage, and communicated with the
recto-genital cavity.  Was this  produced by the operation, or  did it
depend on the manipulations used in the  autopsy?  This is what we
could not ascertain, but we clearly satisfied ourselves that no matter
had been effused through this opening.  In the second case, finding
some difficulty in bringing the cancer down, I introduced without any
great degree of difficulty, above its situation and at two inches depth
in the vagina, the straight bistoury wrapped  in a bandage, and gui-
ding it upon  the palmar surface  of the fingers of my left hand, in this
manner terminated the operation.  This patient, who at first appeared
to be  doing  well,  died  at  the expiration of six weeks.  She  had a
number of cerebriform masses in the lumbar  region, and also in the
substance of the broad ligament on the right  side.  I proceeded in
the same manner with the third patient,  about the close of the year
1832, at the  hospital of  La Pitie.  The  top of the neck formed an
encephaloid  mass of a mushroom appearance, which  was as  large
as the  half of the  fist.   No accident interrupted the cure, and the
woman, who was perfectly restored, came to see me a year after to
know if she  could  resume her conjugal  duties without  any danger.
In the fourth, fifth,  sixth and seventh cases, there  was a return of the
disease.  The eighth woman, whom I operated upon at La Charite,
in 1836,  was cured without any accident, but it is not certain that
the tumor was a  cancer.  None  of them had any serious hemor-
rhage.
  A. A patient operated upon by AL Blandin, died  of uterine phle-
bitis.   MAI.  Rust and Graefe at Berlin, and M.  Roux and Dupuy-
tren, have also seen death take place in some instances from the im-
mediate consequences of  the operation.   Excision ofthe neck ofthe
uterus, therefore, though easy and in many  cases unattended with
serious consequences, is  nevertheless in some instances dangerous
and speedily fatal.   From the considerations, moreover, which  have
been laid down in the beginning of this article, it would seem that it
can but rarely be successful.  It has however  been greatly extolled,
and Osiander has performed it 28 times, Dupuytren from 15 to 20,
and M. Lisfranc from 40 to 50.   Women who have been submitted
to it, have been enabled  to become pregnant, and have been deliv-
ered once or oftener without  accident.  Dupuytren even  relates
                              53 
834           NEW ELEMENTS OF OPERATIVE SURGERY.

cases in which he was obliged to  operate a second time, in conse-
quence of a return ofthe disease, but which were nevertheless cured.
Finally, it is asserted that in the great majority of cases the cure has
been  radical.
  B.  Without examining in this place whether, since excision of the
neck of the uterus has been employed in practice, it has not been
quite  frequently had recourse to when there  was no cancer as  some
persons have maintained, I will confine myself to remarking that Du-
puytren, who, so to speak, introduced it into France, ultimately re-
jected it;  that M. Lisfranc also appears to perform it less frequently
than formerly; and that  Osiander himself, according to  M.  Heisse,
no longer made use of it for some  time before his death.  The two
examples related also by M. Stoltz, are but little  calculated to pre-
sent a very favorable idea of it.  Of the six patients operated  upon
by M. Cazenave, (Bull, de  FAcad. Roy de Med., X.  I., p. 930,) four
died, one only was cured, while the sixth  was in  good health at the
moment at which he wrote.  Moreover, a report which was  first in-
distinctly circulated on this  subject, has ultimately made its  appear-
ance in scientific  works.  Thus M. Krimer, (Revue Med., 1835, t. III.,
p. 254,) asserts that excision of the neck of the uterus has never suc-
ceeded when the  disease was an actual cancer; that  at  Paris every
body  is under  a delusion  on this subject; that a lady who was given
out as cured to the learned societies and journals of  medicine, never
has been cured, while M. Pauly, (Mai. de F Uterus, 1836, in  8vo. of
536 pages,) sustained by MAI. Carron du Villard, Treille, Duparcque,
&c, holds precisely the same language !  M. Lisfranc, who is  espe-
cially implicated  in this matter, and who states that he has succeeded
in 84  operatians  out of  99, (Gaz.  Med., 183 4, p. 389,) must, if his
former assistants  are  to be  believed, have recklessly (effrontement)
abused the public, the physicians, and the academies, in citing as cured
a naober  of  women  who  died;  in  exaggerating   to  twice  their
amount the number of his operations; in amputating as cancerous
the neck of the womb when it  was scarcely diseased ; and  in being
guilty, we must confess it, of actual atrocities, (atrocites,) if the ac-
cusations against him are true.   The facts enumerated by M. Pauly
are moreover so  precise, so  numerous, and apparently so conclusive,
that the feelings are outraged by them, and that it must ever appear
extraordinary  that M.  Lisfranc  has never  disavowed them.  Per-
ceiving that AL Pauly is deceived in relation to what concerns my-
self, I am on my  own part disposed to  think that he  errs also in re-
gard to his former preceptor, but the honor of M. Lisfranc,  and his
regard to truth, (sa moralite,) imperiously demand an explanation on
his part of so grave a question.
  C.  Reducing the operations  of M. Lisfranc  to 47 for  example, in
place of 99, M. Pauly finds at least thirty failures.   In  a list of 23
successful cases,  deposited at the Institute, and which  this  physician
has examined, he finds that  three were repetitions, 9 supposed cases,
2 cases of excoriations that were merely cauterized, 2 excisions of
small polypi, 2 cases of return  of the disease, and three or four only
of actual success !  Out of  14  operations which he himself was wit-
ness to in the  practice of M.  Lisfranc, from January 1st,  1833, to
January 1st, 1836, M. Pauly affirms that one only probably was fob 
EXTIRPATION OF  THE UTERUS.               835
lowed with success !   It must be confessed that if such assertions are
false, M. Pauly is highly culpable, he especially the favorite  (partic-
ulier)  pupil and  confidential secretary of M. Lisfranc!   But also,
if they are true, what a  disgrace to the profession, and by  what
name should we  characterize the author of such crimes, (mefaits ?)
  D. In fine, I would not recommend that  the  neck of the uterus
should be excised for simple ulcerations, if it  is not in a cancerous
state.   I am aware that in cases of cancer the disease  may repullu-
late ; that when  it is not possible to remove the whole it  had better
not be meddled with; that errors  have been committed under
this double  point of view; that men with a usurped  reputation and
trampling under  their feet the laws of humanity, have  dared to jus-
tify in some  instances the acts  reprobated by M. Pauly ; but  I do
not grant that this operation in itself is as brutal as has been asserted,
nor that when it  is performed under  the conditions indicated above,
it  ought  to  be any  more proscribed than amputation of  cancer-
ous tumors of the breast, testicle, or in fact  any other region; it is
the abuse of the  operation, and  not its use which we ought  to con-
demn.

           Article  X.—Extirpation of the Uterus.

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

                    § I.—Prolapsed Uterus.

  In the additions of Bauhin to the works of Rousset, we find nine-
teen cases  which in  part justify the boldness of the  physician of
Ephesus,  and Schenck relates a  still  greater  number, but which all
have reference to prolapsus of  the womb.  Nevertheless, inasmuch
as among the cases  which are described, there is a considerable
number of  them which are deficient in the  necessary proofs  and
details, they  have  possibly been rejected  without  examination.
Rousset exhibits  so much want of good faith in his work, and Bauhin
and Schenck appear to be so credulous, that we are naturally induced
to distrust their testimony.  How can we believe that the  uterus was
removed  in the  woman mentioned by Plempius, but who neverthe-
less afterwards became pregnant; or how believe in the case of
another who, according to Plater, retained her venereal desires and 
 836           NEW  ELEMENTS  OF OPERATIVE SURGERY.

 continued to have  her catamenia?  Or in a third  case cited by
 Schenck, from Carpus, or in that mentioned by Morgagni, from Wide-
 mann, and in both of whom Were presented the same phenomena?
 Will Vieussens, who  gives  the  details of  an autopsy in a woman
 from whom  he removed  the  uterus fifteen years before, produce
 greater conviction in the mind  because we find him asserting that a
 remnant of the organ had been  left at the bottom of the pelvis ?  The
 case of a certain Pierrette Boucher, who was operated  upon  three
 years before, and whom Rousset disinterred  three days after her
 death and opened in the presence of a physician and midwife, whom
 he does not name, could it  be any other  than a tale invented for
 pleasantry?  Nevertheless it is an incontestable fact  at the present
 day, that the ablation of the prolapsed uterus has been performed in a
 number of instances, and that  in certain cases the women have sur-
 vived.  Without speaking of the  instances cited by Moschion, Aven-
 zoar, Rhazes, Mercurialis, Woega, Fernel,  and Benivenius, (Bonet,
 Corps de Med., X. IV., p. 599,)  &c, we find one in Pare which can-
 not admit of a  doubt.   The operation took  place in 1575. on King's
 day, and  the woman did  not  die until three months after, and of
 another disease. Upon opening the body Pare was enabled to prove
 the absence ofthe uterus, and he remarked as a beautiful arrangement,
 that nature had done nothing  more than construct, in place of the
 extirpated organ, a simple induration at the bottom of the  pelvis.  In
 this point of  view we may classify the facts that are known in  rela-
 tion to the extirpation of the displaced  uterus, under  two principal
 heads; in one there has been a simple prolapsus of the organ, while
 the others relate to its inversion.
   A. Prolapsus.—Among the first are to be reckoned, as I consider,
 the case of  H. Saxonia, in  which it  is perceived that a servant
 woman of Venice tore  out herself her  prolapsed  uterus; those of
 Paul of Leipsick, Cohauzen, Tencel, Goulard and Blazius;  and those
 even that Laumonier in 1784, Clark, Vanheer and A. Hunter in 1797,
 and that  M. Hosack, and M. Galot of Provence, in 1809, have since
 published.  If all these facts could not be received  as authentic, or if
it  should  seem evident that  Laumonier  and Bardol, among others,
have only removed  a polypus in place of the entire womb, the same
 conclusion no longer applies to  M. Galot, (Bull, de  la Fac. 5th year,
 p.  15,) who transmitted his specimen  to the Faculty of Aledicine at
Paris, nor to  M. Marschall  of Strasbourg who, upon the death of the
woman ten  years after, had an  opportunity of verifying upon the
dead body the  absence of the  uterus.   AL  Langenbeck, moreover,
 (Bull, de Fer.,  X. XVIL, p. 72,) performed this operation with suc-
cess in 1813.  Nor can the case of Fodere, published in 1825, or that
of MM. Recamier and Marjolin, (Revue Med., X. IV., p. 392; Arch. Gen.
de Med., X. X., p. 88,)  that of Delpech and that of AI. Bellini, (Mem. sur
FAmput. de FUterus. Broch., 1823,) admit of the least doubt  on this
subject.  The prolapsed uterus, therefore, has been in several instan-
ces detached from the body without causing the death of the woman.
   B.  Inversion.—In the second class, which also comprises doubtful
facts and such as have a greater  or less degree of  authenticity, is to
be included the case of Ulm, who states that a midwife, after Tiaving
inverted the uterus by drawing  upon the umbilical cord, removed the 
EXTIRPATION  OF THE UTERUS.
837
 organ with one cut ofthe razor; the other fact also, almost in every
 respect similar, except that the woman got well, which is related by
 Bernard;  a third of the same character, mentioned by Vrisberg ; that
 by Viardel; a fifth published by Caille and obtained in the Bas-Poitou;
 that published by Anselin of Amiens, and in which he himself removed
 the inverted organ; in a word,  to this class belong the cases of R. Bax-
 ter, Miillaer, Jean Miiller and Sorbait; those related by Figuet of Ly-
 ons, and Faivre of Vesoul; and that in which it is asserted that Desault
 excised  a portion of  the fundus of the inverted uterus, while remov-
 ing a polypus.   Without enumerating the cases of Gattinaria, Beran-
 ger de Carpi and Fonteyn, quoted  by M. Dezeimeris, we must add
 also to this list those  taken from the practice of MM. Chas.  Johnson,
 (1822,) Newnham, (Journ. Univ. des Sc. Med., September, 1818,)
 Windsor,  (1809,) Rheineck, Davis, Chevalier, Weber, Gooch, Cor-
 deiro, &c.
  I. Partial Inversion.—There is a kind of  inversion which has not
 sufficiently attracted  the attention of surgeons ; it is that which takes
 place partially only.   We then perceive  in the vagina a firm elastic
 pyriform tumor, which readily bleeds and is terminated above by a
 pedicle of an inch or two in diameter, and which  conveys the idea
 of. a fibrous polypus,  and is ordinarily accompanied with intermittent
 hemorrhage, a sense  of drawing down in the  loins and groins, and by
 a feeling of weight upon the fundament.  It is distinguished  from
 polypus  by its  velvety aspect, its reddish or violet-like color, its neck,
 which the orifice of the attenuated uterus encircles in the manner of
 a ring, and by the void which  the fingers introduced into the rectum
 or the Hand applied  over the  hypogastrium, while other fingers are
 introduced into the upper part of the vagina, find to exist in the place
 which should be  occupied by the womb.  This malady,  from its
 coming on in some instances without the  wOman being  conscious of
 it, or without any previous accident, cannot be recognized until after
 the expiration of several months or even of a year.   It is not always
 then easy  to distinguish it from a polypus, notwithstanding the signs
 which I have just given.  The  proof of this I saw in 1836, in a lady
 24 years of age.  Since her delivery, nearly three years before, she
 had been constantly  annoyed  by losses of blood, which were some-
 times small in  quantity and at other times .abundant.   Some of the
 surgeons of the country had at  first supposed it to be an inversion of
 the uterus, but the others finally came to a decision that it was a poly-
 pus.   This lady, having come to Paris, consulted several practi-
 tioners, who all adopted this last opinion.  Its  extirpation  was de-
 cided upon, when I in my turn was requested to see her.  Having
 entertained some  doubts, I repeated  the examination of the tumor,
 which was of the size of an egg, and had the density, elasticity and
 form of a  fibrous body descended into  the vagina.   Having placed
 my hand on the hypogastrium, and the forefinger as high up  as possi-
 ble in the  rectum, while with two fingers of the other  hand I em-
 braced the neck of the tumor, I was enabled to satisfy myself that
 there was nothing in  the usual  place occupied by the womb, and felt
 authorized in asserting that the case in question was one of inversion
of the  uterus, instead of one of polypus.   The event demonstrated,
as will be  related farther on, that this diagnosis was correct.  In a 
838
NEW ELEMENTS OF  OPERATIVE SURGERY.
case precisely similar, which A. Petit (Soc. de Sante de Lyon, 1798,
p. 103) and the  surgeons of the Hospital of Lyons had supposed to
be a polypus, Rey placed on the neck of the tumor a  ligature which
caused such acute pain that he did not dare to continue the operation.
The woman died a few days after, and an autopsy of the dead body
showed that the case was one of inverted uterus.  The embarrass-
ment is sometimes so much the greater from the fact that polypi of
the uterus may dilate and gradually attenuate the neck of this organ
by dragging down the fundus  and  inverting the entire body of  this
organ.  I have already related  an example of this kind, verified at the
opening of the  dead body, in  treating of polypi, and I met another
in 1839, in a woman who also  died of peritonitis.   If no variety of
polypi exhibited a velvety appearance, or emitted  from its surface a
sanguineous exhalation, in the same manner as does the proper tissue
of the womb,  we might  perhaps  obtain more authentic signs by
means of the speculum than by the  touch.  A tumor however which
is velvety,  of a reddish  color, bleeding, destitute of prominences,
pyriform, surrounded above  by a circular groove  like a cul de sac,
sensitive and painful upon pressure, while at the same time there is
found to be a void in the place  that the uterus occupies, must be con-
sidered to be an inversion of the uterus and not a  polypus.  Incom-
plete inversion involves accidents of a more serious character than a
prolapsus or a descent of the womb, properly so called.   The repeat-
ed hemorrhages which it occasions  gradually exhaust the  woman
and ultimately terminate  in death.   The patient  cannot get up or
take the slightest exercise without being threatened with syncope, or
without feeling a sense of weight and, traction, which soon give them
cause for alarm.  A lady whom I frequently saw  with M. Marjolin,
in 1836, was in this condition after four years of suffering; this lady,
who was pale, ancemic and  already attacked with swelling of  the
feet, though in other respects in tolerable  health, could not rise from
her bed, and was constantly troubled with a sanguineous or leucor-
rheal  discharge.  Having returned to her  province without  having
been benefitted  by our treatment, she continued there in  the same
state, and  I have heard nothing further from her since the year 1837.
Should the  accidents which  partial inversion  produces be of trivial
character,  or  allow of the woman taking some exercise,  and of
attending to some of her occupations, we ought to confine ourselves
to the palliative  treatment, that is to say, to a mild diet and astringent
injections,  or even the use of a  saucer  or gimlet-shaped pessary.
Under opposite conditions  there are grounds for attempting a radi-
cal cure.
  a. Reduction.—The diagnosis  having  been once clearly  ascer-
tained, it would  appear that the first  indication to  fulfil should be to
reduce the  tumor and return  the organs to their natural position.
Experience, unfortunately, has  too frequently proved, what  reason-
ing moreover would point out,  that this reduction  is almost impossi-
ble, and that it would not always be  prudent  to attempt it.   In  the
first hours or days which succeed to  a uterine inversion, we might hope
for success in attempting reduction, because then the inverted portion
is still supple, and  the  neck through  which it has protruded is  not
contracted and indurated to such degree as absolutely to prevent its 
EXTIRPATION  OF THE UTERUS.
839
reascension.  At a subsequent period,  and after several months  or
years have passed, we can no longer hope for such a condition  of
things.  Now the tissue of the womb has adapted  itself to its new
form and its new position.  Its mucous surface has assumed the di-
mensions of its former external surface, while this latter has become
contracted within in such manner as no longer to represent anything
more than a cavity of very small extent.  The neck contracted upon
itself, has become too narrow to admit of the  return of the body and
fundus of the uterus, which are below it.
  b. Removal &f the tumor.—Consequently, in order to cure a wo-
man at this period of her disease, we have no other resource left than
ablation or strangulation of the tumor; this operation, therefore, then
becomes a modification of that of extirpation ofthe uterus.  Whether
we make use of the  ligature, or have recourse to excision, the opera-
tion has always appeared to be of so dangerous a character, that but
few surgeons have had  the courage to undertake it.  If we strangu-
late the tumor in the same manner as a polypus, by one of the pro-
cesses pointed out above, we have to  make so powerful a constric-
tion, and one that is protracted to so long a period  of time, that it is
soon succeeded  by  excruciating pains, nervous symptoms, or even
convulsions, and sometimes by a fatal peritonitis.   In cases of ex-
cision, the hemorrhage may be of a frightful character; as we open
the peritoneum, peritonitis is still  more to be apprehended than in the
preceding case ;  the blood retained in  the vagina may pass into the
abdomen, while the  intestines may protrude  in  the  direction of the
vagina.   Unfortunate  cases,  taken  from  the practice of  several
celebrated surgeons, may  be adduced in support of these assertions.
We should go too far, however, in supposing these operations always
fatal.   The  young lady of Chateauroux, whom I  have mentioned
above, is a proof of  this.  I grasped the tumor with an erigne  for-
ceps, which  I placed in  the charge of  M. Rivaille,  the  family phy-
sician of the patient, and who officiated as my assistant.  Two fin-
gers of the left hand introduced  in advance, served  me as a guide
for  a long curved knife,  with which I divided layer by layer  the en-
tire neck of  the organ, in such manner as to  leave  nothing of it be-
hind but the part which was embraced by the neck  of the  uterus.
The finger being introduced through  the wound, entered freely into
the  peritoneal cavity, and could distinctly feel the intestines.  It was
easily perceived immediately afterwards, that the totality  of the
body  of the uterus  had been removed, and  the specimen which I
have preserved for a long time, has left no doubt on this point in the
minds of those who  have examined it.   The  hemorrhage was slight,
but  excruciating  pains, cramps, and an extreme degree  of agitation
with syncopes, which soon  came on, continued with so much inten-
sity during the space of three days, that we  had  entirely given  up
our  patient in despair.   Opiate  preparations internally and exter-
nally,  mercurial unctions upon the lower pari of the belly, Seltzer
water, and the potion of Riverus, administered  for the nausea, ulti-
mately succeeded in calming all these accidents, so that in less than
a month the cure was complete, and has since remained permanent,
though the operation took  place in 1836, (Thouret,  These, No. 345,
Paris,  1836,  p. 20.)   The only circumstance which has sometimes 
 840           NEW ELEMENTS OF OPERATIVE SURGERY.

 still caused anxiety in the mind of this lady, who has never known
 what was removed from  her, is that  of no longer having her cata-
 menia !   A case almost in every  respect similar, belongs to  M. Las-
 serre, (Arch.  Gen. de Med.,  2d ser., t. VIIL, p. 395^)  Operated
 upon eighteen months after  delivery, the  ligature was first placed
 on the neck of the tumor, which resulted  in producing excessively
 acute  pains.   The surgeon then proceeded to excision;  new acci-
 dents supervened, but the woman ultimately recovered.  A similar
 operation performed about the same  time  in England,  by M. Blox-
 ham, (Gaz. Med., 1837, p. 122,) caused the same agonizing pains, but
 ultimately resulted  also in a cure. It was the graduated ligature, and
 not excision, that this surgeon made use of.  A.  Petit (Soc. de Stmt.
 de Lyon, 1798, p. 209)  affirms,  however, that an experienced sur-
 geon, mistaking an inversion of the uterus for a polypus, strangulated
 and successfully effected the separation of the tumor, without .occa-
 sioning any severe accidents.   If it should seem  surprising  that so
 many  accidents  supervene in consequence of  the  excision of an
 everted uterus, while the extirpation of the uterus, in its natural posi-
 tion, or entirely prolapsed  from the  pelvis, does not always produce
 the same results, I would remark that in partial inversion, the instru-
 ments and ligature  are necessarily applied  directly upon the tissue
 of the uterus itself, and  that in cases  of  this kind, the women who
 have been delivered only some months or some years before, are of
 necessity still young.   Those two cases which I have  met with, were
 of the ages of  24 and 26 years.  As  to  the choice  to be made be-
 tween extirpation and the ligature, this must necessarily be embarrass-
 ing in the present state of our knowledge upon this subject.   Stran-
gulation appears to be  constantly followed with  excruciating pain,
 but the hemorrhage which may succeed to  simple excision, has also
 something in it of a frightful character.  It is true however that I did
not find this take place in the patient of M. Rivaille, and that in fact
we cannot in this region divide any vessels of very considerable size.
 This is a question therefore which in  all its relations should be re-
examined and re-investigated.   The manual of the operation, more-
over, whatever may be the process we adopt, is the same as for po-
lypi, or the extirpation, properly so called, ofthe  displaced uterus.
   II. Complete Inversion  and Protrusion  of the  Uterus.—If  all
attempts at reduction have failed, and the disease appears to threaten
the life of the patient, we may have recourse to  the ablation of a
uterus which has descended outside of the  vulva ; but we must not
forget that the  pure and simple prolapsus of the womb is rarely fatal;
that it may constitute nothing more than an infirmity ; that it has in
several instances been susceptible of pregnancy, as is proved by the
case related by  Marigues of Versailles and that  of M. Chevreul;
that in most cases the general health scarcely suffers;  and that there
should be  a degenerescence and morbid condition, which are in them-
selves dangerous, to compel the surgeon to adopt  a decision  of this
kind.   Its inversion after the expulsion of the fostus is in general so
easily remedied, that it cannot, except  in  rare cases, require  the in-
terposition of so  dangerous an operation.  Nevertheless, should the
woman have  been badly  treated, or  should brutal or ill-directed
manipulations have brought about a state of gangrene or disorganiza 
                 EXTIRPATION  OF THE  UTERUS.                841

tion in the uterus, so that there  could no longer be  any possible
hope of replacing  or preserving  it, its ablation  would  be a final
resource, which we should be wrong to deprive ourselves of; not
losing sight, however,  of the fact, that the women mentioned  by
Blasius, F. de Hilden and Ulmus, as having  been operated upon by
midwives,  died in consequence  thereof; that  the  same result took
place in  the patient  of M. Wolf, (Journ. de Graefe et Walther, vol.
VIL, p.  482;) that the patient of MM. Recamier and  Marjolin survi-
ved only two months;  that an  unfortunate woman received  in La
Charite,  in the month of July, 1824. and in whom the inverted  womb
had been by mistake constricted by a ligature eight days before, also
succumbed a few weeks subsequently ; and finally, that if the two
cases related by M. de La Barre and Baudelocque, in which it is seen
that the uterine inversion disappeared spontaneously at the expiration
of several  weeks in  the first, and  after a continuance of more than
seven years in the second, should  be deemed  authentic, amputation
in such cases can be but rarely indispensable.   The woman who, ac-
cording to  M. Swett, (American Journ.  Med. Sc.—Gaz. Med., 1834,
p. 665,) recovered, notwithstanding she had lost in this manner the
entire uterine system,  bladder,  rectum  and  perineum, would  have
obviously been less fortunate, if in place of being born in America,
she had lived among us  !  The persons who have performed ablation
ofthe displaced uterus, through ignorance or rashness, have conducted
themselves in such manner that their process  does not merit any con-
sideration.   Nor can we in fact any longer treat of tearing out or ex-
cising the womb with a kitchen-knife or razor, without any preliminary
precautions, nor of hot ashes, or other caustics used  by certain women
and charlatans, and  by some ancient authors.  The rational methods,
from which we are  now permitted to make a selection, are, strangu-
lation with or without immediate excision, pure and simple amputa-
tion, and extirpation with dissection of the peritoneum.
  a.  The ligature is extremely easy, and so much the more so as we
have under our eyes the pedicle, around which it is thought advisable
to apply it.  But this pedicle possesses a certain volume, and the
pains caused by its constriction have in more than one instance been
so acute, that the life of the patient appeared  to be in imminent dan-
ger from it.  In the patient of M. Marschall, among others, it soon
became necessary to divide the  thread, and the excision, which was
decided  upon on  the  spot, was followed by complete success.   This
ligature, moreover,  exposes to the danger of  including in its con-
striction  either the  urethra, as was seen by Ruysch;  or a  noose
of intestine, as happened to the charlatan mentioned by Klein,  or the
other spoken of by Reyneck ; or the bladder, &c.  With a view of
effecting the excision more promptly, and of causing less intense pain,
M. Windsor, as Faivre  had done before him, perforated  the root of
the tumor with a double  thread, in order to strangulate its two halves
separately.   The cases,  however,  of Newnham, Clarck and M.
Recamier,  prove  beyond dispute, that the ordinary ligature is not al-
ways dangerous in  such cases.  By means of excision we give more
prompt relief to  the  patient.  As the ligature can have no other
object in view than to prevent  hemorrhage,  we  cannot perceive
what advantage at  least, there would be in assigning  to  it the office 
842           NEW ELEMENTS OF  OPERATIVE SURGERY.

of separating the organ entire.   If, therefore, we adopt  strangulation
either in its  simple  form or after having  separated the root of the
body which is  to be removed,  into several portions, it would, as it
appears  to me, be  advantageous to excise immediately the entire
mass, which is  situated  below the constriction.   This is the way in
which Baxter, Bernhard, and a great number of others have operated.
Nothing more  would be  necessary to avoid wounding  the intestines
or excretory apparatus of the urine, than  to make some movements
on the pelvis, by elevating it upon the bed  a little higher than the
rest  of  the body.  Moreover, the pain, which is  caused by pinching
the intestines,  the only accident of this kind that the most delicate
degree  of attention  does not  always  enable  us to  prevent, will
point out the mistake sufficiently soon, to enable us  easily  to ap-
ply  a remedy  without delay, and  unless the  constricting thread
should be carried very high-up,  as it was by the charlatan men-
tioned by  Ruysch,  the  bladder  and  the  urethra will be  always
placed out of any danger.   The  multiple  ligature, which has  un-
questionably  the  same advantages in these cases as in  epiploic her-
nias, causes less pain than an ordinary ligature, because it produces
fewer tractions, and puckerings on the root of the organ, divides the
parts more rapidly,  and  is  less exposed to slip and lose its hold,
when excision  is performed at  the same  time.
  b.  The excision of a uterus which has been for a long time pro-
truded, nevertheless appears to me more worthy of general adoption
than the ligature.  The only danger which accompanies it is hemor-
rhage.   But  the vessels  contained in the  pedicle of the tumor  are
of sufficiently small size not to give rise  to any serious apprehension
in' this respect.   Aloreover, what would hinder our making use of the
ligature upon them should it seem proper, or from employing topical
astringents, tamponing, and  cauterization with the  hot iron ?   Exci-
sion, which is less painful and more prompt, possesses incontestable
advantages over strangulation, and must necessarily procure a great-
er number of successful results.   This was the process  employed in
the patients whose cases  are related by Pare, Bernhard, &c.  Fur-
thermore, I do not see what we should gain by imitating AL Langen-
beck.  The female he operated upon  had  a partial prolapsus with
scirrhous degenerescence, like  those of  Ruysch, and AIM. Hosack,
Wolff, Fodere,  and Recamier.  This surgeon deemed it advisable to
dissect cautiously the whole of the uterine peritoneum,  from the  ex-
terior to  the interior, so  that  after the removal of the organ this
membrane was found intact.   It  is true that his patient recovered
perfectly, and that she is  still living at the  present day.   The intro-
duction  of the  air into the  cavity of the abdomen through  the va-
gina, a thing  which is considered possible even after  the cure, by
Rousset, who mentions an example, and  dangerous by Siebold, who
ascribes  to this  the death of one of  his patients, would then  be
effectually prevented.   We would remark, in  the first place, that
what has been  said on this last branch of the subject, is confined to
bare assertions, which  may be easily refuted; and in the  second
place, that if it were necessary to follow the process of AL Langen-
beck, excision would become one of the most tedious and difficult of
operations. 
EXTIRPATION OF  THE UTERUS.
843
                § II.— The Womb not displaced.

  If we may believe Lazzari, the complete removal of a uterus which
was not displaced, was performed in three instances  by Monteggia,
about  the beginning of the present century.   De Siebold also states
that Osiander, the father, performed  this operation in one instance
with success.  It appears certain at least that on the 13th  April, 1812,
this operation was actually performed by Paletta ; but it was through
a mistake on his part; the author wished to remove only the neck
which had become cancerous, and did not perceive that  he had de-
tached the entire uterus, until on examining it after  the operation.
It is therefore to Dr. Sauter  of Constance, that we are indebted for
having first suggested the idea of this operation, and for  having  per-
formed it.   In this point of view, we may now ask the  question, if
extirpation of the uterus be in reality practicable, and whether  it is
useful, and  in what way it may be attended  with danger.   A word
or two on each of the cases which we now possess, will enable the
reader to form a  correct judgment on these different points.
  A. Examination of the facts.—The patient of M. Sauter, (Bull.de
Fer., X. IL, p. 321—Arch. Gen., X. V., p. 616,) who was  operated upon
on the 22d Jan., 1822, died four months after, and  from, the author
says, ^paralysis of the lung ; the bladder had been wounded.  On the
5th Feb., 1824, M. Hoelscher repeated the operation of the surgeon
of Constance, and death took place at  the expiration of twenty-four
hours.  The patient operated upon by de Siebold on the 19th April,
1824,  survived only sixty-four hours; and the one operated upon by
M. Langenbeck on the 11th January, 1825, died at the expiration of
thirty-two  hours.  The second woman who was thus operated upon
by de Siebold on the 25th July, 1825, died on the following day.  On
the 5th August  of the same year,  M. Langenbeck,  (lb., X. XVIIL,
p. 73—Diet, de Chir. de Rust., X. VL, p. 697,) performed extirpation
of the womb a  second time, and the woman, who died  fifty hours
after,  exhibited, like the preceding cases, indisputable evidences of
abdominal  inflammation.  Of the four patients operated upon by M.
Blundell, (The Lancet, 1829, vol. I., p. 618,) since the 19th February,
1828,  three died,  one at the expiration of thirty-nine hours, a' second
after nine hours, and  the third very suddenly, without our knowing
precisely what kind  of lesions were found upon the opening of the
bodies after death.  The first case, which had been  considered as
cured, died a year  after at Guy's  Hospital  from  a return of the
cancer.
  The case of M. Banner (Journ. des Prog., X. XIIL, p. 272,) opera-
ted upon on the  2nd September, 1828, died  on the fourth day of a
peritonitis.   M.  Lizars was desirous of  repeating the operations of
his two countrymen, and the patient whom he operated upon on the
2nd October, 1828, also died  in the space of 24 hours.  M. Langen-
beck repeated the operation in  1829, and his  patient survived but 14
days.   On  the 26th July, 1829, M. Recamier performed this extirpa-
tion for the first time in France.  It was to this surgeon that appear-
ances promised the most perfect success from it, but he nevertheless
had the misfortune, like M. Blundell, to lose his patient at  the expi-
ration  of a  year.   Another case was operated upon by M.  Roux, on 
844           NEW ELEMENTS OF OPERATIVE  SURGERY.

the 20th September, 1827, and this  one died on the evening of the
next day.   He had opened into the bladder.   Some days after, Pro-
fessor Roux extirpated the uterus a second time, and death took place
at the expiration of 25 hours.  M. Recamier again performed it on
the 13th January, 1830, and the woman died in 33 hours.  AI. Dubled,
(Arch. Gen. de Mid., X. XXIIL, p. 403,) on his part, performed the op-
eration on the 20th June, 1830, and the patient survived but 22 hours.
Delpech also, who thought proper to make trial of it, was  not  more
fortunate than the others, and his  patient died on the third day.   Fi-
nally, the English  journals have furnished another case, which  be-
longs to M. Evans, and which is  said to have succeeded;  but I do
not possess a sufficient number of details on this subject to dwell upon
it  at  greater  length.  A patient operated upon by AL Granville,
(Journ. des Prog., X.  XIIL,  p. 270,) had a return of the cancer.
Without comprehending, therefore, in the above  list, the doubtful
cases of Monteggia, Osiander, &c, we have, in adding the case of
Paletta, whose patient died on the third day, of an intense peritonitis,
twenty-three authentic, indisputable instances of extirpation of the
uterus, performed during the  last  20 years, and out of this number
not a solitary permanent cure !  Can there be  anything in surgery
more frightful ? and the results of such a melancholy catalogue, are
they not of a character to banish this operation forever from practice ?
Among the dangers which it involves, that of peritonitis is  placed in
the first line.  This  inflammation, nevertheless, has not always  oc-
curred.  The patient of M. Sauter, and those of AIAI. Blundell and
Recamier, who all survived, were not attacked with it, and the bodies
after death, in some of those who died in the  beginning, presented no
traces of it.  It is to be added, that in the women in whom death has
taken place most rapidly, for example, in less than 24 hours, the peri-
tonitis could not have yet had time to become  developed, even though
it might have been a necessary result of the operation.   Hemorrhage
is another accident wmich is necessarily attended with danger ;  it oc-
curred in several of the patients, as  I witnessed in one of those ope-
rated upon by M. Roux, and in another by M. Recamier, and has been
noticed also in Germany and England.   It has not, however, taken
place in the great  majority of cases.  Some of the women,  it is said,
died  from  exhaustion produced by the pain and suffering.  The ques-
tion occurs, why those who escaped the immediate consequences of
the operation, and this  first and violent onset, have remained in a lan-
guid  condition, and ultimately succumbed.  In their cases the opera-
tion could not be charged with having produced  either peritonitis,
hemorrhage, or pain.   The patient  cited by Vieussens, who survived
15 years, that of M. Marschall, who  did not die until after the expira-
tion of 10  years, and that of M. Langenbeck, who is still living, &c,
and in all of whom the protruded uterus was removed, are a  sufficient
answer to the objection of those surgeons who consider that the pa-
tients whom I have just spoken of owed their death exclusively and
solely to the extirpation of the uterus.
  B. Indications.—What chances  of success have we from extirpa-
tion of a uterus which  has  become cancerous, and when the opera-
tion is performed under the only conditions in which it is admissible ?
Were we  to undertake to describe those conditions, we should find the 
EXTIRPATION  OF THE UTERUS.
845
it would be a difficult matter, and that their combination must neces-
sarily be a rare occurrence.  So long as the cancer has not attacked
the whole organ, pure and simple excision, from  enabling us to go
very high up, ought to  be deemed sufficient.  It  was by means of
excision that M. Bellini (Journ. des  Prog., X. XII., p. 273,) extirpa-
ted the lower half of the uterus in 1828, with entire success.   It was
also excision which AL  Dubled proposed  as a substitute for extirpa-
tion, (Arch. Gen. de Med., X. XXIIL, p. 142.)  When, on the contra-
ry, the disease  has involved the whole organ, how can we be sure that
it does not  exist in any other  ?  It  is certainly very true, that the
finger successively introduced into the vagina and rectum, while the
other hand rests against the hypogastrium, will frequently enable us
to conjecture that there may or may not exist some decided degener-
escence in the pelvic cavity, in the region  of the  ovaries, or Fallo-
pian tubes, or in a word, in the connections or neighborhood of the
uterus; but under this point of view, the  most  skillful surgeon can
only acquire probabilities of greater or less force, and never absolute
certainty.   How then, with such data, can we decide upon perform-
ing  an operation so formidable  !  Upon the supposition even that the
womb only is affected, it would be necessary at least that it should
have preserved its natural mobility, and  be free from  morbid adhe-
sions, without which the operative processes at present known would
be scarcely admissible.   But so long  as it  remains in this  state, it is
not  probable that  the  cancer has attacked it throughout its whole
extent, and then the idea of excision suggests itself to the mind.  How
also can we decide, when the  disorganization is not very far advan-
ced, that the body of the uterus is actually in a cancerous condition,
or that it is a little larger or a little less than in its normal state,  see-
ing  that we have  no other means of judging  than by the fingers,
through the walls  of the belly,  rectum, or vagina ?
  C: Operative Methods.—Two principal  methods have been  pro-
posed for extirpation of the uterus, one which may be called the hy-
pogastric, the other the infra-pubic
  I. By the hypogastrium.—To believe Musitanus, extirpation of the
uterus at the hypogastrium is far from being a new operation.  This
author, in fact,  on the authority of Wier, asserts that a girl who was
excessively libidinous  was  operated upon in this  manner  by her
father, who made  an incision  at the lower belly, and through this
wound reached the uterus, which he instantly excised.  But  it  is
probable that the peasant mentioned by Musitanus confined himself
to the removal  of  the ovaria without disturbing the womb itself, in
the same way as the operation  is performed upon the female of do-
mestic animals.  The same remark is applicable to the passages in
Aetius, Schurigius, &c, where  we find it mentioned  that surgeons
had  opened  the belly in certain, women  in order  to extirpate the
uterus. However this may be,  the hypogastric method was described
and  distinctly recommended in  1814 by M. Gutberlat, (Rust's Handb.
der  Chir., vol.  VI.)  M. Langenbeck I believe is  the first who ven-
tured to apply this method on the living person.   Slightly modifying
the process of Dr. Gutberlat, he deemed it advisable first to open the
peritoneum through the vagina, in order to be more  certain of avoid-
ing the bladder.  This method was made trial of  in France by Del- 
846           CTEW ELEMENTS OF OPERATIVE SURGERY.
pech.  If it were ever possible to demonstrate that large openings in
the walls of the belly could be unattended with danger, there is no
doubt that  the hypogastric method improved would ultimately render
extirpation of the uterus  quite an easy matter.   But to combine it
with the infra-pubic method is not the way to secure its adoption,
any more than the incision in the  perineum, as proposed by F. Come,
was calculated to give popularity to the  operation of lithotomy by
the high method ; we have enough already with one of them, without
endeavoring also to combine them both together.
  II. By the vagina.—Out of twenty-three known instances of abla-
tion of the uterus, twenty-one have been effected by penetrating from
below upwards.  M. Sauter being  unable to bring down the organ
as Osiander did, divided as he continued upwards, and by means of
small cuts,  the vagina on the anterior surface of the neck, succeeded
by this mode in effecting the anteversion of the uterus, and was thus
enabled to separate in  succession the  two broad ligaments, and to
terminate the operation by gradually  isolating the uterus from the
rectum.  MM. Hoelscher and Siebold operated nearly in the same
manner.  In one instance, however, the last mentioned surgeon was
obliged to incise the  vagina  laterally in order to facilitate his  move-
ments and the introduction of his hands.  M. Langenbeck commenced
by incising the perineum from before  backwards; he then divided
the vagina  behind, in front, and on its sides;  and  finally grasped the
uterus at its fundus and completed its separation by a careful dissec-
tion.  M. Blundell detaches the vagina posteriorly, and penetrates in
this manner into the recto-uterine fossa of the peritoneum ; afterwards
seizes the fundus of the uterus, retroverts  it, divides  the broad liga-
ments and terminates by separating it from the bladder. AL Banner
preferred turning over the organ upon its side, after having detached
it behind and in front and from  one of its  broad ligaments, rather
than reverse it upon one  of its faces.  He terminated his operation
by dividing the other broad ligament.  The incision ofthe perineum
introduced  in practice by  M. Langenbeck, was extended as far as to
the rectum by M. Lizars, who then divided  the vagina on  the two
faces of the diseased organ, before reversing it.  M. Recamier and
M.  Roux have followed with  two modifications the  process  of M.
Sauter.  If it were possible to introduce  one of  the tractor instru-
ments above mentioned, M. Recamier would recommend its employ-
ment, but if  not he would  prefer  introducing into  the uterus the
branch having two prongs of  an erigne forceps, the other branch of
which should  have three prongs, and  be applied as  high up as pos-
sible on the outer side of the neck.   If this cannot be done he recom-
mends that we should have  recourse to .Museux's  forceps, either
simple or articulated, like the common forceps, or bent into the shape
of a Z, or merely at a right angle as  M.  Tanchou proposes, at the
outer third of their  handle, in order that  the parts  may not  be too
much concealed by them during the remainder ofthe operation.  By
means of one  or  the other of  these instruments we are to bring the
cancer down  as low as possible.   A straight bistoury protecteM  by
the hand, detaches from  below upwards the vagina from the front
part ofthe  neck, then from the womb itself, until we arrive very near
the peritoneum, which  is then  to be opened.  The bistoury, which is 
EXTIRPATION  OF THE UTERUS.
847
to be constantly guided by the finger, and operating through the
peritoneal opening successively to the right and left, will enable us to
detach completely the anterior surface of the organ from the fundus
of the bladder, and to expose the roots of the broad ligaments.  The
forefinger glided above the fallopian tube, readily passes upon the
posterior surface of the peritoneal duplicature, enables us to divide
from above downwards the  entire thickness of this fold as far as to
its lower third, and  to embrace the remainder  of it in a strong  liga-
ture.  After having  done the  same on  the  opposite side, M. Reca-
mier terminates the section  of the  broad  ligaments, reverses  the
uterus forward, and finally separates  it from the rectum, conducting
his incision from above downwards.  M. Gendrin proposes that the
uterus should be successively isolated throughout its whole  circum-
ference, and turned  upon its  axis, rather than reversed, when we
have arrived at the end of the operation.  In  place of applying his
ligature below the insertion of the fallopian tubes as M.  Recamier
does, M. Tarral, (Journ. Hebd., X. V., pp. 403,  529,) on the contary,
commences by embracing with it  the whole of the broad ligament,
making use of a curved needle, like that of  Deschamps, in order to
introduce it, and of his  left forefinger and thumb  to guide it in its
progress.  M. Dubled considers, that, after having brought down the
uterus as much as possible and detached the adhesions of one of the
broad ligaments, to the right and  in front, and then posteriorly, and
after having passed a ligature below the root of the fallopian tubes,
through the lateral  ligaments, in order  to include their  two lower
thirds, and to enable him to divide them between the ligature and the
uterus, it would be an easy matter to amputate the uterus nearly as
far up as to its fundus or superior border, in such manner as to leave
the fallopian tubes, ovaria, and  round ligaments  in their place, and
even also without the necessity of opening into the peritoneal cavity.
But it is evident that this process has then no  more to do with the
complete ablation of the uterus, and that it is  only an improvement
of the method of excision such as it was  performed by M. Bellini.
This last surgeon, (Strangulamento uter. porter., &c, 1835—Methode
pour extirp. Futir., &,c, 1837,) who passing posteriorly by the cul de
sac of the vagina, applies the noose of a ligature above the  uterus,
which last he then strangulates from  above downwards through the
interior  of the peritoneum, must necessarily have been arrested by
the fallopian tubes and the broad ligaments.
   III. To assert now which process is the.best  among all these modi-
fications, would be attended with so  much the more difficulty from
none of them having been followed by a decidedly successful result,
and from the fact that the apparent cures in certain women  have been
obtained  from different processes.   Thus  the  case of M.  Sauter, in
which the uterus was reversed forwards, survived four months; that of
M. Blundell, which survived a year, was operated upon by reversing
the uterus backwards ; and the patient of M, Recamier, who remained
cured for a year, had been submitted to the first  process  of this au-
thor.  As to the modifications proposed by MM. Gendrin and Tarral,
I do not consider it  necessary to discuss their advantages or incon-
veniences.  Moreover, as no person will undertake the operation (if
in fact it is ever repeated) without deeply reflecting upon it, it is proba- 
848
NEW ELEMENTS OF OPERATIVE SURGERY.
ble that every one will consider himself entitled to make still further
modifications upon these different methods ;  so  that I should be fear-
ful of abusing the patience of the reader in examining in greater de-
tail those which I have briefly described.

            Article XL—Vesico-Vaginal Fistulas.

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

                          §  I.—Suture.

  The suture, which must have first suggested itself to the mind, is
of such difficult application that but few practitioners have ventured
to make trial of it, so that scarcely any mention is made of  it in  the
works  which have issued from the  school of Paris.  To abrade  the
borders of an opening  when we do not know where to grasp them,
to shut it up by means of needles or threads when we have no point
apparently to sustain them, to act  upon a movable partition placed
between two cavities hidden from our sight, and upon which we can
scarcely find any purchase, has appeared to be calculated to  have no
no other result than to cause unnecessary suffering to the patient.
Roonhuysen, who, according to  AL Chelius, was the first to  recom-
mend the suture, did not make use of it.  If I understand the matter
correctly, it was his nephew who  spoke to  him of  it, and who con-
siders  that after having abraded the borders of the division, we may
perforate them and keep them in contact by means of a quill cut in
the form of a point.  The cures which this method is  said to have
obtained in the hands of Fatio, Walter and Schroeger, are not sup-
ported by sufficiently conclusive proofs to carry entire conviction to
the mind.   Experiments, however, which were made by M. Niegele,
(Journ. Univ. des Sc. Med., X. VIL, p. 160,) in the year 1812, led us
to hope that it  would succeed, while M. Erhmann has since had a
proof  of this success in a patient which Flamant  confided to him,
and  the thesis of M. Deyber (Journ. Hebdom., X. IV., p  241) shows
us that like this last surgeon he was no less fortunate himself in
a second case.   The fistula, which was very large in one case  and
narrower in the other, did not  nevertheless cicatrize until after  the 
VESICO-VAGINAL FISTULAS.
849
separation of the  threads  and a suppuration, which was prolonged
for a considerable period of time,  so that the cure did not take place
in consequence ofthe immediate contact of the parts.   In 1828, M.
Malagodi of Bologna performed it with no less success, and the un-
fortunate result which it riiet with in the hands of M. Roux, (Repert.
d'Anat.et de Phys., (fee, t. V., p. 147,) in the year 1829, at La Charite,
speaks nothing in reality either for or against it, inasmuch as the symp-
toms which preceded the death of his patient, were altogether dis-
connected with those which  would naturally  belong to the suture ;
cures moreover, it is said, have since been obtained from it by MM.
Hobard, Charnham  and S. Cooper.
  A.  Interrupted Suture.—M. Malagodi, after  having caused his
patient to be laid on the bed and held in the same manner as in the
operation for stone, introduced the extremity of his  forefinger, pro-
tected by a leather finger glove, into the bladder through the vagina
and the fistula, and then made use of it as a hook to bring out one of
the lips of this last to the vulva, and to exsect its callous portion with
a straight bistoury; having done the same for the other  side by
changing his  hand, he  then attended to  the insertion of the threads.
M.  Alalagodi, for  the second  stage of  the operation,  again seized
one of the borders of the wound  as before, with the left forefinger,
introduced  near its  posterior extremity a small curved needle, at
the distance  of two lines outside of  it, brought this out by a cir-
cular movement from  the bladder into the vagina by making it
pass through the vesico-vaginal septum, and  was thus enabled to
disengage it  immediately afterwards.   The  second needle,  fixed
at the other extremity  of the ligature, was also  introduced through
the fistula and brought out from the bladder to the vagina, to be
disengaged like the preceding.  The  surgeon  applied  a second and
then a third thread in pursuing the same method, then  knotted them
separately in such manner as to effect an exact coaptation, and termi-
nated by cutting their  extremity^near each knot with  the  scissors.
A catheter  was kept in the  bladder  and the patient made  to  con-
tinue in bed.   During  the first and  succeeding day the urine ran
wholly through  the catheter, but on the  third it was perceived that
some few drops of it had passed into the  vagina.   The two posterior
points of suture had succeeded perfectly.   A single one, that which
was nearest to the urethra, had torn out from the tissues, but it was
not deemed advisable to reinsert it.   Cauterization with the nitrate
of silver, repeated at different times, terminated the cure, which was
completed at the expiration of a few weeks.
  B.  It was  the twisted and not the simple  suture to which M.
Roux deemed inadvisable to give the preference.   In order to abrade
the fistula he  made use of forceps very  nearly similar to the disc of
chimney tongs, after the half of the disc had been removed.   One of
the lips of the perforation  having been  grasped  by this instrument,
AL Roux was enabled to exsect it by means of a  bistoury, and could
have  done  so also  with  a long pair  of scissors.  The suture was
 assed from the vagina into the bladder, and first through the left lip
 y means of a curved needle and the ordinary needle-holder.   This
needle was  then  brought from the bladder into  the vagina  through
the other lip of the fistula, then drawn to the outside, dragging after
                              54 
850           NEW  ELEMENTS OF OPERATIVE  SURGERY.
it through the two lips of the wound a small metallic stem, fixed at the
extremity of the ligature.   Three of these were successively inserted
with the  same  precautions;  after  which the noose of a  ligature,
passed upon the first  needle, adjusted and crossed  successively on
each of the others, a& is done in harelip, allowed of the approximation
of the bleeding surfaces, and finally the  completion of the twisted
suture.  Symptoms of intermittent, fever, and afterwards of functional
derangements of the brain, and of inflammation of the peritoneum and
pleura, began to show themselves  after the lapse of a certain time,
and became so serious that this woman died in the space of about
twelve days.  Upon opening the dead body there was found a con-
siderable enlargement of the fistula, the lips of which had in no place
contracted the slightest adhesion together.
  C. The method adopted by M. Schreger, though  less judiciously
arranged, had  nevertheless less unfortunate results.  It has been
incorrect, however, to  state that the cure was complete; the suture
was performed  three times ; and the words of the author himself suf-
ficiently point out that  the patient was not cured after the third appli-
cation :  " I was satisfied," says he,  " that  the wound  was  perfectly
cicatrized, except for about the space of a, line, where it was difficult
to incise the borders.  The patient found herself considerably better,
and I had even flattered myself that I should obtain a perfect cure in
a fourth  trial,  when  indispensable matters  obliged  her  to  leave
Erlangen."
  D.  The  condition of the female  operated upon by Duges,  (Bull.
de Ther., X. IL, p. 145,) was rendered worse, rather than ameliorated,
by the suture.  Nor did the young girl,  who was sometime in  my
department at La Pitie and upon whom AI. Robouham made similar
trials, derive any decided  advantages from  them according to what
M. Mondiere tells me, who was present at the operation.  It is use-
less therefore to enumerate in this  place the details of the process
employed by these  practitioners.   Unless the fistula  be extremely
large, the forefinger cannot seize its lips in the manner of the surgeon
of Bologna, nor reach them with the forceps in the manner performed
by M. Roux.  The longitudinal divisions  only could  be treated with
the suture after the  manner of these two surgeons.  But experience
shows  that vesico-vaginal fistulas constitute in  most cases a  trans-
verse fissure, or even a kind of half moon with its  concavity for-
wards, between the urethra and the entrance of the ureters into the
bladder.
  E.  If the instrumental apparatus  of M. Ncegele was not so com-
plicated, it would certainly offer more chances of success  than  the
preceding  processes, though this also is  scarcely applicable but to
longitudinal openings.   But art requires something more simple, for
the suture to he generally adopted.  AI. Schreger by abrading, so to
speak, only the posterior half of the fistula, and introducing each point
of suture at only a line or two from the bleeding borders, considered
himself exceedingly fortunate  in being  enabled almost to effect  a
complete cure of his patient, and to obtain  so successful a result in
the three trials  he made.
  F.  The author.—Trials made upon the dead body induce me to
believe that we should succeed better in adopting the  following me- 
VESICO-VAGINAL  FISTULAS.
851
thod.  I cause the patient to be placed upon a bed, or upon a table
sufficiently elevated and properly arranged.  A round-shaped mat-
tress is placed under the belly, in such manner  as to  enable  her to
keep her thighs flexed  while lying  upon  her abdomen.   An assis-
tant keeps the vagina dilated by means of a  large gutter of metal,
horn, or thin wood.  With  one cut  of a  straight pair of scissors, I
enlarge the fistula  a line or two in  extent posteriorly, and do  the
same on its  anterior angle with a  narrow bistoury, in order to  be
enabled to seize each lip successively with a good pair of staphylo-
raphy forceps, and  to excise a strip from them by means  of scissors
that are straight or slightly curved  flatwise.   The points of suture
are then introduced at three or four lines outside of the abraded sur-
faces.   In order to  support the parts, the forceps replace the thumb
and forefinger of the left hand, while small needles are  introduced
through the borders ofthe fistula in the manner they are inserted  by
M. Roux or M.  Malagodi.   Finally, each  thread is knotted  at  the
bottom of the vagina by means of the fingers.   If the cleft is trans-
verse, a bistoury curved flatwise near its  point, and very sharp, and
introduced through the vagina, very readily  detaches  a  strip from
its deep-seated border, which also is to be kept reversed or depressed
by means of an erigne  or good forceps.
   G. Moreover, if  the  suture of vesico-vaginal fistulas succeeds with
so much difficulty, and constitutes so embarrassing an operation, per-
haps we ought to charge it  on  the imperfections of the instrumental
apparatus.  At  the present day,  when  by means  of the  spiroidal
needle of M. Colombat, we may in one operation introduce a whip
suture in any part of the vagina whatever ; and when by enlarging
the urethra with a double lithotome, as M. Sanson has done, in order
to enable us to  introduce the finger by this route, and to  seize  the
fistula so as to depress it towards the vulva; and when by means of
the needle-holding   forceps of M. Bineau, M. Soteau,  M. Beaumont,
M. Bourgognon, or M.  Foratier, we may readily pass  such number
of points of suture  around the fistula as we may desire, without any
serious difficulties;  we have, as it would appear to me, a further pros-
pect of effecting cures, and sufficient grounds to justify new trials in
this treatment. If, as M. Erhmann, (Begin, Elem. de Chir., X. L, p. 442,)
has successfully done, M. Sanson, who endeavored to close the open-
ing by a sort of pucker ; M. Leroy  who  had  recourse  to five  or  six
different processes; M. Buret  who  passed his  threads by means of
a needle, directed along the urethra  through the vesico-vaginal sep-
tum ; and  other surgeons of Paris  who  have  endeavored in latter
years  to cure vesico-vaginal fistulas by the suture,—have not suc-
ceeded, there is reason  to believe that the irregularities of the abra-
sion, or of coaptation, have been the cause of these failures, and that
the instruments  of  M. Coglioso would give greater  facility  to  this
stage  of the operation.  The apparatus  contrived  by  M. Fabbri,
(Memoria intorno  alcuni  nuovi instrumenti, <fec, 1838—Soc. Med.
Chir.  of Bologna, vol.  II.,)  to  abrade, approximate, and suture   the
lips of vesico-vaginal fistulas, whether oblique or transverse, is  un-
doubtedly ingenious, but scarcely adds to  the chances  of  a favorable
issue to the operation. 
852           NEW ELEMENTS OF OPERATIVE  SURGERY.

            §  II.—Process of M. Lewziski.—Ligatures.

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

                       § III.—Erignes.

  In 1826, M. Lallemand (Arch.  Gen. de Med., X. VIL, p. 481,) pub-
lished a case of ancient vesico-vaginal fistula, cured by means of an
instrument, the principle of which has some analogy with that of M.
Lewziski.  The apparatus ofthe professor of Montpelier, is compos-
ed, in fact, 1st, of a large canula about 4 inches long ;  2nd, of a double
hook, which is moved in the principal instrument by means of a stem,
in such manner as to push it out, or to  make it enter into its sheath;
3d, of a circular plate which terminates the  other extremity of the
canula, and  which would hinder, if necessary, this latter from pene-
trating too  deep into the urethra; and  4th, of  a cork-screw spring,
(ressort en-boudin,) intended to draw forwards the small hooks as soon
as they are inserted in the  posterior lip of the  fistula.   It is applied
also in the same manner as I have, just stated  in speaking of the pro-
cess of M. Lewziski.  The canula being passed into the bladder, al-
lows of our pushing the  two small hooks into the vagina through the
ves;oo-vaginal septum, which latter is supported by  the left forefinger.
By making  a  turn of the  screw, they  are kept in this  position; a
pledget of lint, or fine  linen, designed  for protecting  the tissues, is
then  placed  between the front part of  the urethra and the external
plate ofthe  canula ; finally, we relax the spring, which acts  then at
the same time by making traction on the posterior  lip with its hooks,
and by pressing backwards the lower wall of the  urethra by means
of the circular plate, or the lint, which serves  as  its point d'appui.
By a mechanism which would be too long for description, we may regu-
late the stop of the spring in such manner that  there will only result
from it a moderate degree of pressure, though sufficient for bringing
the two borders ofthe fistula into contact.   During the space of three
days, everything appeared to M. Lallemand  to promise' entire suc-
cess.   On the fourth day. some drops of urine having made their es-
cape into the vagina, the instrument had to be  removed, and a dark 
VESICO-VAGINAL FISTULAS.
853
brown spot was observed upon its lower surface, at the distance of
four lines in front of the hooks.   The  fistula nevertheless, appeared
to have considerably diminished  in its extent.   Another application
was now made with the erigne canula, and this time the reunion ap-
peared to be perfect.   Nevertheless, some imprudence committed at
the expiration of about ten days,  enabled the urine to escape into the
vagina.   A very small  disunion  had taken  place, and  the surgeon
supposed that he could complete  by means of cauterization a cure to
which his instrument had  so  greatly contributed.  Sometime after-
wards they wrote to him that nothing any longer escaped through
the fistula, and that the cure appeared to  he complete.   The opera-
tion having been commenced  and terminated with the nitrate of sil-
ver, the use of which alone counts at the present day several unques-
tionable examples of success,  this fact was in reality much less con-
clusive than it was at first supposed to be.   A similar attempt  was
made with the same apparatus in the course of the year 1829, at the
Hospital BeaujOn.  The success  which was  at first anticipated  was
not sustained, and the patient  soon found  herself in the same  condi-
tion of infirmity as before.  M. Lallemand, however, (Arch. Gen. de
Med., 2nd ser., t.  V., p. 482,)  in publishing another case of success,
appeared to be very much annoyed with  the doubts expressed in re-
gard to his first patient, Aldme. Martin, of Marseilles, who continues to
remain effectually cured.  The lady, who has been seen at Paris, had
deceived him herself, and is the subject of another observation.  I re-
ceived from him, on the 2nd October, 1837, the positive assurance on
this subject, that out of 15 or  16  trials, he had obtained six or seven
cures, two of which moreover have been published  by M. Deville,
(These,  No. 107, Montpelier,  1833.)

                             § IV.

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

                  § V.—Process of M. Laugier.

   If the suture is rarely applicable except to longitudinal fistulas, it is
evident that the erigne canula in its turn is only suitable to transverse
fistulas.  M. Laugier, with the view of obviating this difficulty, and to
make the method of M. Lallemand applicable to all kinds of fistulas, has
had constructed an erigne forceps, which is jointed after the manner of
a Smellie's forceps, and the form of which is modified according to the
kind of fistula. If the case is one of a transverse fistula, the prongs of
the instrument are bent into an angle on one of its sides directly up-
wards, one to the right,  and the other to the left.   In  longitudinal
fistulas, on the contrary, the two  hooks of each prong must be paral-
lel to the axis of the body, while the extremity which supports them
is  bent into an angle on the border.   Finally, we should bend the for-
ceps  obliquely, if the  fistula itself had this intermediate  direction.
The hooks of this forceps, says M. Laugier, should be very short, in
order that they may not go through  and through the vesico-vaginal
septum.  They are introduced through the interior of the vagina, and
not through the bladder.  Those of one of  the branches are inserted
at some lines outside of the fistula, which has been previously abraded.
Those of the other are  applied in the same manner on the opposite
side; after which they are approximated by shutting up the forceps.
In order that this approximation may be graduated, augmented or di-
minished at pleasure, a screw is made to pass  through the two han-
dles of the forceps, nearly in the same manner as in the enterotome
of Dupuytren.  The whole is  protected  by means  of lint, properly
arranged in the interior of the vagina, or at least  in  the opening of
this passage.   The process of  M. Laugier,  whenever it has been put
in practice on a living person, has always failed  up to  the  present
time, and I doubt if it in reality  possesses any great degree of efficacy.
It  is difficult  to conceive, that upon  a partition so movable, simple
hooks would  be sufficiently steady to keep  in exact  contact, during
the space of three or four days, the two lips of a fistula  of any con-
siderable extent.   If they do not go  through  the entire thickness of
the tissues, these  hooks will almost unavoidably slip, while tearing at
the same time the vaginal membrane, or the urine will become lodged
in the depression left in the  bladder, and will not  fail to make its
appearance on the side of the forceps.  If they go as far as into the
bladder, would not the openings  they make, and which would be en-
larged by suppuration  before  they  could be withdrawn,  incur the
risk of  making additional fistulas instead of curing the old one  1
Then also, the contour of a vesico-vaginal fistula is  far from being
always of the same thickness on all its different points.  Those for
example, (and  these are incomparably the most frequent,) which oc-
cupy the termination  of  the  bas fond of the bladder, are in general
exceedingly thick in the direction towards  the  urethra,  and very
thin on the contrary, behind.  It would  be necessary, therefore, for
the anterior  claw of the instrument  to penetrate to the depth of
two or  three lines, while  the other would be implanted in a lamella
of only a line or half a  line  in thickness.  In longitudinal fistulas
the hooks would probably affect only a partial coaptation, since their
contour almost always presents some points that  are  more resistant 
VESICO-VAGINAL FISTULAS.
855
than others.  Finally, for fistulas  that are more remote, would not
the suture  be attended  with more certainty, or would it be much
more difficult to  execute in practice ?

                     §  VI.—Cauterization.

  Cauterization, which at first  sight would seem to  be only calcu-
lated to increase  the loss of substance, is, nevertheless, one  of the
best means which have  been made trial  of up to the present time.
(Alonteggia, t. V., p. 339, 1st edit.)  Used to the extent of irritating
and of inflaming the tissues  to  a sufficiently intense degree, without
effecting their  mortification, it produces  an  engorgement and intu-
mescence, which  closes up or contracts, at least for the time  being,
the opening which we are desirous of healing up.   After the  subsi-
dence  ofthe engorgement, the exhalation and  suppuration  which
supervene are accompanied with a manifest tendency to coarctation.
This, therefore, is a method  which deserves all  the attention  of the
practitioner, and one which appears  to  be especially calculated  to
succeed where the perforation has but little extent.  The cauterization
is effected by means of the actual  cautery or nitrate of  silver.   The
concentrated acids, and nitrate acid of mercury, which Dupuytren had
at first thought of, ought  to be rejected.   The incandescent iron has
the advantage of acting with more rapidity and with greater energy.
Unfortunately also, it exposes to the risk of forming an eschar, and of
destroying  the  tissues which we wish only to inflame.   The nitrate
of silver is generally preferable, and the actual cautery ought not  to
be  substituted  in its place, except in  some  particular  cases, as for
example, when the  borders of the fistula are callous, or cannot be
inflamed without too much difficulty.
  A. On the supposition that we adopt the  red hot  iron, we must
commence by introducing a speculum into the vagina.   The ordi-
nary jointed  speculum is as good as  any other.  If, however, we
should desire to protect the surrounding parts with still greater secu-
rity, and to leave  nothing but the fistula hare, we might  make use of
a simple cylindrical speculum pierced on its side, or the flute-beaked
speculum of  Dupuytren, (Journ. Hebd., X. V., p. 256.)  This instru-
ment being introduced in such a manner as to expose the fistula  to
view, we pass  into  the  opening either a. probe heated to a white
heat, or a small bean-shaped cautery, while taking care to leave  it
there but an instant, or to apply it  a second time  if the  first cauteri-
zation should not appear  to  be  sufficiently powerful.  Delpech, who
obtained a remarkable cure from this application, thinks  that the
cautery should not act upon the vesical circumference, but only on
the vaginal portion of the fistula, in order, he says, to avoid the loss
of substance, while  at the same time bringing into full play the ten-
dency to coarctation; this is a remark which the practitioner ought
to attend  to  in the trials which may  hereafter be made  with this
process.
  B. In using the nitrate of silver, the assistance of the speculum is
not  indispensable.   We  should never make use of a simple port
crayon to cauterize  with  this substance.  For then it would scarcely
touch any other than the inner surface of the vagina, and would  in 
 856          NEW ELEMENTS OF  OPERATIVE SURGERY.

 most cases leave the fistula itself  wholly intact.  We  fasten to the
 extremity of a dressing forceps a portion of the nitrate, by means of
 a thread, in such manner that the  caustic forms a projection at ri^ht
 angles to the  border of the  instrument.  By means of this forceps
 thus prepared, nothing is more easy than to introduce the lapis infer-
 nalis into the interior of the  fistula, and to cauterize the whole of its
 circumference.  A ring surmounted with a small beak destined to
 receive the nitrate, and which could  be guided by the  extremity of
 the finger  protected  with leather, would perfectly  replace the for-
 ceps, did it not, like the lateral port crayon,  constitute a  separate
 instrument.   In whatever manner  the cauterization has been effect-
 ed, it is advisable immediately after to throw up one or more injec-
 tions into the vagina, and to place  the patient in a bath.  A catheter
 should be left to remain in the bladder, and continue open upon the
 border of a vessel arranged for this purpose in  front of the vulva, in
 order that the urine may escape freely and not be retained.   When
 the inflammation and swelling have ceased, the  same operation ought
 to be repeated.  We have recourse to it in this manner four, five, or
 six times, according to the benefit  that results from it, that is to say,
 until the urine ceases to pass through the vagina.   Because the fis-
 tula, after being at last  reduced to very small dimensions, appears
to resist and contract no more, we should be  wrong in totally de-
spairing of success, for in more than one  instance it has been seen
to close  up finally at the expiration  of a  few weeks, though it had
appeared to be no longer making any progress  towards a cure.
  C. Cauterization, either by means ofthe iron or chemical substances,
 appears to have  obtained a certain  number of cures in the hands of
Dupuytren.   M. Sanson, who was an eyewitness, gives some exam-
 ples of them.  An attentive perusal of the case published by M.
Malagodi. also furnishes grounds for believing that in his patient the
lapis infernalis probably had more to do with the cure than the suture,
 and in the other cases where the caustic has been used as an auxili-
 ary or combined with those means which have been considered the
 principal, it is quite possible this application of itself has  procured the
 results in question.  Cauterization, in vain made trial of by M. Earle,
 succeeded in the hands of M. AlcDowel,  M. Baravero, AL Bellini
 (Journ. des Prog., t. V., p. 248) and of M. Taillefer, (Bull, de FAcad.
 Roy. de Med., 1.1., p. 583,) which latter at the  same time made use
 of the erigne to  approximate the borders of the wound.

                             § VII.

  The method the most ancient and the only one which Boyer treats
 of,  is the  one  which  was  improved  by Desault.  It consists in
 arranging a catheter permanently in the bladder, at the same time
 that we  keep up in  the vagina  a   cylinder of linen, lint, or what is
 better, of gum-elastic, in order to  make moderate tension upon the
 angles of the  fistula.  Desault and Chopart, who were a lpng time
 embarrassed with the difficulty of keeping this sound immovable, at
 last discovered a means of doing so : in place of a double T bandage
 to which were attached the threads fastened on the  extremity of the
 instrument, and  in place  of tying those threads to  the hairs of the 
VESICO-VAGINAL FISTULAS.
857
vulva, these  authors  contrived a  sort of truss, the pelote of which
reaches to the mons  veneris, and  which has at this place a metallic
plate curved into an  arc, which is made  to descend at pleasure on
the front part of the pudendum, and which is opened at its extremity
to receive  the  catheter.  This however  is an apparatus much too
complicated, and does not appear in fact to possess much more secu-
rity or advantage than the one in linen, made use of  by other practi-
tioners.  Desault and Chopart maintain that they have cured several
women by adopting  this  method,  and even furnish a particular ex-
ample of it.  In this  example, however,  they leave us in a certain
degree of  doubt, in  saying that  the  woman  appears  to be  cured,
and not positively that she is cured.  Moreover, since we are some-
times  obliged to wait months and even  years to obtain  a perfect
cure by means of this  method, is it not probable that the fistula in
such cases  disappears spontaneously ?   If  however, we should decide
upon employing permanent catheters, it would appear at least  that
we ought to reject the foreign body, which is  placed  in the vagina,
according to the process of Desault.  This, by dilating the  passage,
must necessarily present an obstacle to the contraction of the fistula.

                § VIIL—Anaplastic  Processes.

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

                § IX.—Obturation  ofthe Vulva.

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

                   §  X.—General appreciation.

   I have now  an  unpleasant duty to fulfil, in stating  that among the
cases related of cures of vesico-vaginal fistulas, there are but a very
small number  which  are entirely free  from  all contestation.   It is
certain,  as M. Jeanselme has shown, (FExperience, X. L,  pp. 257,
270,)  in  a detailed memoir on this subject, that the  cases attributed
to Desault by Chopart, to Flamand by M. Erhmann  or  M.  Deyber,
and to Dupuytren by AIM. Sanson and  Paillard, and  those  ascribed
to AL Ncegele, M. Malagodi, and M.  Jobert, and several  of those
which belong to M. Lallemand, are far from being conclusive.
   A.  To understand ourselves on this subject, and to enable science
to advance in a proper manner, it is necessary to  divide  urinary fis-
tulas in  women into three classes.   Those which  cause  a communi-
cation between the urethra and the vagina, may be treated success-
fully by cauterization or the suture.  There is every reason to be-
lieve also that  a certain number may be cured  by adopting the pre-
caution  of catheterizing the woman whenever she is  under  the  ne-
cessity of urinating, and by not allowing  her to evacuate her blad-
der herself.  I have succeeded in this manner in  one instance.   In
another woman whom I operated upon  in 1838 at La Charite, I con-
fined  myself to the extirpation of the urethral bridle, which separated
the fistula from the meatus urinarius.   As the neck of the bladder
was not implicated, this small  operation was attended with  entire 
VESICO-VAGINAL FISTULAS.
859
success, and the urine could afterwards be evacuted in the same way
as before the disease.   The fistulas which are situated  at  the  neck
of the  bladder  or  root of the urethra, in other words,  those which
are established  at the expense of the trigonus vesicalis, appear also
to be susceptible of a radical cure.   Nor do  I  doubt that  many of
those patients treated by MAI. Lallemand  and Jobert,  were of this
description.   There is also every reason  to  believe that  the cures
attributed to Dupuytren and others, belonged to this class of fistulas.
It was  probably from having overlooked this  distinction, that several
practitioners have felt themselves aggrieved by the doubts which M.
Jeanselme in his memoir has expressed  in relation  to  their cases.
As to the fistulas of the body of the bladder, there is  no fact  up to
the present  time, which proves  indisputably that  they have  been
cured.   It is true that Levret and Deleurye state, that the depression
of the  uterus and its neck will succeed in such cases ; but we find by
the case  of M. Horner, (Gaz.  Med., 1838, p. 124,) that  tractions
made upon  the neck  of the womb by means of an ephelcometre,
have proved insufficient for the cure of those fistulas  which  have
been hitherto treated by this process.
   B. It is to be recollected, moreover, that fistulas of the body and
the bas fond of the bladder, present numerous varieties.   In  many
women whom I have seen, the vesico-vaginal septum was so com-
pletely destroyed, that the bladder and vagina no  longer constituted
anything more than one and the same  cavity, that the, anterior wall
of the  bladder, from being no longer supported, descended  down as
far as the vulva, under the appearance of a reddish-colored fungus,
so that it would have been absurd to have thought of curing an infir-
mity pf this  description in any other manner than by the method of
M. Vidal.  I have  had  an opportunity of examining two women in
whom  the fistula was so high up that its superior  border was repre-
sented  by the anterior  side of the neck of the uterus.  Is it not evi-
dent that cauterization or abrasion, combined with depression of the
uterus, might in these cases  have presented  some  prospect of suc-
cess ?  In another  woman, the fistula, which was  at the  bas fond of
the bladder, and of a circular form, was situated in such manner ex-
ternal to the mesian line, that it could be closed up quite entirely  by
means  of slight pressure made through the vagina.
  C. For the future, therefore, it  will be advisable not to cite cures
of vesico-vaginal fistulas, without actually defining their precise seat,
form, and dimensions.  This, it would appear, is what is required by
M. Jeanselme, and I consider that an  advantage would be derived
from it in  practice.  In conclusion,  however, I would remark, that
uretro-vaginal fistulas  yield without  any great difficulty to the re-
sources of art or the salutary efforts  of nature;  that those  of the
trigonus-vesicalis rarely disappear when they have more than eight
to ten lines diameter; that those  that are the  highest up in  the vagi-
na also do not appear to be absolutely incurable ;  but that in  regard
to those of the  bas fond, I feel myself compelled, without  being as
wholly  incredulous on this subject as M. Jeanselme, to avow, notwith-
standing, that there is reason to call in question almost every one of
their alleged cures  which have been published up to the present time. 
860           NEW  ELEMENTS  OF OPERATIVE SURGERY.
                  §  XL—Palliative Treatment.

  Where the case is incurable, an oval ball of gum-elastic is one ofthe
best remedies to make use of.  The means then to be used are no longer
designed for any other purpose than that of cleanliness, and to protect
the organs against the acridity of  the urine, or to receive this liquid,
in such manner that  the patient may be incommoded by it as little
as possible.  For  this purpose J.  L. Petit  had an instrument con-
structed  which he called  the trou d'enfer, and which, according  to
him, fulfilled the intention perfectly;  but as he has not described
it, we have not  been  enabled to  derive  any advantage  from  it
since; fortunately  that of Feburier,  and  which  is met  with  in
most  of  the gum-elastic instrument-shops, leaves nothing to desire
on this subject;  it is a sort of cup  made of  caoutchouc, which
may be  kept in front of the vulva, and prolonged into  the vagina
without  preventing the woman from walking or attending to her
usual occupations.   M. Barnes, who  in consequence of the frequency
of vesico-vaginal fistulas among English women, has been frequently
obliged to direct his attention to this subject, makes use of an elonga-
ted gum-elastic bottle, which can be adjusted in  the vagina,  and
which has on its anterior face an opening in which a sponge  is intro-
duced and  applied  to the fistula in order that the urine may gradually
pass into it.  The patient withdraws the whole two or three times a
day, expels the urine by simple pressure, which, acting on the sponge,
empties the instrument completely.   M. Guillon and Duges have each
contrived an instrument which may be considered as an improve-
ment  of  that of Barnes.   Finally, if none of these means  are  at
command, the only resource which the woman would have woidd be,
to make  use of portions of fine sponge,  dry linen and  silk paper,
which would have to  be renewed  a  greater or less number of times
daily.  The semiflexed position on the belly, as recommended by M.
Challly,  (Transact. Mid.,  X. VL,  pp. 283, 293,)  with the view of
forcing the urine  to  escape by the urethra, with the catheter or
aspirating syphon which was to be introduced to prevent the urine
from passing through the  fistula,  has in  the first place the incon-
venience of not effecting its  object.   In the next place it is impossi-
ble for most women to keep it up over a day or two.  AL Schraeger
and M. Sanson, who made  use of  this process  a  long  time since,
derived rlo benefit  from it and were  soon deterred from its employ-
ment by  the sufferings and the sores that it was calculated to pro-
duce upon the knees, elbows  and spines of the ilium.
  [Vesico-Vaginal Fistulas.—M.  Berthe of Gay, (Arch. Gen., Aout,
1844, p. 511,) states that he  has cured three fistulas of this  descrip-
tion by cauterizing, with the cautery at a white heat, which hp was
enabled to accomplish effectually by making the borders of the fissure
project freely into  the vagina, by keeping  the bladder constantly dis-
tended with air during the operation.
  Even the great destruction of the vesico-vaginal septum from diffi-
cult labor, did not, in our opinion,  justify the severe operation of AL
A. Berard  (Arch. Gen., Sept.,  1845,  p".  77,  (fee.)  in attempting  to
alleviate  the difficulties by dissecting a circular  mucous diaphragm
or flap behind the nymphas, drawing that backwards and then bring- 
RECTO-VAGINAL  FISTULAS.
861
ing the abraded surfaces, both of the flap and of the parts from which
it was removed, into coaptation, (the latter by the quilled suture,) so
as to obliterate the vagina both in front and behind by a species of
infibulation.  Death followed as a matter of course.
  In regard to the obliteration of the vagina as a remedy to the dis-
tressing annoyance from the urine in cases of extensive vesico-vagi-
nal fistulas, M. Velpeau, like  most  other surgeons  of experience,
disapproves of this  operation, which has  been attempted  by  AIAL
Vidal, A. Berard, &c, but now contends (Arch. Gen., 4e ser., t. VIL,
Mars, 1845, pp. 370, 371) that  it is not  so alarming as some think,
and that the  objection  raised on  account  of the obstruction to the
escape of the catamenia through the small aperture left, is unfounded,
inasmuch as the menstrual fluid, from not being coagulable, can as
readily  flow through this aperture  as  the  urine  does.   See  text
above   T.]

           Article XII.—Recto-Vaginal Fistulas.

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

                    § I.—Spontaneous  Cure.

  From recto-vaginal fistulas being  somewhat more  inclined to a
spontaneous cure than  those of the vesico-vaginal septum, it has
very naturally happened that they have  been generally overlooked.
Ruysch  had already mentioned the case of a woman  who had an
opening in the  recto-vaginal septum of an inch in diameter,  but who
got well without an Operation.   M. Philippe of Mortagne (Arch. Gen.
de Med., X.  XXIIL,  p. 568) noticed in 1829  a case nearly similar.
The patient whom he mentions  had an enormous perforation, which
made a communication  between the rectum and vagina.  The most
celebrated surgeons  of the capital were consulted, and all  of them
gave it  as  their opinion that  the disease would probably remain
incurable, and  that they saw no operation that could be undertaken.
Means for cleanliness, together with a position upon the side, consti-
tuted the whole  treatment  made use of by. M.  Philippe.  After
having become considerably enlarged, the  fistula began to contract,
so much so  that after the expiration of a few months it  was found to 
862
NEW ELEMENTS OF  OPERATIVE SURGERY.
be completely closed.   At the time the case was published the cure
continued perfect and there was no  reason to apprehend a  return.
Analogous cases have been related by Fichet de Flechy, M. Capu-
ron and  M. Deschamps.   Sedillot (Journ. Gen. de Med., X. 56) had
already published a case nearly similar; it differs from it only in this,
that  the  disease belonged to that description which Smellie  had  in
vain endeavored to cure, but which Noel  overcame by means ofthe
twisted suture.   Unfortunately the system  does not always co-operate
so kindly with the wishes 6f the practitioner, and  it  is but too com-
mon to find that lacerations of the recto-vaginal septum persist not-
withstanding the best directed efforts.   All the means proposed for
vesico-vaginal fistulas are equally applicable to this.

                              § II.

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

   The operation which at  first sight would  appear to  present the
greatest degree of  certainty, is the suture.  Only  that it is an unfor
tunate circumstance that it is so difficult of application  that we can-
not, up to the present time, enumerate  but a  very small number  of
cases in  its favor.   Gardien states that it was  unsuccessfully attempt-
ed by A. Dubois, and Boyer considers  that if all  the failures by this
process  had  been published, there would at the present day  be a
great number made known. It has  nevertheless succeeded, and as
it is probable that by improving it we may ultimately derive  more
benefit from it, I consider  that it is worthy  of further  trials.  The
first cure which was effected by this process, was in the case pub-
lished by Saucerotte, (Recueil Period, de  la Soc.  de Med., t. IV.)
The patient  had at the same time a perforation of the recto-vaginal
septum above the sphincter, and a laceration of the perineum  in front
of the anus.  The surgeon caused the vagina to be dilated by means
of a speculum with two branches,  and  introduced into the  rectum,
through the  anus, a sort of wooden  gorget, the convexity of which
was placed underneath the fistula, to serve as a point d'appui to  the
other instruments.   The opening being  thus exposed to view, Sau-
cerotte  exsected its borders, one half by means of a  bistoury pro- 
RECTO-VAGINAL FISTULAS.
863
tected by a bandage, and the other half by a species of cutting rasp.
The glover's suture, which he gave the preference to, was applied by
means of two curved needles, one which was shorter to begin the
operation, and the  other  longer to  terminate it.  The forceps and
usual needle-holder had been slightly modified for this purpose, that
is to say, that their extremity was arranged in  such manner that
the needle could  be fastened in them in any direction.  Saucerotte
then introduced, by means of this instrument, his first point of suture
as far as to the upper angle of the abraded fistula, where he secured
his ligature by means of a portion of adhesive plaster, in  order that
he might dispense with knotting it.  He afterwards made with the
other needle six turns of spiral or whip suture, proceeding from be-
hind forwards, and secured it ultimately by knotting the two  halves
of his ligature upon a foreign body.  For  several days there was
reason  to  believe that the cure  would take place, but the woman,
who had not had a stool during the time, was then obliged to make
use of so much effort to evacuate the hard and lumpy foscal matters,
that the suture was thereby torn  out, by which  the greater  portion
of these matters  escaped through the vagina. Saucerotte, however,
finding that the adhesion maintained itself in  the upper portion of the
fistula, and that the woman herself desired the operation to  be re-
peated, made another trial at the expiration of a month.  This time
he took the precaution to divide the bridle formed by the sphincter,
in order that  there might be no obstacle to the  free passage  of the
matters; the case was completely successful.   A similar success, it is
said, was since obtained by M. PI. Portal, (Gaz. Med., 1835, p. 696,)
in a young girl four years of age.   But a woman who had been al-
ready operated upon in this manner unsuccessfully at Clermont, was
not more fortunate in the second  trial under  the hands of M. Roux,
(Mercier,  Journ. des  Conn. Med.-Chir., Mars, 1839,  p. 97.)   Noel
(Rec de la Soc.  de Med., <fec, t. VIL, p. 187) also made use of the
suture in a case very similar to that of Saucerotte.  The woman had
the entire perineum and the anus,  and a portion of the septum, rup-
tured during a protracted labor.  He had recourse to the scissors  to
abrade the two lips of this ancient  fissure; inserted  several needles,
one on a line with the sphincter, and also another at an inch above;
secured them by means of threads,  as in the twisted suture; kept the
thighs together by some  turns of bandage  which embraced both
limbs; and enjoined upon her to keep upon her back, in order to en-
able the foscal matters to escape by passing along the  posterior wall
of the rectum, and  ascertained to his  satisfaction, after  having re-
moved his  second  needle, that the reunion was  perfect, not only at
this point,  but also  in the entire upper portion of the wound,  where,
nevertheless, the suture had not been applied, and the lips of which
had not been brought into contact, except by means of the approxima-
tion of its lower portion.  This cure, which remained permanent, proves
that Smellie, in his case, might probably have obtained the same re-
sult if he had proceeded more methodically.   These two facts, how-
ever, belong rather to suture of the perineum than to recto-vaginal
fistulas.  Ih a case since published by M. J. Nicols in England, it is
perceived that the operator was obliged to repeat the suture three 
864
NEW ELEMENTS OF  OPERATIVE SURGERY.
times.  But  his exertions were  ultimately crowned with complete
success.
                              § IV.

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

           Article XIIL—Entero-Vaginal  Fistulas.

   Other fistulas, as those denominated entero-vaginal, have also at-
tracted the attention of surgeons.  A noose of  small intestine, or the
sigmoid flexure of the  colon when it has protruded into the recto-
uterine cavity, may on being  perforated, show itself outwards pos-
terior to and above the vagina, as has been seen by AL Roux, (Arch.
Gen.  de Med., X. XVIL, p. 300,) and also" by AI. Caza-Alayor, (Journ.
Hebd., X. IV., p. 174.)   Two very different kinds of operations, both
in their processes and in their results, have been devised as a remedy
for this description of accident, which, when  it  happens, constitutes a
sort of  artificial anus.   The patient  of M.  Roux, a  young woman
whose fistula had existed for the space of several years, having been
admitted into La Charite, was anxious at every hazard to be relieved
of her disease. The surgeon considered that he might effect the cure by
opening upon the intestines through the abdominal walls.  His inten-
tion was to invaginate the termination of the ileum, after it had been
previously detached from the vagina, into the lower end ofthe large in-
testine,  and in this manner to re-establish the continuity of the alimen-
tary canal", by means ofthe suture, according to its modified  applica-
tion in these latter times. This bold attempt was followed by the most
disastrous consequences.   The  patient died, and it  was found on
opening the dead body, that the gut which should have  been placed
downwards, had been placed in an opposite direction.   The process
adopted by M. Caza-Mayor, in his case, though more rational in  ap-
pearance, and less dangerous, did not nevertheless succeed perfectly,
the patient haying been suddenly carried off by a pneumonia.  The
instrument used by this  surgeon, is constructed upon the  same princi-
ple as the enterotome of Dupuytren.   It  is a kind of forceps, each
branch of which is terminated by an oval  plate eight  lines long, and
four lines broad, and having some teeth on its,side towards the intes-
tine.  Being introduced, one;branch through the vagina and fistula
as far down as to the perforated gut, and the other through the rectum
so as  to meet the first, the object of these plates is to approximate and
to place in contact the corresponding walls of the two portions of the
alimentary tube, to destroy immediately  the septum which results
from  this adossement,  and to  produce in this part  a  loss of sub-
stance.   The forceps  in  its whole  extent was  8 inches long; its
branches, which were articulated like a common forceps, left between
them  a sufficient space to include the  entero-vaginal  septum and the
perineum ; while a quick screw which perforated their outer extrem- 
FISSURES ANO SUTURE OF THE PERINEUM.
865
ity, allowed of their action being regulated at pleasure.  The results
took  place as the operator  had anticipated; the  stercoral matters
partially resumed their natural course, and everything led to the be-
lief that the fistula in the vagina would have speedily closed, when the
woman died, a victim  to her indiscretion.  It may, in fact,  be readily
conceived, that when an artificial perforation takes  place in the rec-
tum, the  foscal matters  might partially escape through  it; but in
regard to a primitive fistula, how can it become obliterated and cease
to receive these matters ?

    Article  XIV.—Fissures and  Suture  of the Perineum.

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

                     § I.—Spontaneous Cure.

   Thymceus  had already mentioned that a woman who  had  her
perineum  completely  lacerated, had recovered  without   any kind
of treatment.  Peu  affirms that  a patient whose perineum was rup-
tured to such extent as to render her incapable of retaining her stools
or the injections, was nevertheless perfectly re-established ; but it is
proper to add that De la Motte, who alleges that he saw this woman
thirty years afterwards in Normandy, maintains that she  was not at
all cured.  Mauriceau, in speaking of the suture, confines himself to
recommending  to women that they should  no longer bear any chil-
dren.  Deleurye says positively that these large solutions of conti- 
866           new elements of operative surgery.
nuity do not require the suture.   A perineum  lacerated as far as the
anus is,  says  Puzos, an unfortunate  accident;  but  by keeping the
limbs together by means of a bandage,'women  may, he says, be cured
full as well as by the suture.   Aitken considers  that the suture is
never admissible in such cases.   In this he is supported by M. d'Ou-
trepont and some other modern accoucheurs.   A  cure it is said was
obtained by this process in one instance by Trainel, (Journ.  Gen. de
Med., X. IV., p. 427.)  It would be going too far, therefore, to  say
with M. Roux, that no one has ever seen reunion effected  in these
cases by the efforts of nature alone.   This reunion was so complete
in a case related  by Trinchinetti, that it subsequently became neces-
sary to incise and dilate the entrance  to the vagina to allow of copu-
lation.
                               §11.

   The suture, nevertheless, which has frequently been made trial of
unsuccessfully, and again in our time  by A. Dubois, and by M. Paul
Dubois in two different cases, and afterwards by another practitioner
quoted by M. Blundell, has often succeeded.  Guillemeau, who had
to treat in this manner a laceration prolonged as  far as to the anus,
made use of one point of twisted suture and cured his  patient in
fifteen days.  De la Motte, who considers the suture infallible, placed
three points in one case, one on  the recto-vaginal septum, one on the
perineum near the anus, and  the other in  the neighborhood of the
fourchette, and succeeded without any difficulty.  M.  Morlanne, by
proceeding in the same manner, was no less fortunate in a similar
case.   The same was  the  case with  M. Montain  the younger, who
had  recourse  to  the quilled suture;  with  Osiander, who cured his
patient with the simple suture ; with Dupuytren, whose case was not
published until the year 1832;  with  M.  Rowley,  Mursina, Mentzel,
(Roux, Restaur, du Perin., p.  12—Institut. Sav. Etrang., X. V.,) and
M. Dieffenbach ;  so  that, including the case in the Ephemerides Cu-
riosorum  Naturae, science  already possessed  at least  ten examples
without  adding those which  M. Meissner attributes  to  Churchill,
Alcock, and Zang, before M. Roux again drew attention to this sub-
ject.  M. Busche extols especially the method of AL  Dieffenbach,
who, together with the simple suture,  made a long  arched incision on
each side of the laceration.  A rupture of the recto-vaginal septum
was cured by  Laugier by means of a  simple suture, as in the case of
Saucerotte, which last gave the preference to the  glover's  suture.
Without considering the  twisted suture  indispensable, I am, never-
theless, of opinion that this is the one  that deserves the preference in
every case where there is no special indication to the contrary.  This
is the one that M. Roux has made use of in all his patients, while in
the only case in which this practitioner employed the twisted suture,
he failed (Restaur, du Perin. (fee, p.  16.)  He counts at the present
day thirteen cases.   It must be remarked, however, that  two of his
patients died, in one of which (Ibid.,  p. 36,) there was only a partial
rupture, while  the other,  on the contrary, (Ibid.,  p. 27,) was placed
under very unfavorable circumstances.  M. Roux, who imputes the
rupture of the perineum in this last woman to  an operation for fistula
in ano, allowed himself to  be imposed  upon by false statements of the 
FISSURES AND SUTURE OF THE PERINEUM.
867
case.  It was  in  my  department at La Pitie where this  case had
been received, and while there she appeared to me to be  so exten-
sively ravaged by ancient syphilitic ulcerations,  that I confined my-
self to excising one of the bridles which obstructed the anus, without
deeming  it advisable  to pay any attention to the laceration of the
perineum.  Having rectified this error  in my Treatise on Accouche-
ments in  1835; I  had reason to be astonished to see it repeated in
1839 by  M. Roux, (Ibid., p. 27,)  and by M.  Mercier, his  pupil,
(Journ. des Conn. Med.-Chir., Mars, 1839.)  I  will remark, more-
over, that in two other patients  he found it necessary to repeat the
operation. A lady of New Orleans, also, who had been unsuccessfully
operated  upon by M. Roux, had the disease return, but was unwilling
to undergo another trial.   Moreover, it has been performed at the
present day  by other surgeons; M. Convers, among others,  (Gaz.
Mid., 1835, p. 44,) has employed  it in one instance with success.   I
myself have had recourse to it in two cases ; one was cured and re-
mains in  good health ; in the other death  was caused  by  a perito-
nitis at the expiration  of thirty days, though the perineum had be-
come perfectly agglutinated.   A patient whom M. Mercier states that
he operated upon, (Journ. des Conn. Med.-Chir., Mars, 1839, p. 94,)
a short time after the accident, also died.   A  circumstance which
is not  to  be overlooked is this, that after the reunion there  remains
quite frequently  a  kind  of fistula at  the lower part of the recto-
vaginal septum.  M. Roux asserts (Restaurat. du Perin., <fec, p. 24,)
that this opening  continued for a long time in the wife of the surgeon
of Valogne.  It also continued open, (Ibid., p. 31,) he says, in another
patient, after which he saw  no  more  of her.  M. Roux, in assert-
ing that  this opening has, in almost every  instance, ultimately be-
come obliterated, or so narrow (Ibid., p. 34,) that it no longer ad-
mitted the escape of anything but a small quantity of gas, does not
thereby prove that it has in reality completely closed up.   I find, in
fact, in the thesis of  one  of his pupils,  (Rampon, These  No. 332,
Paris, 1837,)  that it quite frequently remains open.  I  know a lady
operated upon by M. Roux in whom this fistula  has not diminished
any since  the year 1834.
  In conclusion, lacerations at the vulva should be divided  into two
classes:  those which extend only to the neighborhood  of  the anus,
but leave intact the sphincters and the recto-vaginal septum, consti-
tute the first class;  while  the second  comprises all those  ruptures
which completely unite the anus and  vagina, and  which  encroach
more or  less upon the septum.  When the  accident is recent, what-
ever may be the species of rupture, it is not proper to have recourse
to a surgical operation; we must then confine ourselves to the ap-
proximation of  the thighs, and to repose, and also to the keeping of
the bowels open and to various means of cleanliness.  The  tumefac-
tion and congested state of the parts, would  not  allow of the suture
succeeding under such circumstances.   I once had recourse to it in a
case of this kind and it failed completely.   If, at the termination of a
month or  two, the rupture has not reunited, nothing more is  to be ex-
pected from the  efforts of the system; but we must wait  until the
woman has recovered her strength, and  until the lips of the wound
have cicatrized separately.   We have then to ask ourselves the 
868
NEW ELEMENTS OF OPERATIVE SURGERY.
 question, which is the preferable kind of suture.   It  is certain that
 the simple suture would succeed in a very considerable number of
 cases, even where there was a rupture of the entire  perineum.   De
 la Motte, contrary to the assertions of M. Roux, has positively used
 this suture with entire success.   I have already said  that it was no
 less efficacious in the hands of  M. Morlanne.  Nevertheless, if the
 simple or twisted suture in reality answers in cases of partial rupture,
 as is  proved, moreover, by the numerous  examples of episiography
 published by M. Fricke, and by my own cases, it is also certain that
 where the rupture is complete this suture, in many  cases, will  be
 found to be uncertain or insufficient.
   A.  Partial ruptures.—Those fissures of the perineum, which stop
 in front of the anus without including the recto-vaginal septum, do
 not disturb the functions of the rectum, but  they favor  the descent
 of the uterus, and may be attended with unpleasant consequences in
 respect to the conjugal relations and duties. It is  allowable, there-
 fore, to undertake their cure when this is desired by the woman.   In
 these cases the twisted  suture, or better still, the  simple interrupted
 suture, will almost always be found sufficient, and possesses scarcely
 less efficacy than the quilled suture.
  I. The woman should be placed in the same way  as for the opera-
 tion for lithotomy.  The surgeon being in front,  and  either seated,
 standing up,  or on his knees, begins by abrading the borders of the
 fissure.   For this purpose he removes from it a pellicle, commencing
 at the neighborhood of the anus, and  proceeding to the distance of
 an inch and a half or two inches in front.    The excision should be
 carried through the entire depth  of the fissure, from  the cutaneous
 tissue to  the inner membrane  of the vagina; we should take  care
 also that all the points of the periphery of  this fissure are completely
 rawed, without excepting  the lower extremity of  the  posterior co-
 lumna of the vagina, which in such cases usually makes  a very con-
 siderable projection at the deep-seated border of the wound.
  II.  After having wiped off the blood, which sometimes flows out in
 considerable  abundance, the surgeon inserts the threads, one behind
 in the direction of the  anus, another in  front towards  the  nymphae,
 and the third at the middle portion.  For this purpose, beginning al-
 most indifferently with the first of the last, he seizes and plunges  in
 from  without inwards, and  with his  right hand, a curved needle
 through the left lip of the wound, taking care to enter at from four
to six lines outside of the  bleeding surface, and to come  out very
near the mucous tissue.  A good  pair  of  forceps, when the fingers
 of the left hand are not found  sufficient, will serve to support the
 tissues while  they are being thus perforated.  The needle is then im-
 mediately conducted with the same hand from within outwards, and
 from the bottom of the wound, through the other lip of the  division,
 in such manner that it may come out through the skin  at  the same
 distance from the abraded tissues.   We proceed in  the same manner
 for the introduction of the  second and  third thread.   I would how-
ever remark, that  it would be possible, if we begin  by the upper
thread, to make traction upon its  two  extremities, in  order to  give
tension to and to approximate the division, so that by placing the two
fingers of the left hand outside of  this division, as if for the purpose 
FISSURES  AND SUTURE OF THE  PERINEUM.
869
of pinching up its sides, we would  be enabled by one movement to
introduce-the needle through the entire thickness of the tissues, which
are to be embraced by the suture.  It is also important that the mid-
dle thread should comprise in its  noose the abraded extremity of the
posterior columna of the vagina,  at the same time that it includes the
sides of the wound.
   III. Having arrived at this point, the operation has no longer any
thing remarkable ; each of the threads is knotted on  one side by a
simple knot, supported by a bow, and in such manner as  to exercise
a certain degree of constriction on the parts.  In case the  twisted su-
ture should have been preferred, we would have  nothing more to do
than to introduce each of the needles or strong pins,  with the same
precautions, or in the same manner as in the preceding case.  After-
wards throwing a noose of thread round,their extremities, we would
proceed in the same manner as  has  been described  in treating of
twisted suture in general, except  that their points and  heads would
have to  be  afterwards  carefully  protected   and raised  up,  be-
cause of the perineal groove where they are  obliged  to remain  im-
bedded.  As the quilled suture does not require any other rules under
these circumstances than in the  following case, it is unnecessary to
dwell upon it at this time.
   IV. Subsequent treatment.—In order that the operation may suc-
ceed, the woman is required to remain for a week at least at rest,
with her thighs kept together, and not to evacuate her urine sponta-
neously.  It is advisable also that she should not  be compelled to go
to stool, and that the perineal region, though not requiring  any cover-
ing, should be cleansed  and carefully washed several times a day.
A catheter left in the bladder irritates and fatigues  the patient  too,
much;  it is better to introduce it every eight or six hours.  A meche
in the anus is only calculated to  jeopardize the success of the opera-
tion.  Nor does the one which could be  introduced through the  re-
mainder of the vulva, or through the anal angle  of the wound, into
the interior of the vagina, appear to me of any more utility.  Nor are
the lateral incisions, which are made by M. Dieffenbach under these
circumstances, any more indicated in these cases ; for the tissues  are
naturally so pliant that it does not become necessary to make any great
degree of traction upon them to bring the lips of  the wound into  ex-
act coaptation.  The reunion is usually so far advanced at the sixth
day, that  the ligatures, which are then generally  loose and movable,
may be divided and withdrawn without any inconvenience.  Before
doing this, however,  it is well to encourage a stool by means of one
or two glasses of Seidlitz water, in the same way as we should in  the
beginning have dissuaded from any inclination of this  kind by means
of opiate preparations.  Some days more are still required to con-
solidate the agglutination of the parts, and it would be dangerous to
allow the woman to separate her thighs  or legs  entirely before  the
tenth or twelfth day.   Injections  into the vagina, and lotions exter-
nally, with emollient, detergent, or antiseptic  liquids, would be  advi-
sable, during the first days after the operation, if purulent or  other
matters should have accumulated in quantity in the vagina or upon
the perineum.
  V. Dangers.—However simple  and innocent  this operation may 
870          NEW ELEMENTS OF OPERATIVE SURGERY.
 appear to be, it nevertheless sometimes exposes to the risk of serious
 accidents.   Two ladies upon whom it was performed, were seized on
 the third day with  a hemorrhage, which continued in one of them to
 the termination of the  second week, and  which in both of them was
 sufficiently copious to  cause repeated syncopes, and  to give  me se-
 rious alarm.   Notwithstanding  which, no artery  of any importance
 had been opened, but  the blood escaped by exhalation; but I could
 not assert that  it came rather from the  bottom  of the wound, than
 from the inner  surface of the vagina or uterus.  A young woman who
 was operated upon in this manner, and who did very well until  the
 tenth day, was then attacked with obscure pains in the bottom of the
 pelvis, and soon after with a peritonitis, which ended in death.
   B. Complete Ruptures.—It was for cases principally in which the
 perineum was completely ruptured, that AI. Roux proposed the quilled
 suture.   This surgeon having failed with the simple suture,  in one
 instance in which he used it, supposed that this result was owing to
 the circumstance that the bottom of the parts  had not been kept in
 perfect contact; from  that time, his method has not changed.  The
 woman is placed and supported in the same manner as for the suture
 of partial divisions.   The abrasion of the parts is effected also in the
 same way, and with the same precautions.  It is necessary, moreover,
 that it should be performed upon the anterior half of the anus, and the
 border ofthe recto-vaginal septum.  The threads should each con-
 sist of a ligature two lines broad, terminated on one end by a noose.
 The other extremity is inserted through  the eye of a long,  strong
 curved needle,  with a very sharp cutting edge.   They are plunged
 in and brought  out  at  6 or 8 lines distance from each side  of the
 wound.  We must  commence with the ligature that is nearest to the
 anus, so as to endeavor to comprise the  extremity of the septum in
 its noose.   The two other ligatures are to be made to pass as near as
 possible to the mucous membrane of the  vagina.   The second stage
 of the suture  consists in adjusting the  supports (chevilles,)  and knot-
 ting the threads.  We  pass therefore, for this purpose, the end of a
 gum-elastic sound or bougie, which is of an exact cylindrical  shape,
 into the noose of each ligature which has been left expressly for that pur-
 pose, on the left side of the rupture.  We place another on the oppo-
 site side, between  the two separated halves  of each of  the same
 threads, in order that by means of a simple knot, the two cylinders
 may be approximated  together, while they compress  in a uniform
 manner the bottom of the two  sides of  the division  throughout its
 whole length.   These last knots being each fastened by a bow, com-
 plete the quilled suture.  In order to remedy the  swelling and sepa-
 ration even of the lips of the fissure on that portion of the integuments
 which is not supported, we pass around  the cylinders, and in  the in-
 terval of each point of suture, another thread, the two halves of which
 are to be crossed in front of the wound before knotting them on one
 of its sides.   We have in this manner all the advantages of the sim-
 ple with those  of the  quilled suture.  The needles made use of by
M. Roux, from being uniformly curved into half circles, do not pene-
trate the tissues without difficulty, and are not of very easy applica-
tion.  M. Vidal, in  fact, has devised  others which are much more
convenient; they are merely common needles, almost straight, with 
             FISSURES AND SUTURE OF THE  PERINEUM.          871

 an eye near the point to receive the ligature.  After having inserted
 them as I have said above, through the left lip of the wound, he dis-
 engages the thread from the eye, and withdraws the needle ; then
 inserted from without inwards, through the right lip, this needle again
 arrives into the bottom of the wound, to be armed there with the lig-
 ature, which it brings out in returning from it.  The rest of the suture
 has nothing further of a particular character.   As to myself, having
 made use of ordinary suture needles of some strength, 1 have found
 their application so convenient that I have had no occasion to think of
 making trial of others.  It would appear to me, however, that for
 penetrating a  considerable thickness  of tissues, M.  Vidal's needle
 would possess some advantages over those of M.  Roux.   In what-
 ever way the quilled suture has been applied for complete ruptures of
 the  perineum, it  requires precisely  the  same  precautions  as those
 which I have described above.   It is better in all cases to encourage
 a few stools by means of a laxative rather than  by  injections, and on
 the day before dividing the threads rather than immediately after.

                   § III.—Process of Montain.

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

                     § IV.—Cauterization.

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

                               §  V.

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

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

       Article XV.—Dystochia, (Difficult Parturition.)

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

                     § I.—Symphysiotomy.

  Some moderns,  on the strength of a vulgar tradition  mentioned
by Riolan and Pare, and which has given rise to an opinion among
the people that in different countries the pubes are ruptured in female
infants at the time of their birth, in order  that parturition afterwards
may be rendered more easy, have supposed that symphysiotomy was
practised at the remotest antiquity. It is true that De Lacourvee, who
wrote in 1655,  makes mention  of a woman who  died  before being
delivered, and  in the dead body of whom he divided the symphysis
pubis, with a view of enlarging  the pelvis ; also that Plenk proceeded
in the same  manner, in   1766, on another  subject.   But it is never-
theless certain, that no one  had formally thought  of proposing this
operation on woman during  life until Sigault, who was yet a pupil,
made it the subject of a memoir which he read in 1768 to the Acad-
emy of Surgery.   It is  the  only certain  means which we can  have
recourse to, to save the  infant:  1. When  the head  is closely wedged
in the upper strait or below it; 2. When the head has passed through
the abdominal strait and has become arrested  by the narrowness of
the perineal circle ;  3.  When,  after the trunk is delivered, the head
is found retained in the cavity.   In such cases it is preferable to the
Cesarean operation, even after  the death of the woman, because it
would be next to impossible to extract the foetus alive through the
walls of the abdomen.
  A. Ordinary Process.—The patient being placed upon an operating
table or upon a bed, in the same way  as  for introducing the forceps,
with her  lower limbs slightly  flexed  and properly separated apart, 
dystochia.
873
is to have her shoulders supported by an assistant; two others take
charge of her knees ; a fourth stretches the integuments of the abdo-
men ;  and to the fifth is assigned the duty of handing to the operator
the instruments he  may require.   The  surgeon, seated or standing
up, to the right or between the  legs  of the woman, makes with the
convex bistoury an incision which should commence a little above
the symphysis  and  be  prolonged to the  upper  part of the clitoris.
This incision, which comprises the  skin, which has been previously
shaved, and all the soft parts of the mons veneris, will be parallel to
the axis  of the body, and fall as accurately as possible upon the
middle of the articulation.  At its lower part, however, it is well to
incline it  a little to one side between the apex of the labium majus and
labium minus, or even to separate from the pubic branch one of the
roots of the clitoris, in order to avoid afterwards dangerous lacera-
tions.   There  can be no other than  small arteries to tie, unless the
internal pudic has been divided  by prolonging with too little caution
the division of the parts below.
   To  divide the  cartilage, the most certain mode is to incise it  from
above downwards and from the cutaneous to the pelvic side of the
symphysis. It will always be found sufficient to restrain the bistoury
to some lines from its point by  means of the two first fingers of the
left hand, while the cutting edge is  made to operate with the right
hand.  This inconvenience also  is  prevented by introducing  the
catheter at the beginning or at least before commencing the second
stage  of  the operation.  By this means we empty the bladder, and
the catheter afterwards serves to push the urethra to the right, while
we slightly incline to the left the incision of the infra-pubic ligament.
The ligamentous matter having been divided, greater precautions
are required, and we no longer  cut  except by drawing upon,  so to
speak, the point of the instrument, and we cease to make  use of it
as soon as we encounter nothing more to divide of an elastic or re-
sisting nature.
   B.  Various Processes.—We might also, as M. Imbert appears to
have done in several instances on living women, as was done, it is said,
in 1780, at Utrera, in Andalusia, as is suggested also by Aitken (Journ.
de Med.,  X. LV.,) and advised by M. Petrequin, (Bull, de  Therap.,
X.  XL, p.  275,) divide  the cartilage  from below upwards, and  from
behind forwards as it were  by puncture, so  as to leave the integu-
ments intact in front.  If  it should happen  that the  symphysis was
ossified, there would be so little chance of obtaining any  considerable
degree of enlargement, that in place  of sawing through the articula-
tion, as Siebold has done,  I would  prefer having recourse  to the
Cesarean section.   In  applying  the saw on the body of the bone it-
self, outside of the symphysis, as is recommended by Desgranges, the
operation would be neither more nor less dangerous, for it  is in the
sacro-iliac articulations that the difficulty is found and not in front.
   C. The separation  of  the cartilage is scarcely effected when the
posterior  branch of the angular lever formed by the  os ischii, acted
upon by the elasticity of the posterior ligaments, produces a certain
separation between the bones of the pubis, which must vary also ac-
cording to the degree of narrowness of the pelvis, and that of the
consistence or softening of the symphyses.  Moreover, I  can scarcely 
874           NEW ELEMENTS OF OPERATIVE  SURGERY.
believe that this, of itself, can go  so far as to become dangerous, or
that it can  be necessary to limit  it. as has been recommended, by
compressing the hips before terminating the operation.  On the con-
trary, we are almost always obliged to make pressure with gentleness
and moderation  from before backwards, and  from within outwards,
upon the spines of the ilium, or to  separate cautiously the thighs of
the woman, in order to enlarge the opening to the proper extent.
  D.  The parturition having been accomplished, the surgeon washes
the woman, approximates the bones of the pubis together, and covers
the wound with  linen besmeared with cerate, and with lint and com-
presses, and supports the whole by means of a body-bandage drawn
sufficiently tight to make partial resistance at least,  to the re-separa-
tion of the bones.   The patient should  continue on  her back, and  in
the most perfect state of rest.  Her thighs especially, are to be kept
in a state of absolute repose for the space of six weeks or two months,
which is the time required  for  the consolidation of the symphyses.
In other  respects we proceed in the same way in the treatment as for
grave operations, taking care to combat  the symptoms with energy
if any should supervene.  As the termination Of the cure approaches,
no movements or walking are to be permitted except with the great-
est degree of caution.   If there should  be ever  so little mobility or
pain remaining in the pelvis the patient should again be placed in re-
pose for a certain length of time.   It is not often found practicable for
the patient to stand up or walk without danger until at the expiration
of three  or four  months.  Nothing, doubtless, would be more de-
sirable than the consolidation of the divided symphysis ; but women
in whom this has not taken place have, nevertheless, been enabled to
walk and to stand  up, and even jump without being sensibly incom-
moded by it; a  peculiarity  which is explained by  the great degree
of solidity which has been acquired by  the posterior symphyses.  A.
Leroy and AL Lescure go so far as to say that we ought to  encou-
rage this by withholding any bandage from about  the  pelvis;  they
allege, and perhaps without  being  entirely erroneous, that the inter-
pubic void  is then filled up, by a cellulo-fibrous tissue,  which impairs
in no respect the resistance of the articulations, and  by which means,
therefore, the woman would be afterwards delivered with much more
ease.
  E.  Process of M.  Galbiati.—AL Galbiati, of Naples, substitutes
for  symphysiotomy another operation, which, properly speaking, is
nothing else than a modification of what  had already been proposed
by Desgranges.   In place of dividing  the  cartilage, he recommends
that we should make the section of the  body and branch of the pubes
on both sides, between the infra-pubic foramina, as had already  been
recommended by Aitken.  By this process the sacro-iliac symphyses
remain intact; we run no risk  of wounding the bladder or urethra;
no traction  scarcely is made on  the  cellular tissue  of the pelvis;
the consolidation is readily effected ; no abscess,  caries, fistula,  clau-
dication or peritonitis are to be apprehended, and we obtain a  con-
siderable degree of amplification in the sacro-pubic diameter.  Some
trials made upon the dead body, and certain experiments which  have
been undertaken by AL Ashmead, induce me to believe that we ought
not to precipitately reject the suggestion of the Neapolitan professor, 
DYSTOCHIA.
875
though the  essays  which he  has hitherto  made  can scarcely be
considered encouraging.  The  operative  process, in his method,
moreover, would  be rendered very simple, if, as M. Stoltz (commu-
nicated by the author, October 1st, 1837,) recommends, we  should
make use of Aitken's saw, conducted through a small  incision of the
soft parts, in order to saw the bones from behind forwards.

                   §  II.—Cesarean Operation.

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

              §  III.—Examination of the Methods.

   When the Cesarean operation  was not  had recourse to until after
death, it was performed on the left side  of the abdomen: the  wo-
man,  says Guy  de Chauliac, was  opened  by means  of a  razor
along the left side,because of the liver, and so much the more so from
this part being more free than the right side ;  but  since it has been
performed  on living woman, it has been  subjected to more rational
rules.  Among the different processes recommended by accoucheurs,
there are five which have more especially  attracted attention; in  one
the incision is made  on the median  line, parallel to the axis of the
body;  in the second, outside of the rectus abdominis muscle;  in the
third, the abdominal walls are divided transversely on one side; in
the fourth, the wound is made immediately above and  in the  direc-
tion of Poupart's ligament; finally, the operation in the fifth variety
is  performed on a line with the crest of the ilium.
   A. On  the linea  alba.—This  process, preferred  by  Baudelocque,
and now generally adopted in France, England, and Germany, en-
ables us to avoid the muscles, to  divide only upon the linea alba,  and
to inflict but very little pain; no artery can  be wounded, and we in-
cise the uterus moreover in a direction parallel to its principal fibres.
   B. The ancient accoucheurs, in operating upon  the side, selected
m general the left one, and made an  incision sometimes straight, at
other times slightly oblique, and occasionally in the form of a cres-
cent, but always immediately outside ofthe rectus muscle.  Accord-
ing to those physicians who have adopted this method, it has over the
preceding the advantage of preventing the bladder from being in  any
manner wounded, of  allowing of a ready cicatrization, and of pre-
senting less obstruction to the  discharge of  matters which must es-
cape from the wound.   As the uterus has almost always undergone
a twisting movement  upon  its  axis by becoming inclined to the right
or to the left, it has been supposed that by incising upon the median
line we should come down nearer to its left border than to the mid-
dle of its anterior region.  It  was also from this  consideration  that
the recommendation has been given to operate upon the side toward
which  the uterus has naturally become deviated.  In admitting these
advantages to be well founded, they would  nevertheless, as it ap-
pears to me, be more than counterbalanced  by the danger of wound-
ing the epigastric artery or its branches, of  having  a solution  of con-
tinuity, the lips of which, in consequence  of the retraction of the ob-
lique and transverse muscles, it would be  almost impossible to keen 
DYSTOCHIA.
877
 in a state of approximation, and by the impossibility of obviating the
 defect of parallelism in the wounds of the uterus and abdomen.
   C. Lauverjat, who at  first  considered  that there would be  great
 advantages for hysterotomy upon  the linea  alba, endeavored, in
 order to avoid the inconveniences connected with the two  methods
 above,- to  systematize a process which  had  already been in  use
 among some practitioners, and recommended that we should make a
 transverse incision, five inches  long,  upon the  side, between  the
 rectus muscle and the spinal column.  By proceeding in this manner,
 he says, we  separate  rather than divide the fibres of the transverse
 muscles;  we  avoid  the  epigastric and lumbar arteries; and  come
 down upon the fundus of the uterus, the cavity of which forms a fun-
 nel which readily admits of the escape of the lochia through the va-
 gina and wound. The parallelism is very easily preserved, the suture
 becomes unnecessary,  and the simple position is all that is required
 for keeping the lips of the division approximated.  Finally, from the
 external angle of the wound occupying a depending position, effusions
 into the abdomen are infinitely less to be apprehended  than in  the
 other methods; but  it may be  objected  to this  method, that  the
 fleshy fibres  of  the  external  and  internal oblique  muscles  have
 necessarily to be divided, that the slightest effort  must protrude  the
 viscera externally, that the uterus from being divided transversely
 upon its fundus, the  part where its vessels are of the largest dimen-
 sions, must soon become separated to a considerable distance  from
 the external opening, and that  its fibres in  contracting must rather
 interfere with than favor the approximation of the borders of the
 internal division: so  that  notwithstanding the two successful results
 obtained by Lauverjat, and the preference which appears  to be given
 to this method by Sabatier and Gardien, it is scarcely attended with
 less danger than the two others.
   D.  At the iliac fossa.—I. M. Ritgen especially dreading any wound
 to the peritoneum and body of the uterus,  has recommended that we
 should incise transversely the attachment of the large muscles of the
 abdomen above  the crest of the ilium, detach the  peritoneum down
 to the upper strait, and divide the neck of the uterus to  a sufficient
 extent to allow of the  extraction  of the foetus.   In the first place I
 cannot see how it could  be possible  to open into the apex of the
 womb without dividing the serous membrane which covers it;  then
 again the difficulties inherent in this process, together with  the dis-
 section which  has to be made in the iliac fossa, do not  appear to me
 calculated to  render  the  operation less  dangerous than those which
 have  been mentioned.   As far  moreover  as  I  am informed, this
 method exists as yet only in idea, and nobody, up to the present time,
 has ever performed it upon living woman.   -
  II. M. A. Baudelocque, considering that  the principal  dangers of
 the Cesarean operation are to be imputed to the double lesion which
 is made in the peritoneum, and regarding wounds of the uterus as
 almost necessarily fatal,  has proposed a method which, under  this
 combined aspect of the subject, appears to  him  to be infinitely pre-
 ferable to all the others, and which in reality differs but little from the
 preceding.  His  incision, which begins near the spine of the pubis, is
prolonged in a direction  parallel to Poupart's ligament  as  far as 
878           NEW  ELEMENTS OF OPERATIVE SURGERY.
beyond  the antero-superior  spinous  process of  the  ilium.   He
selects the left side  because of the inclination of the neck when the
uterus has deviated to the right, and the right side in the contrary
case.  After having divided the abdominal wall without touching the
epigastric artery, he pushes back the peritoneum from the iliac fossa
as far down as into the pelvic cavity, and detaches from it, the upper
portion of the vagina, which he opens  into.  Through this opening,
which ought to have a certain extent, the finger is to be introduced into
the uterine orifice, which we endeavor to draw towards the wound in
the belly, at  the same time that we make pressure on the fundus of
the uterus in an opposite  direction to favor its inversion.  When we
have succeeded in placing the neck in relation with the opening
through  the abdominal walls, we  leave  the labor to the contractions
of the uterus, or should it  become absolutely necessary the uterine
orifice is to be dilated  with the fingers, when  the foetus  can be
extracted either with the hand or with the forceps.
  III.  Mdme. Boivin and Chas. Bell, having a special dread of he-
morrhage after the Cesarean operation, also felt the necessity of in-
cising the uterus as  near as possible to its  apex, which is the part
where there are scarcely any vessels to be found.  It would  be dif-
ficult for me, however,  to  believe that an  operation of this kind
could be practicable in the majority of cases, or that the laceration
of the vagina, with the  destruction necessarily made in the iliac fossa
or cavity, would be less dangerous than the simple methodical incision
of the peritoneum or uterus, in the manner it may be  performed in
the usual operation of hysterotomy.  I may add also that M. Baude-
locque, after having made trial of his  operation  of elytrotomy in a
woman whom he met with a long time  since, and  in which case he
was assisted by M. Hervez de Chegoin, nevertheless deemed it ad-
visable to recur to the Cesarean operation, properly so  called.   A
single fact, I am aware, does not  authorize  us  to form rigorous con-
clusions ; but this one,  and which is the  only one in  relation to living
woman, appears to me to impart a great degree  of force to the ob-
jections which had been a priori  entertained  against the ideas of the
author.
  IV.  Another mode of operating, which is somewhat similar to that
of M. Ritgen, and which also does not appear to  differ much from
that of M. Baudelocque, appears to have been  proposed almost  at
the  same time by Physick.  From having remarked that in pregnant
women the  peritoneum  is easily  separated  from the bladder  and
neighborhood ofthe neck of the uterus, this surgeon supposed that by
making a horizontal incision immediately above the pubis, we might
reach  the  apex of the womb, and open into it, without wounding
the serous abdominal membrane  ; but  whatever M. W. E.  Horner
may say on this subject, this operation is but  little worthy of its in-
ventor, and is not of sufficient importance to be dwelt upon.

                   §  IV.—Operative Process.

  We should never neglect to empty the rectum  and bladder before
commencing the Cesarean  operation, especially when we propose to
follow the process  of Mauriceau.   The articles required, consist of 
DYSTOCHIA.
879
a convex and probe-pointed bistoury, forceps, scissors, suture needles,
ligatures, tubes of quills, adhesive plasters, and lint in the form of
small balls, and gateaux.   There will also be  required portions of
linen spread with cerate, long and. square compresses, a body ban-
dage, large fine sponges, a syringe, canulas of gum-elastic, in case of
the necessity of injections, tepid and cold water, vinegar, wine, and
eau de  cologne.  The patient is to be placed  as  far as  practicable
upon the bed,  where she is  to  be continued during the first days
after the operation.   Her position ought not  to be disturbed.  Being
placed  on her  back with her head moderately elevated, and her legs
and thighs slightly flexed, the assistants are charged to  pay  attention
to any sudden movements that she may be induced to make from the
pains.   Two intelligent assistants are to apply their hands  upon the
sides and fundus of the uterus, so as to circumscribe it completely, in
order that no organ may slip between its surface and the abdominal
walls, and that it may, so to speak, constitute one  united mass with
these last mentioned parts.   To effect this purpose, the  naked hands
appear to me to be not quite so commodious, as when  they are ap-
plied over large portions of sponge, as recommended by MM. Hede-
nus and Kluge.   The surgeon, with a convex  bistoury, incises the
integuments from the neighborhood of the umbilicus to the pubis, to
the extent of from five to six inches. The sub-cutaneous tissue, apo-
neurosis, and  muscular fibres, as well as  the cellular tissue, are,
should  we not  operate upon the median line, divided in  succession in
the same manner and to the  same extent. The incision ought not to
descend too near to  the  symphysis, because of the proximity of the
bladder, and that the walls of the abdomen  in this part usually pos-
sess a great degree of thickness.   It would be better  to prolong it
above the umbilicus, while taking care to pass to the left of this ci-
catrix,  in order to avoid  the  umbilical vein, and especially the anas-
tomoses which may exist between  it and the epigastric vein.   After
having  opened through the peritoneum in such manner as to allow of
the introduction of the left forefinger, which is to serve  as a director
to the  instrument, we enlarge the  wound  with  the probe-pointed
bistoury, so as  to give it the same extent as the  division of  the skin.
If, as I  saw in  the case operated upon by M.  Dubois in  1839, the in-
testines should, notwithstanding all our efforts, escape externally, it is
to be well understood that they are to be reduced before we go any
farther.  The uterus  is now exposed to view.  We incise it layer by
layer, and with caution, until we come  down to the  surface of the
fbetal membranes; in  order to preserve as much length  as possible to
its neck, we direct the assistants gently to depress  its fundus by ma-
king a  vibratory movement  upon  it forwards.   We might, in fact,
after the manner of M. Kluge, seize hold of  the lower and  deep an-
gle of the  wound in order to effect, or at least to favor a movement
of this  kind, which by enabling us to prolong the section with ease
very high up, would allow us to respect the apex of the uterus.  Nor
can I see moreover any inconvenience in separating beforehand with
the finger, the  placenta and the membranes  to a certain extent.  It
is at this period, and  not  before  commencing  the  operation, that it
might perhaps  be allowable to follow the recommendation  of Plan-
chon, and to rupture the membranous bag in the  upper part of the 
 880          NEW ELEMENTS  OF OPERATIVE SURGERY.

 vagina,  either by means of  the  fingers or  Siebold's  instrument.
 Upon the supposition that we perforate the membranes of the fostus
 through the wound, which appears to me to be the preferable course,
 it is important that the assistants redouble their  attention, in  order
 that the abdominal walls may not be separated from the uterus. We
 should by this means oppose an obstacle to the effusion of the waters
 into  the  peritoneal cavity,  while  the  tendency  which  the viscera
 have to escape outwards would be effectually resisted.   The ex-
 traction of the infant is to be made without delay  ; when it presents
 itself by the head or breech, we  draw it out in this position, and in
 order to aid its escape, direct the assistants to  make gentle pressure
 through the walls  of the belly upon the sides of the uterus.  Should
 it present itself in  another position, we seize it by the feet, and ex-
 tract it  with the same  precautions as in parturition through the natu-
 ral  passages, while taking care  especially not to displace or make
 traction upon the lips of the division.   Immediately after the extrac-
 tion of the foetus, the placenta is soon forced by the contraction of the
 uterus to protrude itself  into the  wound.  We  grasp it by one of its
 borders, when that can be done, rather than make  traction only upon
 the cord.  As to the membranes, we  take care to roll them up in
 cords as in natural labor, in order to prevent any of them being left
 in the uterus.  If blood has been effused or formed into clots, it is to
 be removed with the  hand.   It would be well, moreover, to cleanse
 all the parts with an injection of  tepid water; but I do not think that
there would be any utility, with a view of keeping the neck open, to
place a  thin  meche in  it  as  recommended by Baudelocque, nor any
species  of canula whatever.   These  means would not  prevent the
orifice from  closing, and  without conferring any  advantage would
augment its  irritation.  The finger, which is to be occasionally intro-
duced, will be sufficient to open it again, should it cease to give egress
to the matters, which nothing  in  fact  can prevent,  from passing
wholly or in part through the wound.

                              § III.

  The operation being terminated, we have to look to the  suspension
of the flow  of blood.  In the lateral  process, and especially in that
of Lauverjat, several small arterial branches may have been divided,
which are to be constricted by the ligature or by  torsion, unless we
should prefer to  do this in proportion as they have been opened.
During  the  operation  the principal orifices of the uterine arteries
 should have  been  closed by the fingers of the assistants, nor has it
ever  been deemed proper to  apply a ligature to  them.   After the
lapse of a few minutes the incision in  the  uterus is reduced to the
 extent of one or two inches, and from that time every kind of hemor-
 rhage becomes impossible.   The wound of the abdomen is usually
reunited by means of the interrupted or twisted suture, which is the
only  means of preventing a protrusion  of the viscera.   The lower
angle of the division should  be left free to enable the discharges to
escape and to allow the meche, one extremity of which  is to be in
the uterus, to conduct them to the outside.  The  points of suture,
moreover, do not  prevent our applying adhesive plasters between 
VAGINAL  UTEROTOMY.
881
 them, nor from assisting their action by means of a uniting bandage
 and a favorable  position.   The wound is afterwards to be covered
 with a perforated linen.   Two long and large compresses are placed
 upon  the  sides.   Plumasseaux and ordinary compresses, with the
 body bandage, all properly applied, will complete the dressing.  An
 antispasmodic potion, rendered slightly opiate to calm the  nervous
 agitation, proper precautions to enable the lochia to escape through
 the vagina, and not to become effused  into the belly, with  diluent
 drinks, and should the slightest  symptom of inflammation supervene
 bleeding and leeches, together with the most perfect repose of body
 and mind, constitute all  the advice  that the surgeon can give to the
 patient to prevent the dangers with  which she is threatened.

             Article XVI.—Vaginal  Uterotomy.

  There may be a  great number of reasons, according to authors,
 which  would render it necessary to  have recourse to the vaginal
 Cesarean operation.  An obliteration with a fibro-cartilaginous indu-
 ration of the neck, as in the case related by Simson, and even in the
 one mentioned by Van Swieten ;  violent convulsions, which put the
 life of the  woman in danger while the orifice is too tense or still too
 little dilated to  allow of the introduction of the hand, as is seen in
 the cases of Duboscque and Lambron; as also an extreme obliquity
 ofthe orifice backwards, at the  same time that the head ofthe foetus
 drags into the cavity and to the  vulva the anterior wall of the uterus,
 which it distends, attenuates and  ultimately lacerates, if we do  not
 hasten to make the incision, as Lauverjat did,—constitute the accidents
 which have in most cases required this operation.   It may also be-
 come advantageous when the uterus, after having escaped from  the
 pelvis, during pregnancy, has not  been reduced, and when its neck
 cannot be dilated by means  of the fingers, even though there be dan-
 ger in retarding  the labor, examples of which are related by The-
 nance, Jacomet and  a surgeon of Vaux, cited  by Bodin.  But it  has
 been more especially proposed in cases of scirrhosities, and when
 the orifice  presents so great a degree of resistance that the woman is
 exhausted in fruitless efforts to effect its dilatation.  Finally, it would
 be also applicable, as Bodin has endeavored to demonstrate, in cases
 of presentation of the arm, should it ever be in  such cases actually
 impossible  to make an attempt to seize the feet, and should there not
 be other means of avoiding the amputation of the limb.   The specu-
 lum, which is employed by  some persons, is not necessary for this
 operation.   By means of the probe-pointed  bistoury protected by a
 bandage and guided  by the finger, we readily reach into the neck, if
 it is not  too distant  from the pelvic  axis.   In the contrary case,  we
 should have to replace the straight bistoury by the curved bistoury
 of Pott.  In a case of necessity, we might confine ourselves to a sin-
gle incision; but as it is important that this should  not be too deep,
 we should give the preference to several incisions made at a certain
distance from each other.    At  first  sight it would appear that the
passage of  the head  could  not  be effected  without  enlarging such
wounds so much  as to prolong  them to  the body of the uterus and
to lacerate the peritoneum.   Nothing of this kind, however, happens,
                              56 
882           NEW ELEMENTS OF OPERATIVE  SURGERY.
and they are usually restricted to the tissues of the neck.  When we
operate for a scirrhous or fibrous induration, it rarely happens that it
gives rise  to a discharge of more  than  a few ounces of blood.   In
such cases Duges recommends and with reason, as I conceive, that
we should  at the same time remove all the diseased parts, in place of
merely incising them.   When we divide  the anterior wall of the
uterus without going as far as the orifice, we are obliged in begin-
ning the operation, which is always more delicate than in the prece-
ding case,  to make  use of a straight or convex  bistoury which is
not probe-pointed.  In making the incision we cannot observe too
much caution to  prevent  our wounding  the part of the foetus which
should first present itself.   When, however, we have penetrated into
the uterus, the finger becomes a sure  guide, and the wound may be
enlarged by the instrument, without any danger, to as great an extent
as may be  necessary.  We will remark, however, that there would
not be as much  danger in  prolonging it  posteriorly as in front,  be-
cause of the proximity of the bladder, and that it would be, more-
over, useless to give it any great degree  of extent.   After the deliv-
ery this wound  contracts very rapidly, and frequently the neck has
already resumed its natural position before the lapse of half a day.
Should the blood flow in too great quantity, injections wifh the oxy-
crat, together with tamponing, would in general  arrest  it without
any difficulty, and cauterization, which could also be  applied with
facility, could but rarely become indispensable in such cases.  As to
the lochia, they will make their escape either  by the neck or by the
wound, and the  woman, in this respect,  does  not  require any other
attentions than those which are had recourse to after ordinary partu-
rition.   As to what  relates  to  cephalotomy, the employment of
crotchets, cords, forceps, turning of the child, <fec, I  do not think
it necessary to repeat them here, as I have entered in detail upon these
subjects in the second volume of my Treatise on Tocology, and so
much the less  as such operations belong exclusively to the province
of the accoucheur.  If I have allowed myself to say a word on the
subject of symphysiotomy and the Cesarean  section, it is because the
surgeon is sometimes  sent  for to perform these operations, even by
those  persons who exclusively occupy themselves with obstetrical
practice.  I refer also to what I have said, farther back, on the  sub-
ject of the occlusion ofthe neck ofthe uterus  and of the vulva.
  [Cesarean Operation.—The Cesarean operation on the linea alba,
by Dr. Wolff, in the  case of a woman aged 24, (Neue Zeitschrifft
fur Geburtskunde, Von Busch, d'Outrepont, Ritzen and Siebold, 1840,
t. XIX.,—also, Arch. Gen.  de Paris, 3d ser., t. X., 1841, pp.  499,
500,) in whom the head of the child, although perforated by the for-
ceps, could not, in consequence of the narrowness of  the pelvis, be
extracted, was perhaps not  altogether justifiable, though the mother
did recover.   Because in the methodical course of proceeding, at-
tempts  should, as the editors of the  Archives say,  have been  first
made to turn the child, as the upper  strait  had full  two inches and
a half in diameter, and had not that succeeded, the foetus itself could
have  been detached  in  piecemeal, which was certainly preferable
to a step so hazardous as that of gastro-hysterotomy.
  Rupture  of the  Uterus  during Parturition.—M. Velpeau, re- 
VAGINAL  UTER0T0MY.
883
marking on a case of this kind, transmitted to the Paris Academy of
Medicine, (sitting of Sept.  12,  1843,  in  Arch. Gen. de Med., tome
III., 4th ser., p. 223, 224,) by M. Castelli, and in which this latter ex-
tracted the child by the operation of gastrotomy, considers it impro-
per to recur to this extreme surgical  means, until all attempts to re-
turn the child into the uterus, whether it has escaped either partially
or wholly from it into the abdominal cavity, have failed.   In  M. Cas-
telli's case, an exostosis in the pelvis is stated as the cause.  M. Vel-
peau considers that certain tumors  in this region might be readily
mistaken for exostoses.
  A remarkable case, in which  the Cesarean operation was unne-
cessarily performed by a country physician in Germany, is furnished
by Professor Behm, of Stettin,  (Neue Zeitschrift fur Geburtskunde,
1843, t.  IX.. No. 2,—Arch. Gin.  de Med. de Paris,  4th ser., t.  IL,
pp. 103, 104, 105.)   The Cesarean operation had been performed
under the erroneous impression that  there was malformation  and  ab-
normal contraction of the uterus, which on the woman who  had  re-
covered from the operation  becoming again  pregnant four years  af-
terwards, wTas  found by Prof. Behm  on examination not to exist.
There was, however, a remarkable  diminution in the depth and size
of the vagina, this cavity having an  extent only of an  inch and a half
when it terminated in  a dense fibrous contraction or stricture, pre-
senting so small an aperture that it scarcely admitted  of the inser-
tion of a crow's quill.   This may have led to the mistake ofthe pre-
vious accoucheur.  M. Behm, by means of dilatation with pieces of
sponge, succeeded  in increasing this opening to  a small extent, but
when labor came on at the  full term, a few weeks afterwards, it was
still found to present such serious impediment to  the progress of  the
membranes and  head, that  he was  obliged to enlarge it by  the bis-
toury, after which the delivery was  readily effected  by the forceps.
The mother and child were both  preserved.   It is a remarkable cir-
cumstance, say the editors  of the Archives Gen., (lb. loc. cit.,) that
the cicatrix of  the original uterine wound  should  have  not ruptured
during  the violent  contractions  of the womb for a whole day,  the
more so as it would seem that perfect  cicatrization of the uterus does
not always take  place, (see Bulletins  de la Soc.  Anatomique, Mars,
1841.) after the Cesarean operation.
  The Cesarean operation  was in one case  first performed by  the
surgeon, and in the next pregancy by nature herself!  This  is cer-
tainly one of the most remarkable cases on record and can scarcely
be credited.   The surgeon who  gives its details, Dr.  Prael, of  the
Obstetrical Institute of Hildesheim, (see Neumeister's Allgem. Re-
pertorium der Gesam. Deutsch Med. Chir. Journalistik, June, 1844 ;
also Arch. Gin. de  Med. de Paris, 4e  ser., t. VL, Sept., 1844, p. 114,
&c.,) states that in  the first  pregnancy of the woman in question, who
was twenty-eight years of age and with so contracted a pelvis as to
render parturition impossible in the  natural mode, he performed  the
Cesarean operation Jan. 11, 1842, on the  linea alba  without  the
slightest difficulty,  delivering the  child alive and perfectly well, and
closing up the wound  in the uterus  by six points of  suture.  The
child shortly afterwards died of trismus, but the mother speedily
recovered and was restored to perfect health.   This woman, not- 
884          NEW ELEMENTS OF OPERATIVE SURGERY.

withstanding the dangers in view, becoming again pregnant in Jan-
uary, 1843, and the child  being  dead, labor shortly after came on,
(July 18,) when a rupture  of the uterus and  abdominal walls sud-
denly took place, causing thus the  speedy dehvery of the  child  by
the efforts of nature alone.  The surgeon being sent for, detached the
placenta and membranes,  and  returned  the epiploon, and  then
brought  the wounds in the abdominal wall and uterus  together  by
adhesive plaster.   Their direction  was  transverse to  the original
incision.   The  most remarkable  point is  that  this woman, after a
series  of dangerous accidents,  fever, suppuration, (fee, perfectly
recovered !   No doubt the previous  operation paved the way for the
rupture.
  The Cesarean operation was, it is  stated, successfully performed
July 4, 1844, by Dr. Bresciani of Borsa in Italy, (Annali  Univ. di
Med.,  Dec,  1844,) on a young  married woman aged  twenty, in
whom the  pelvis and  spine were too much deformed to admit  of
natural labor.   In addition to this, the  anterior  obliquity of the womb
was such as to preclude the  possibility of adopting any of the ordi-
nary processes, as  those of  Alauriceau, Baudelocque and Lauverjat.
The surgeon, after ascertaining the  position of the epigastric artery
on the external border  of the rectus abdominis muscle, and directing
the assistant to make  compression  upon  it, proceeded to make his
incision  through  the  integuments,  peritoneum  and uterus.   The
woman is said to have  recovered  entirely.
  Successful removal of the uterus  by ligature.—The uterus has, in
a recent  instance,  been successfully removed entire by  ligature by
Mr.  Parsons at Bridgewater, (Eng.,) April  21,  1844,  (Provincial
Medical  and Surgical Journal,  July 10, 1844,)  in a maiden lady
aged  sixty years, who  had  been troubled with  prolapsus for sixteen
years ; the first three years of which it appears she had persisted in
retaining in the vagina a large globular India-rubber pessary, which
she had neglected  to remove occasionally as had been directed, and
which produced a discharge so offensive and profuse and had become
so wedged  in that Dr. J. Toogood, the  former partner of Mr. Par-
sons, and to whom the  case  originally belonged, was actually obliged
to deliver her of the foreign body  by the forceps !  The prolapsus
then returned, and suffering "from  it  for years, the whole body of the
uterus finally extruded  itself  from the vulva in the shape of a pyri-
form, ecchymosed tumor, seven  to eight inches long.   The taxis
prolapsi, cold  applications, <fec, proving  fruitless, a  ligature was
applied around the neck or  narrow part of the tumor just within the
vagina, by  which the  whole organ  was  speedily and  effectually
removed.  The mass weighed nearly two pounds, having the shape
of the uterus but much altered in  character, the cavity being quite
obliterated, and the os  uteri become almost cartilaginous.  No had
symptoms ensued, and  the  recovery was  perfect.   On examination
no uterus could be discovered, the vagina appearing to terminate in
a cul  de sac.  Dr. Toogood says  he advised the operation with
greater confidence from having known of two other cases in which
the whole body of the  uterus was removed by ligature without any
immediate  danger; but he is ignorant of their final result.
  The greater portion  of, if not the  entire uterus in a case of prolap- 
VAGINAL UTEROTOMY.
885
sus of this organ, is stated by Dr. Esselman of Nashville, Tennessee,
to have been extirpated by  him by ligature, under the impression
that it was a polypus.  Further details are desirable in this case than
those published in the American Journal of Medical Sciences, (1844.)
The same remark  perhaps is  applicable to the prolapsed, degenerate
and transformed uterus stated  above to have been excised (Provincial
Med. and Surg. Journal, 1844) by Dr. Toogood.
  Spontaneous descent  and expulsion  of a  cancerous  uterus.—A
case was transmitted by M. Estevenet, of Toulouse, to M. Velpeau,
(Arch. Gen.  de Med.. Sept., 1844, p. 119,) in which a woman, aged
37, affected with a cancer of the womb, was, while at stool, seized
with a prolapse of the organ, by which the whole  uterus was spon-
taneously  expelled entire through the vagina !  The fact was estab-
lished some days subsequently, by an examination of the parts, after
her death, which was caused by  peritonitis.
  Cancer of the Uterus.—Dangerous mistakes may occur from the
too frequent neglect of examinations per rectum  as  well as per vagi-
nam, in all diseases in which the pelvic organs are  implicated.  Dr.
E. Hocken has given a recent striking illustration of this (Ed.  Med.
and Surg. Journ.,  vol. CLXVL,  Jan. 1, 1846, p. 24, <fec.) in the case
of a woman who was supposed to have a cancerous affection of the
womb or rectum ;  but in whom it was found, upon examination, that
almost the entire colon,  and all the rectum, had  become enormously
distended  with hard, impacted fosces, causing apparently acute pain
over the whole abdomen.  This state of things had endured for a
month, during which a partial excretory drain appears to have been
established by the frequent vomitings of the ingesta, and a  muco-pu-
rulent discharge from the vagina.   Nothing whatever passed per
anum.  The constipation, it would seem, was first caused by the pain
in going to stool, after she had injured the vagina by a fall, causing
hemorrhage  from  that part.   The woman at the  last report was
nearly quite restored by the mechanical removal of the indurated fos-
ces by means of a lithotomy scoop.
  Forcible tearing  out  of the uterus by mistaking it for  a second
foetus.—Prof. Rossi furnishes  a perfectly authenticated fact, (Annali
Universali di Medicina, vol. 101, January, 1842,) in which  a woman
aged 28 had the uterus, in the year 1837, forcibly torn out by a mid-
wife, on the supposition that she was extracting a second child after
the  delivery of the first.  The  most remarkable point is that the
parts  left,  cicatrized, and that the woman was  yet alive four years
afterwards.  This  fact, however, would not, as Prof. Rossi seems to
think, justify a resort to  excision  of the uterus for cancer.
  AL Riberi has completely excised the urethra, except a small por-
tion adjoining the neck of the bladder, in  removing  a cancerous tu-
mor of this passage from a woman  aged  60.   (Translation of a bro-
chure of M. Riberi on  this subject, by Dr. F. Cazalis,  Montpellier,
1845, in octavo, 20 pp.)   M. Riberi knows of no similar  operation.
The  patient recovered  entirely  and  without incontinence.  In the
event of the operation being required again, he advises the sound to
be introduced into the bladder as a point d'appui for the instrument
before making the excision.
  Improved Speculum Vagina.—One of the best  modifications  of 
886
NEW ELEMENTS OF OPERATIVE SURGERY.
this valuable instrument is that of a skillful manufacturer of surgical
instruments at  New York,  Mr. George Tiemann.   His  improved
speculum vaginas is a modification ofthe speculum vaginas of Weiss,
in London.  It is composed of three blades, which, when closed, form
a cylinder sufficiently small  to be used likewise for any operation in
ano.  Instead of the enlargement by the revolution of the screw, like
Weiss's, the three blades open by compressing the handles gradually
with the hand, and securing them by turning the thumb-screw.  The
advantage  of this instrument is this: the operator can judge  better
how far he may open the three blades without injury, whereas in
turninsr the screw handle, he does not feel to what  extent he forces
the instrument.
   This speculum, considered as one of the most useful, can be man-
ufactured for almost half the price of that of Weiss's, which  places
it therefore within every practitioner's reach.
   The instrument on the plate annexed, is a German silver cylinder,
to serve as a reflector when the speculum is opened and the wooden
plug withdrawn.
SPECULUM VAGINJE ET AN I.
CYLINDER  AND PLUG. 
DIAGNOSIS OF VESICAL CALCULI.
887
PART  SEVENTH.

  URINARY APPARATUS.
                        CHAPTER  I.

                  CALCULI OF THE BLADDER

          Article  I.—Diagnosis of  Vesical  Calculi.

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

                     § I.—Natural Signs.

  Alost persons affected with stone  experience a dull pain, or sort
of weight in the fundament, and which is increased by the movement
or concussions which the patient undergoes while riding in a carriage
or on horseback, or when he is obliged to submit to the least jolting.
The urine deposits a wiiitish  sediment, mucosities that are flocculent,
sometimes thready or tenacious, or that are frequently sandy, muddy,
or as it were  purulent, fetid and sanguineous.   At the time of their
emission it sometimes happens that they are suddenly suspended, and
that a simple change of position of the body will again enable them to
flow out with  freedom, as if they had been momentarily interrupted
by a valve placed over the  entrance into the  urethra.   The  pains
sensibly increase in proportion  as the bladder is being emptied, and
especially immediately afterwards.   The extremity of the  penis be-
comes the seat of  a  pruritis, which incessantly induces the patient to
make traction upon it, from whence  it happens that  an extreme de-
gree of length of  the prepuce or penis, in infants particularly, con-
stitutes of itself a  symptom of vesical calculi.   The  patients have a
frequent desire to  urinate, and some  of them discharge from time to
time gravel or fragments of stone of considerable size.  But  these
signs are far from  being found combined in the majority of calculous
patients;  in many of them scarcely any are present; on  the  other
hand various  affections of the urinary passages, and which are dis-
connected with calculi, have in numerous  instances simulated this
ensemble of symptoms.  A  catarrhus vesicas for example, may be
accompanied with all those changes which have reference to the urine.
If at the same time there  should  have been an irritation and altera-
tion at the infundibulum of the  urethra, the pain, together with  a fre-
quent desire to urinate, and  the tractions made upon the penis might
exist in the s'ame manner as  if there was  a stone.  The weight felt
upon the fundament is produced also  by a tumefaction of the prostate
gland.  As  to gravel and sandy deposits, many persons have  them
without  calculi  being actually present.   The sign which would ap-
pear to be the most conclusive, that  is to  say, the sudden suspension
of the passage of the urine, though  the bladder may not be empty, 
 888          new elements of  operative surgery.

 may be also  met with  under other circumstances.   The  prostate
 may give rise to the production of a fold behind the urethra, which
 may lead to deception on this point.  The same might  take place
 from fungous  tumors or a cerebroid mass formed upon the bas fond of
 the bladder.   The same circumstance might still more readily occur,
 if the lower wall of the urethra should give rise to the production of
 any polypous  or pediculated growth whatever, and  which should
 have become  prolonged into the neck of the bladder.  A patient who
 died at the Hospital of St. Antoine, while I was in that institution, in
 1829, presented to me an arrangement of this description.  On many
 occasions the  passage of the urine  had  been  suddenly interrupted
 before the bladder was emptied.  This man died, and we found on the
 vesical luette  that a tumor had been  developed, which was similar to
 the fibrous tissues of the  uterus in its density  and  structure.  This
 tumor  having  a slender pedicle which was very much flattened in the
 direction towards the urethra, was of the size of a small pullet's egg.
 However little it was pushed forward, it closed up the excretory
 canal of the urine in the  manner of a plug.  Since  then I have fre-
 quently encountered  analogous tumors  attached  to  the  prostate.
 The proof, moreover, that none of these signs are conclusive is  this,
 that experienced, surgeons have in  many cases operated for lithotomy
 upon patients who had no stone.  Such signs, therefore, in themselves
 are not sufficient to justify the operation.

               § II.—Catheterism.—Physical Signs.

   Those catheters and sounds that are not metallic, are not suitable for
the catheterism of calculous patients.  We make use of such as are
of silver,  copper, gold,  or platina.  Nevertheless,  these  three last
mentioned metals, which have the advantage of being more sonorous,
are rarely employed, while the silver sound is the one that is generally
preferred. Some persons also have considered that a solid sound ought
to be substituted for those that are  hollow, since, from its being more
heavy  and compact, it would enable us to feel the calculus better;  but
these are particularities of little importance, which the skillful  surgeon
may dispense  with.   When the,catheter is in the bladder it is neces-
sary to withdraw  its stilette, as the latter from some unexpected
movements might lead to error.  The thumb, which  is kept applied
upon its shoulder, while the fore and middle finger embrace it  be-
hind its rings, should entirely  cover over the opening.  If we should
allow the finger which shuts it to  move, a valvular motion might be
thereby produced, and also a sound which would lead to a deception.
By stopping it up with a peg,  as recommended  by Boyer, we should
have no danger from this inconvenience.   We should take care to
introduce it while the bladder is filled with urine, by which means
 we are enabled to explore with greater certainty all the various re-
 gions of the organ.
   A. Should the patient  be lying upon his back, we begin by moving
 around the point of the sound backwards, and upon the median line,
 and to the right and left, inclining it with more or less force to  one
 or the  other side.  We then, by strongly depressing its shoulder, di-
 rect it  as high as possible towards the summit of the  bladder; after 
DIAGNOSIS of vesical calculi.
889
which, it is advisable to bring back its beak again to the neck of the
bladder and its neighborhood, as well as upon the different points of
the bas fond.  If, after having proceeded in this manner, the sound
does not encounter any calculi, we cause the patient to be seated on
the edge of his bed, or we may even make him get up and  walk a
few steps, as it likewise may be  advisable, in some cases, to make
him lie down successively in various positions.
  B. In the last place, the surgeon  allows  the escape of the urine,
and without disturbing  the  instrument, waits till  the bladder  con-
tracts upon  itself, in such manner as to push the  calculus towards
the urethra and to place it in contact with  the metal.   In the major-
ity of cases these different researches soon enable us to ascertain
with certainty the existence df a stone ; but from the mere fact that
we do not find it, we are not therefore  authorized  in  declaring that
there is in reality no stone.  Small stones sometimes elude the most
skilful manoeuvres.  Frequently there are pouches (vacuoles) in the
bladder, of considerable depth, so that the sound in passing over these
imparts no sensation of any solid body.  It is not rare, for example,
to find" immediately behind the prostate, a cavity either to the right or
left or throughout the whole extent of the bas fond of the organ, where
stones  of a  certain  size will  readily escape the explorations of the
operator, as I  have  myself seen, and as is  proved  also  by the facts
related by M. Camus,  (Rev. Med., 1831, t. IL, p. 283.)  and AL Bel-
mas.   It is even proved by the cases since  collected by M. Boucha-
court, (Arch.  Gen.  de  Med., April, 1839,)  that in certain patients,
most usually those at an advanced age, this secondary cavity, occu-
pying the bas  fond, and bounded above by the prostate, and behind
by the orifice of the ureters  and  that portion of the vesical parietes
lying between them, may encase and retain  the calculus, and that it is
usually accompanied with quite an extensive ulceration of the walls
of the  bladder.  This  alteration  constitutes, according to AL Bou-
chacourt, a very serious  form of  calculous  disease, for  none of the
patients, in fact, in whom it has been possible to identify it with cer-
tainty during  life, have survived the operation.  Nor, moreover, is
lithotrity better adapted to  these  cases than  lithotomy, this last in
fact being preferable to the  first.   M.  Bouchacourt,  in such cases,
inclines to  a preference for  the recto-vesical incision.   Under other
circumstances the  calculus is, as it were,  pinched  up between two
folds of the bladder, as it may be also  retained in a  special  cul  de
sac, whether  it be that the mucous membrane  has  only  simply
formed a hernial pouch through a laceration in the muscular fibres,
as so often happens in what are called columnar sacs, (vessies a co-
lonnes,) or that an actual cyst has formed around the  stone, as F. de
Hilden, (Bonet, Corps  de Med., p. 444,) and Meckel,  allege to have
seen, and a specimen of which M. Gensoul has informed  me he has
in his  possession.   In a  man who died of ischuria in  1833, at the
Hospital of  La Pitie, the natural bladder  communicated by an ori-
fice of six lines in extent with a second pouch, of the capacity of
a demilitre, and which  contained  a calculus.  I  have  since  seen
two  other  cases, which were  in almost every  respect  similar.
There  were seven  calculi in one of three pouches of  a bladder
which M. Sanson has shown to me. 
890           NEW ELEMENTS OF OPERATIVE SURGERY

  C.  It may be readily conceived  that if the foreign body does not
present itself entirely naked on some one point of its surface, cathe-
terism would  not recognize its  existence, and that in other cases
it would be by varying the position of the patient, the distension of
the bladder, and the movements ofthe sound, that we might hope to
meet  with it.  When the difficulty arises from  the small  size  of
the stone, or  from  the frictions being  too feeble to be  accurately
perceived, Laennec supposed  that auscultation  might be  of some
assistance.  We then apply either  the ear or stethoscope upon dif-
ferent points of the  hypogastrium,  with the usual  precautions, while
on the  other  hand,  we are manipulating  the instrument in the in-
terior of the bladder.  By acting in this  manner  no sound  will es-
cape, and the  slightest concussion  ofthe instrument upon the stone
will be  perceived  by the ear.   In order to render this resource still
more  perfect, M. Ashmead, from the fact that air is a better conduc-
tor of sound than liquids, has  proposed to fill the bladder with this
fluid.   By screwing the plate of a  stethoscope upon the shoulder of
an ordinary sound,  M. Moreau  de St.  Ludgere, (These, No. 247,
Paris,  1837,) finds, and I have ascertained with  him, that we hear
the bruits of the calculus  better than by any other method.  But it
is  important that  we  should  not  allow ourselves  to be deceived
upon  the value of  processes of this kind.   Whenever  the sound
freely comes in contact with  the  calculus, we feel it as well by the
hand  as by means of auscultation.  I  advise no one to assert from
the testimony  furnished by this last mentioned process, that a stone
exists  in  the  bladder,  provided we have not  also obtained evi-
dence of this by simple catheterism.  In conclusion, it is not the feel-
ing or hearing of  the calculus which is  the difficult  point,  but that
of touching and striking upon it naked.
  D.  Though  in a number of cases the  catheter may not encounter
a stone  where one or  more exist, there  are other cases which may
lead us  to the  commission of an  opposite  error.   Exostoses behind
the pubis, such as have been  seen by  Houstet,  Garengeot, M. J.
Cloquet, and M. Belmas, and especially by Brodie, who met with one
of the weight of 20 ounces ; also other osseous tumors, situated upon
the ischium, as related by M.  Damourette, on the  sacrum or coxcal
bones, as in the case figured by M. Haber, also an osseous cyst in the
tissues of the walls of the bladder,  an instance of which is found in
the work of Boyer, may all lead to  deception on  this subject.  The
same  may arise from the sacro-vertebral projection.  The most fre-
quent sources  of deception, nevertheless, are to be found in the con-
texture  of the  bladder itself.  I have  frequently  noticed that by ma-
king the point of the sound glide from the median line towards the
sides, a jerking motion is produced, from whence results a sensa-
tion of resistance and of inequalities which are well calculated to de-
ceive  those who are  not aware of this peculiarity.  This arises from
the interior of the bladder being frequently rugous and  bosselated,
and from the fibres of its muscular membrane being united together
into fasciculi that are more or less distinct.  This may arise also from
the presence of fibrinous or scirrhous (F. de Hilden, dans Bonet, p.
445,)  masses, or those of any other  description developed on its inter-
nal surface, whether they are free or adherent.  However  little doubt 
                 DIAGNOSIS OF VESIDAL CALCULI.              891

may exist on the subject, the operator should not neglect to introduce
one or two fingers of the left hand into the rectum, in order to raise
up the bas fond ofthe bladder, and to favor the other  manipulations
with the catheter.  It is also known  that the fingers  placed in this
manner, when  assisted by the application of the other hand upon the
hypogastrium,  have in more than one instance succeeded in identify-
ing the presence of calculi without being aided by the  sound.
  E. These details might seem  superfluous, had it not been demon-
strated by numerous observations, that enormous stones may exist in
the bladder, without  the patient being conscious of them, and  that
lithotomy has,  notwithstanding the most skillful explorations,  been
performed in other patients in whom no calculi existed.  Every body
knows the history of  the monk who bequeathed his body to the sur-
geons, from the certain conviction in his mind that he had a calculus
in his  bladder, which nobody had been enabled  to identify.   The
sound was  introduced, and nothing was found.  The patient  died,
when the stone and bladder were ascertained to have passed into the
scrotum, (D. Sala in Bonet, t.  IV., p. 432.)   Bartholin (Bonet, Corps
de Med., X. IV., p. 431,)  has seen something similar.   Lapeyronie,
d'Alambert, the watchmaker Portalier, mentioned by Deschamps, also
Sabatier  and  M. Richerand, each of them had  an  enormous  cal-
culus in the bladder,  though  none of them  had scarcely any symp-
toms of it.  M. Texier cites another case of this kind, related by M.
Marjolin, in which it became necessary to saw through the bones of
the pubis, in order to extract the  calculus.  On the other hand, we
find in the Journal of Desault, that Le Blanc acknowledges to  have
performed lithotomy on a patient who had no  stone.   Desault him-
self, as well as Cheselden, (Lassus, Med.  Oper., X. I., p.  403,) ap-
pear to have fallen into the same error.  M. S. Cooper asserts  that
he knows seven instances of this kind, which occurred to different
surgeons.  M.  Moreau has collected most of the cases which relate
to this kind of error.  I myself have been enabled to ascertain four:
in the first case the  patient was perfectly restored; the second at-
tempt occurred in the  case of an  infant, who died ; the third took
place in a public establishment  of the capital, and the patient  also
succumbed;  and the  fourth  relates to a young confrere who is  still
living.  Now as all these operations were performed by men whose
learning and skill cannot be called in question, we may well be  per-
mitted to hesitate, when we are compelled  to come to a decision un-
der such circumstances.
  F.  The prudent surgeon therefore, forewarned of these errors, will
not decide upon performing lithotomy, without having identified the
calculus by  means of the sound, not only once, but twice,  thrice, or
even a greater number of times still, should the slightest doubt remain
in his mind, after the  first exploration.  For greater security he will
also take the precaution to have others  confirm what he believes to
have felt himself.
  G.  Catheterism may moreover point out to a certain extent under
what condition the calculi, it has ascertained, exist,  their volume,
density, and position, and whether  they are  movable or fixed. When
the stone is felt sometimes at one point and sometimes at another,
that it escapes  on coming into the  slightest  contact with it, and that 
892          NEW ELEMENTS  OF OPERATIVE SURGERY.

after having touched it we have some difficulty in finding it again, it
is evident: 1st, that it is completely free ; and 2d, that  it is not of
very large size.   If, on the contrary, we encounter it on arriving at
the neck of the bladder,  and that the instrument touches it in what-
ever direction we make the research, it is evidently very large, unless
however it should have  become  lodged upon  the trigonus vesicalis,
or in the entrance into the urethra.
  H.  The volume of  calculi being  an important  point to ascertain,
attempts have been made at every epoch to  discover a mode  of as-
certaining this point.   The catheter may in this respect, when it has
once reached into the  bladder, impart sufficiently accurate informa-
tion, if we are much practiced in the use of it.  For this purpose it is
necessary that the surgeon, without allowing  the patient to  move,
should attentively watch the first contact  of the two bodies, and af-
terwards  gently pass the beak of the sound from  before backwards,
and over the whole surface of the calculus, or he  should endeavor to
embrace it in the concavity ofthe instrument, as if for the purpose of
bringing it forwards, towards the urethra.  When the bladder is empty
this manoeuvre will frequently answer to convey a proximate idea of
the dimensions of the stone.   Surgery  moreover  possesses  at the
present day other means of arriving at this result.  One  of the best
would  be in  my -opinion the catheter,  (Clinique des Hopit., X. IL,
p. 387.) which I  have caused  to be constructed, and which will be
described further on.   This catheter is arranged in such manner that
after it is  introduced, the two halves of which it is composed, by gli-
ding over each  other  in the manner  of a shoemaker's  podometer,
transform its beak  into a forceps which can  embrace the calculus
and determine its dimensions.  The present lithotritic  forceps will
still more  accurately attain this object.   We should  be wrong how-
ever to suppose that we may always, by means of these instruments,
determine with precision the volume of a stone. This could not hap-
pen unless it was perfectly round, or that we have satisfied ourselves
that we have grasped it in a proper manner.  Now the forceps may
have embraced the calculi ,which are to be extracted by one of their
angles or  one of their extremities.  They may also be embraced too
near to the root of the instrument, or only grasped by its extremities.
  I. We are authorized in believing that the stone is friable, and of
little consistency, when in striking against it the sound gives only a
dull bruit, or when, notwithstanding it is of considerable size,  it nev-
ertheless appears to be very light.   When, on  the contrary, the col-
lision produces a  clear sound, and the calculus cannot be displaced
but with some difficulty, its  density  must necessarily be very con-
siderable.   When we encounter  it always on the same  side, and it
follows the changes in the  position of the  patient, and  when  alter
having touched it on  one point, the instrument may pass around all
the remainder of the  bladder without meeting with any others, it is
probably  alone.   If, on  the  contrary, the sound comes  in contact
with one on the right, and then on the  left, and if after having placed
the patient on  one of his sides, we can  feel it no longer in the highest
part of the bladder; if during the  catheterism we  perceive a collision
which  is distinct from that which the  instrument had with the first
stone;  and if the sound appears to disturb  in  succession  several 
INDICATIONS.
893
movable bodies, we may well be permitted to suppose that  there  is
more than one calculus  existing at the same time in the  bladder.
Nevertheless, we are easily liable to err in this matter, and the most
exact researches scarcely furnish any thing more than probabilities,
with the exception of certain cases where the fact is self-evident.
  J. Nor are the adhesions of vesical stones, or their fixity, matters
that are very easy to determine.   The calculus appears to be im-
movable, sometimes  because it fills up almost  the whole bladder, or
because of the contraction  of this organ, or from the volume of the
stone itself, and at  other times because it is situated  in a cavity,
though  we may notwithstanding soon after identify  it in another re-
gion.  It may be situated in the urethra at one of its extremities ; an
arrangement which many observers have pointed out, and which has
this remarkable feature, that the stone may make only a slight projec-
tion into the bladder, wiiile  at the same time  presenting  a length in
the aggregate of several inches.   The catheter will ascertain this
fact if it meets with a sort of point which can in no wise be displaced,
near the neck, and a little outside of and towards the base of the tri-
gonus vesicalus. Moreover, we cannot perceive how it is possible to
distinguish by this  process  those  which  are  confined in  accidental
pouches, or in small  abnormal sacs, from those which have contract-
ed actual adhesions  with any part whatever  of the mucous  tunic.
It is the same with this part of the diagnosis,, moreover, as with the
preceding: the catheterism,  if well executed, will afford presumptions,
but scarcely ever absolute certainty.   Nevertheless, should the stone
be imprisoned by one of its  extremities in the prostatic portion ofthe
urethra, and project at the same time into the interior of the  bladder,
an instance of which is related both by Le Dran and AL Blandin, wre
could satisfy ourselves on this point by introducing the finger into the
rectum, while the sound rests against the head of the calculus.   We
shall, however, have occasion to return to these details in describing
the last stage  of lithotomy.

                   Article II.—Indications.

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

                               v  I.

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

  It  would  be  so much the more important  to ascertain  at the
present day the  volume, nature, hardness and  contexture of the cal-
culus, inasmuch  as the  treatment applicable to each case might  in
this manner be very materially  influenced.  If,  as I saw in an old man
in 1833, the calculus should be friable, and as it were an aggregation
of grains of sand, or  composed, so  to speak, of fragments of dried
plaster, as in another patient whom I shall mention further on, it is
evident that its  dissolution  and breaking up  could be more easily
effected and would be more simple than  by lithotomy.   This friabil-
ity, which existed  in a patient of M. Sanson, (Mem. de la Soc. Med.
de Gand., 1835,  p. 93,) and in a patient operated upon by M. Lenoir,
(communicated by the author, April, 1839,)  is  sufficiently frequent to
require some notice.   Should  the stone  on  the contrary have a for-
eign  body for its nucleus, as I have remarked in  several instances,
and  one hundred  and sixty-six examples of  which have been col-
lected  by M.  Civiale, (Gaz. Med.,  1838, p.  269,) lithotomy might
become absolutely indispensable.  Should the calculi contain a ball,
(Larrey, Clin. Chir., X.  IL, pp. 530, 536,) or a portion of bone  or
fragment of a barometer or pipe or lead, (Bull, de la Fac,  X. VIL,
p.  180,)  difficulties would present themselves in  attempting  their
destruction by dissolution or by lithotrity.  Those which include  a
pin, (Petrequin,  Gaz.  Med., 1837, No. 42, feuilleton,) a needle, ear  of 
LITHOTOMY.
895
wheat, lint, a portion of sound or bougie, would be nearly in the same
condition.   Nevertheless, if the nucleus ofthe calculus were a pea or
portion of a stalk of grass, or a clot of blood, as has been seen by
MM.  Larrey  (Gaz. Med., 1838, p. 677) and Chelius, (Clin. Chir.,
t. IL, p. 230,)  it might yet be practicable to break it up.

                              § III.

  As to the treatment of calculi without  an operation, it would  ap-
pear, at the present day, to have a tendency to come into new repute.
Without speaking of galvanism and electricity, made trial of by MM.
Gruithuysen, Pravaz, Bonnet, (Arch. Gen. de Med., X. VIIL, p. 254,)
and Bellanger,  (These, No. 105, Paris, 1837,) or of injections, as re-
commended by AL Thibault, (Arch. Gen.  de JHed., X. XL, p. 302,)
or of bicarbonate  of soda by  the method of M. Robiquet,  (Bull.
de Ferr.,  X. Nil., p.  275,)  or of the  dissolving liquid which an
Englishman, under the  patronage of AI. Donellan, proposed to me in
1838, I have to  remark that the observations and facts published up
to the present  time by AIM.  Chevallier, 0. Henry, A. Berard, and
C. Petit, (Expose d'un  rapport a FAcad. Roy. de Med., 1839,) plead
already strongly in behalf of the  mineral waters of Vichy, used in
the form  of baths  and drinks  and  injections.  These waters, which
modify the bladder in a beneficial manner, act by dissolving various
kinds of calculi, and by disintegrating others by their influence upon
the urine  or on the  animal  substratum  which  agglutinates its
salts.  This, therefore, is one of the  remedies which are  to be
made trial of when the stone is not very large, and when there is no
opportunity of immediately removing it from the patient.

               Article III.—Lithotomy, (Taille.)

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

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

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

   Lithotomy at  the perineum, which is the most ancient of all, has
been performed  in so many different ways that it becomes indispen-
sable, in  order to analyse their processes  with  any advantage, to
unite them together in classes and to assemble  those which have the
most analogy  to  each  other,- in order to  form from them a  certain
number of principal methods.  In some of these processes we reach
the calculi without  dividing the urethra, while in others the most
distant portion of this passage is always traversed  by the  instru- 
LITHOTOMY.
897
ment.  Among the first are to be classified those which relate to the
lateral operation, a method which would appear to include the pro-
cess  of the ancients, that of Frere Jacques, that of Foubert, &c.
The  median or great  operation, whether oblique or  by the lateral
method of Frere Come, &c., belong to the second elass.
  A. The lateral method, (Cystotomy, properly so called.)—I. The
process of Antylus or Paul of Egina, vulgarly known as the little
operation.—The description given of lithotomy by Celsus had been,
as it  would appear, up to these  latter  times, the subject of inter-
pretations that were altogether erroneous.   The  result of this has
been that the  process known under the name of Methodus Celsiana,
does not  in reality belong to him.  We must go to  the Greek au-
thors to find the principle of this operation, while the actual process
which Celsus  adopted, belonged  to the school  of Alexandria.  As
Antylus is the  first  who has given a  clear description of it, it is
proper in my opinion to designate it under  the name of this ancient
author.   To perform this operation, the surgeon introduces two fin-
gers into  the rectum, and endeavors to grasp the stone through the
walls of the bladder, while with the other  hand he makes pressure
upon the hypogastrium, with the view of favoring its descent.   Hav-
ing seized the calculus he pushes it against the urethra, between the
anus and  the scrotum, and a little to  the left of the perineum.  He
then incises all the soft parts down to the stone,  in the direction of a
line which would extend obliquely from above downwards and from
before backwards towards the left ischium, arrives in this manner into
the bladder and expels the calculus through this opening by means
of the fingers wThich have been  kept  in  the rectum.  A species of
scoop, having points On its interior, is introduced through the wound,
in order to seize the stone and bring it to the outside, when the opera-
tor has not been enabled to expel it by his fingers.   This  method,
which is known under the name of the little operation,  on account of
its great simplicity, and which subsequently received the name ofthe
Guydonian method, because  it  appeared to have  been overlooked
until Guy de Chauliac revived the knowiedge of it in 1363, was nev-
ertheless  described by a number of  authors who  lived anterior to
this last mentioned surgeon.  Guy de Salicet, for example, as clearly
points it out as Antylus does.  Paul of Egina, Albucasis, and most of
the Arabic surgeons also so understood it.  Ali-Ebn-el-Abbas, among
others, explains it in this manner: " You will take a cutting instrument
and incise," he says, " between the anus and the testicles, not  upon
the median part, hut by directing the instrument  towards the left
part of the thigh.  The incision should  be oblique, in order that the
opening may be large and proportionate to the volume of the  calcu-
lus."  Ebn-el-Couf, another author of the same epoch, some fragments
of whom  have been translated by M. Clot, (Gaz. Med., 1830, p. 167,)
gives a description which is in every respect similar.   I classify this
process under the lateral operation or cystotomy, properly so called,
because in following it we cut into, at least in most cases, the side of
the neck  of the bladder and  not into  the urethra or prostate.   It is
easy to conceive, in fact, that  the fingers can but very rarely  bring
the calculus into the prostatic portion ofthe urethra, and that they must
merely secure  it upon the  trigonus vesicalis, and that it must be 
898           NEW ELEMENTS OF OPERATIVE  SURGERY.

through the  walls of the bladder  itself that the  calculus is  de-
pressed to the perineum, and laid bare by the cutting  instrument.
The objections that may be  made  to this process  are,  besides  the
difficulties of seizing and grasping the stone with the fingers, and of
incising with precision the tissues down to the calculus, and effecting
its expulsion through so irregular an opening ; that of wounding the
bladder itself outside of the  prostate and thus exposing  to effusions
into  the  sub-peritoneal cellular tissue, and to urinary fistulas, and
especially to  the wounding of the vesiculas seminales, without abso-
lutely being exempt also  from lesions to the rectum and vessels of
the perineum.
  II.  Process of F. Jacques.—I have remarked that the process of
F. Jacques,—I speak now of his primitive process,—belongs to  the
lateral method.  This singular man, who  was at first a simple domes-
tic of Pauloni, a  Venetian,  and who soon  after became a monk,
commenced his operations at  Besantjon in 1695.   When he came to
Paris two years subsequently, recommended* by influential  persons
to the canons of Notre Dame, as the possessor of a new  method  for
the extraction of calculi,  he  was in the habit of using the following
process : A cylindrical sound  and without any groove was introduced
into the bladder; plunging in afterwards a long knife between the
anus and tuberosity of the ischium,  F. Jacques  penetrated  into the
bladder and enlarged  his incision by carrying it obliquely inwards
towards the symphysis pubis ;  if after having withdrawn his litho-
tome, the incision did not  yet appear to him to be  sufficiently large,
he increased  its dimensions in the direction  towards the bladder  by
means of a second knife of the shape of a scraper ; finally, he grasped
the stone with a tenaculum and terminated  while  exclaiming to the
patients, like  Pare : /  have operated upon you, and may God cure
you !
  Every body must perceive at first sight, that Frere Jacques, by
penetrating on one side  of  his catheter, avoided  entering by the
urethra, and that he reached  directly into that portion of the bladder
which is protected by the  prostate, or a  little outside of  this gland.
He divided, therefore, nearly  the same tissues as  the Greek and
Arabian surgeons ;  with  this difference, that  his wound  must have
been more uniform, at  the same time  that its dimensions were such
that  they could be altered  with greater ease, according as cir-
cumstances  required.   Experiments made  by the lithotomist Bau-
lot or  Beaulieu, as he was also called, upon the dead body at  La
Charite, in  presence of Marechal, and at the Hotel  Dieu under the
eyes of Mery, show that he was far  from cutting down always upon
the same parts ; that he frequently divided the rectum or vagina in
women, and the vesiculas seminales  in man, and that  he especially
wounded the side  of the bladder at  the  point where  ft  enters into
the prostate,  to form the  urethra.   The shoemaker  that Duchesne
took to him  at Fontainebleau, and  whom he operated  on  in pre-
sence of Felix, Bourdelot, Bessiere  and  Fagon, and who was seen
walking about the  streets at the expiration of three weeks, was not-
withstanding, according to F. Collot, left with a urinary fistula.  Out
of 60 patients confided to his  care  in  the two principal hospitals of
Paris, 13 only were completely cured; 23 died,  and the others were 
LITHOTOMY.
899
left with fistulas, wounds of the rectum, &c.   As soon as F. Jacques
had adopted  the  modification which was pointed out to him by
Mery, Fagon, Duverney,  and Hunault d'Angers, and which con-
sisted in making  a  groove on the  convex  portion  of his sound,
his method was in reality no longer the same, and it is to set out
only from this point that it can be received among the  uretro-pro sta-
tic methods, and  that it has become the source of a great number
of useful improvements.  We shall return to it again in speaking of
the lateral  operation.
  III.  Process of Raw.—Though it were true, as S. Albinus alleges,
that Raw  reached the  side of the  bladder without introducing his
lithotome  upon the groove of the sound, his process would  still have
to be ranked under the lateral, operation,  or  under the method of
Jacques or that of the  Arabs ; but as history  has  furnished nothing
authentic on this point,  it is unnecessary to dwell upon it.
  IV.  Process of Cheselden.—It  is  evident  that the  first process,
at least, of Cheselden,  would come under the same category, inas-
much  as the  distinguished  surgeon of St. Thomas's confined him-
self at  first to laying bare the membranous and  prostatic portions
of the urethra, in  order to divide the parts afterwards from behind
forwards, commencing  at  the neck  of the bladder, and without fol-
lowing the groove in the sound.
  V. Process of Foubert.—The secret that Raw persisted in keep-
ing in respect to  the details of his  method, which in  fact was no
other probably than that of Frere Jacques, which had been at  first
so zealously  attacked  by  him,  induced a  great number of  sur-
geons  to endeavor to ascertain a  mode  of  performing what was
called at that time the lateral operation, that is  to say, lithotomy
at the side of the bas  fond of  the  bladder.  After having endea-
vored to attain this object, by varying the application of the sound,
and the  extent  and   direction of  the incisions, they succeeded
in constructing a  method  different apparently from all the others,
and which  Foubert, its  inventor, supposed to be that of Raw.   This
surgeon plunged  in a long trochar  at  some  lines distant  from the
tuberosity of the  ischium, and obliquely upwards, inwards, and for-
wards, until he reached  into the  bladder.  The groove of the instru-
ment immediately allowed the escape of a few drops of liquid ex-
ternally, which, with the absence of resistance perceived by the ope-
rator, served to indicate the entrance of the trochar into  the blad-
der.   This groove also served  as a director to the lithotome of
Foubert, which lithotome consisted  of a bistoury  from four to  five
inches long, somewhat  convex, and  bent near its handle, and on the
side of its  cutting edge, into an angle of from 20 to 30  degrees.
Having arrived into the bladder, this knife was directed in a course
parallel to  the ischio-pubic branch  of the pelvis, that  is to say, ob-
liquely  from behind forwards, and  from without  inwards, in order
to give to  the bladder  and perineum a wound corresponding with
the presumed  dimensions of the calculus.
  VI.  Thomas, a surgeon of Salpetriere, though he adopted the
same ideas, nevertheless deemed it advisable  to follow another  pro-
cess ; he plunged  in his trochar  at the place where Foubert termina-
ted his incision, which he did with a view of dividing the parts from 
900           NEW  ELEMENTS OF OPERATIVE  SURGERY.
above downwards, and from within outwards, in place of proceeding in
an opposite direction, as the inventor of the method recommended is to
be done.   Moreover, he finally transformed into a kind of concealed
lithotome, the instrument which he had made use of for the puncture.
Many persons were operated upon by this method, in the hospitals of
Paris, and it was also submitted to some trials in England and Germany.
Numerous objections, however, were soon raised against it.  The di-
rection ofthe axis of the pelvis, and  the deep-seated position ofthe
bladder, do not allow of a trochar being passed through the perineum
without danger.   Nothing would  be more easy in such cases, than
to deviate by mistake either in front, posteriorly, or to one side, and
thus to wound the rectum, vesiculas seminales,  ureters, or peritoneum
itself, or to penetrate into the bladder, at  too high a point upon its
body.  To all these  unquestionable objections, there is one more to be
added, which of itself would  be sufficient at the present day to cause
the rejection  of Foubert's method, were it  ever  possible for it to be
revived.   It  is that the object itself, which is to be obtained, is an ob-
jectionable one.   As the incision of the bladder  has to be  made out-
side of and above the prostate,  between the peritoneum  and pelvic
fascia, the least quantity of urine effused into the bottom of the wound
might give rise to  inflammation of the cellular layer which lines the
pelvic cavity, and in this manner speedily terminate in death.   The
previous division of  the perineal layers, as has  been  recommended
by Pallucci, in order to allow the forefinger to feel the fluctuation  in
the bladder before plunging  in  the trochar, would  only remedy the
least of its inconveniences.  The ingenious sound contrived by Lecat,
and  which, after  being introduced, shut up, may, when  opened,
stretch the bas fond of the organ, and render the introduction of the
principal instrument more easy, would not succeed any better.   The
instrument contrived by  AL  Schwartschild, (Bull, de I'Acad. Roy.
de Med., X. III., p. 77,—Arch. Gen. de Med., 3d ser., t. IL,  p. 372,)
would be still less efficacious.

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

  The processes which comprise in their incision  a part of the urethra,
and which are the only ones which can be adopted in infra-pubic litho-
tomy,  are  also those which have most  engaged  the  attention of
lithotomists.   It is under these  that we shall find the median taille, or
great operation, the  lateralized taille, or  that of Frere Jacques im-
proved, also the transversal taille, together with all their modifica-
tions.
  A. Process of Mariano.—The method which has been  designated
under the name of the great operation, in consequence of the numer-
ous instruments  that it requires, remained for a long time  a family
secret.  It was, according to all appearance, invented  by some of
those inhabitants  of ancient Norcia, in  Italy, who had acquired  a
great reputation,as operators, about the 14th and 15th centuries, under
the common  title  of Norcini.  The archives of Turin, moreover,
prove, if we  may believe  M. Bonino, that  Battista da  Rapallo, who
died in 1510, and was preceptor  of Giovani,  was the  real  inventor
of this process.   However this  may be, Giovani  di Romani  is the 
LITHOTOMY.
901
first person to whom history ascribes it, and it was Mariano Santo,
his friend, who published it about the year 1520 or 1530.  A. Bene-
detti, however, was probably acquainted with it;  for after having
announced that we may extract certain calculi without a bloody ope-
ration, he says, " Nunc inter  anum et cutem, rectd plagd, cervicem
vesica incidunt."  It only became celebrated by the cures of L. Col-
lot, to whom O. Da Villa had taught it, and who on that account was
appointed lithotomist to the court  of Henry II.  At this epoch, the
great operation was always kept secret from the public. P. Collot and
R. Giraud, who succeeded their relative,  were so unfortunate with
the ten students to whom they were employed to teach this process by
order of the  government, that  their children  alone would have pre-
served the secret until F.  Collot should have thought proper to pub-
lish its details, had not the  pupils of La  Charite and the Hotel Dieu,
contrived to  make a hole through the ceiling of the operating ward, in
order to see them at work, and in this manner to  become acquainted
with their method.   These  then are the details of the process:  a
grooved sound introduced  into the bladder, enables us to  depress the
perineum a little to the left of the  raphe, and not  exactly upon the
median line,  as Heister alleges.   The surgeon, with a lithotome  simi-
lar to an enormous lancet,  incises the  skin, cellular tissue, and  mus-
cles, from the root ofthe scrotum  to within a few lines  of the anus,
then divides  the bulb of the urethra, and arrives  in  this  manner into
the groove of the sound.   A director, which is a sort of stem formed
of a male and female branch, differing from  each other in this, that
the first terminates in a blunt and  slightly  flattened extremity, while
the other is bifurcated in the same direction, is immediately introduced
into the bladder  in place of the  lithotome.   The sound, which has
become useless, is immediately withdrawn.  The female branch of
the director, which has remained outside up to this time, is now gli-
ded  by means of its  bifurcation  upon the square edge  of the  male
branch, until it has reached into the bladder.  The two  branches of
this instrument being thus fixed upon each other, enabled  the  surgeon
to dilate the  wound  by separating them  at their  external extremity,
which terminates  in a cross,  in order to  render the  manipulations
more easy; but their special object was that of guiding the tenacula
which were intended to grasp the calculus.  Also an ordinary gorget,
as well as  another instrument called a dilator, formed of two branch-
es, articulated in the manner of a scissors, and which were introduced
shut up and opened,  by  pressing  upon the rings which terminated
their outer extremity, were sometimes  substituted for the above
mentioned instruments.  The great operation, performed  literally ac-
cording to the details  laid down  by Mariano Santo, is one of the
most objectionable methods that have been invented.  The incision
evidently had  to fall  upon the bulbous  portion, or in  any  event
upon the membranous portion of the urethra.   The dilators could not
enlarge the wound without lacerating the  prostate.  The urethra it-
self was sometimes  completely  torn, while its  lacerations frequently
extended as far as to the neck ofthe bladder, and the vesiculas semi-
nales.  The  contusion of the veru-montanum, and the lacerations of
the ejaculating ducts, involved among their consequences fistulas, or
an incontinence of urine, swelling ofthe testicles, and  frequently ste- 
902          NEW ELEMENTS OF OPERATIVE SURGERY.

rility.   The incision into the integuments, if too much prolonged in
front, favored the infiltration of blood, urine, or pus into the scrotum.
The bottom of the wound, moreover, became in  a great number of
persons the source of purulent collections, which extended  either
around the rectum, or towards the pelvis or the upper part of the
thighs.  The operation, in fine, in its ensemble, was exceedingly la-
borious, and so dangerous that, according to the editor of the works
of F. Collot himself, a cure was rarely effected in the third or half of
the patients who  had the courage to submit  to it.
  B. This method  has undergone quite a number of modifications.
Already at the time of Dionis and La Charriere, the director and di-
lator were no  longer made use of; for  after having extensively in-
cised into  the urethra, the'y confined themselves to conducting upon
the groove of the sound, a gorget to as far as beyond the neck of
the bladder, which gorget afterwards served as a director to the or-
dinary tenacula.  Marechal and  Mery had simplified it  still more.
After having made  their first incision, like the Collots, they plunged
the lithotome into the  bladder  by a  combined vibratory movement,
executing by this motion what the surgeons at that epoch denomi-
nated the  master  stroke, (coup de  maitre) and in  such manner as to
divide  almost the entire substance ofthe prostate in its posterior di-
vision,  (rayon.)   D. Schacchi and C. de  Solingen  had already for-
mally advised  that  we  should  cut those  parts which  Mariano pre-
ferred  to  tear.  It  is evident that Marechal, by proceeding in this
manner, incised the membranous  and prostatic portions of the ure-
thra, and that he  was enabled  consequently to have an opening of
from 8 to  10 lines at the neck of  the bladder, and to extract calculi
of very considerable size  without  causing the  slightest rupture; he
thus obtained a  considerable number of  cures, and terminated his
operation  with surprising rapidity.  The  dilatation by means of the
finger,  as  De  la  Faye  recommended,  would have  doubtless been
less  dangerous than the instruments of Giovani, but it  cannot be
compared to the modification of Marechal.
  C. Process of  Vacca.—Modified in this manner, the great opera-
tion appears to have been divested of so many of its dangers, that a
surgeon of repute undertook to reproduce it as a method of his own
invention.   After having for a long time eulogized and employed the
recto-vesical taille, Vacca (Bull, de Ferr.,X. VIIL, p. 72)  finally sub-
stituted in its  place a modification  of  the  process of Mery.   The
Tuscan surgeon incises in fact  with an ordinary bistoury, upon the
median line, after the manner of  Mariano, then  comes down to the
membranous  portion of the  urethra, and afterwards fixes into the
groove of the sound the tongue of his lithotome bistoury and pushes
this instrument into the bladder, from the interior of which organ he
then brings it  out by elevating his wrist  and in  such manner as to
divide  the prostate as extensively as  he  wishes.   M. Jameson, (Bull.
de Fer., X. VIL,  p.  274,) who makes use of small forceps-tenacula to
extract the calculi, also incises the parts nearly upon the median line.
  D. A thesis supported by AI. Treyeran. (Paral. des Dif Meth., &c,
in 8vo,) at the beginning of the present century, exhibits another mod-
ification of the median operation.  The urethra and the prostate are
laid open  from before backwards ; a dry slip of carrot is then inserted 
LITHOTOMY.
903
every morning into the bladder through the wound, while the calculus
is not extracted until after the extirpation of some days.  Guerin of
Bordeaux, (Bull,  de Fer., t. X., p.  276,)  who was the inventor of
this process, obtained, it is said, decided success from it.
  E.  The median operation  reduced to its greatest simplicity, pos-
sesses but one indisputable advantage, which is that of not exposing
to the risk of hemorrhage.  Vacca, who accords to it  moreover the
advantage of allowing of the extraction of the  stone  at the widest
portion of the lower strait, had  undoubtedly not reflected  upon this
assertion ; for in this respect  it can effect nothing more than a great
number of other processes helonging to the lateral operation.  With
the improvements of Mery and \Tacca, it is less painful, more ration-
al, and infinitely better in every respect, than when it came from the
hands of Mariano ;  but it is nevertheless the most dangerous of all in
respect to the rectum, nor does it allow us to respect the ejaculating
ducts.   Moreover, as it divides the prostate from before backwards
in the direction of one of the smallest lobes of this gland, it does not
in  reality deserve  the  eulogies which have been lavished upon it
by AL Balardini  and by M. Clot,  (Compte-rendu, &c, p. 4, 1832,)
which latter moreover  states that  he  has performed  it in 13 cases
with success.

          § III.—The Oblique or Lateralized Operation.

   It was from having improperly confounded the method pointed out
in the work of Celsus, with that described by Paul of Egina and An-
tylus, that the error  also was  finally committed of confounding the
lateral method, such as it was first performed by Frere Jacques, with
the lateralized operation, which  has since been so extensively intro-
duced into practice.  A great difference however exists between these
two modes of proceeding.  In one the incision is principally designed
to come down upon the side of the neck of the bladder, without neces-
sarily involving the urethra;  in the  other, on the  contrary, the  pos-
terior portion of this passage is always divided, while the bladder it-
self may, if necessary, be respected.  The lateralized operation con-
sists essentially of an  oblique incision into the prostatic portion ofthe
urethra, comprising at the same time a more or less considerable ex-
tent ofthe membranous portion ofthe same passage.   The only pro-
cesses therefore  which  belong to  it are evidently those in which
the operator makes use  of a grooved sound to direct the cutting in-
strument into the bladder.
   A. Process of  Franco or of Hunault.—The idea of the oblique
method has so little to  do with F.  Jacques, that  this  monk did not
adopt it, but because  of the representations of his antagonist, and not
until after it had  been very clearly described by Franco,  as well as
by F. de Hilden.  Franco (Theses  de Haller, X. III., French transl.)
states positively, that  in order to incise the perineum in lithotomy, a
curved  and grooved sound  must be previously introduced into  the
bladder, that this sound is to be used as a director to the bistoury,
and the neck of the bladder  to be divided obliquely from within
outwards, and in  the  direction  towards  the  ischium.   It is true that
he recommends, like Tarin, (Ibid., X. II.,)  that this incision should be 
 904           NEW ELEMENTS OF OPERATIVE SURGERY.

 made to the right, but it is possible that in expressing himself in this
 manner, he meant to the right of the surgeon, which would corres-
 pond to the left of the patient.   G. Fabricius evidently adopted the
 same rule, which had already been recommended also by A. de  la
 Croix.  It is to Hunault of Angers, however, that we are most indebted
 in this matter. Certain plates which he had executed, but which have
 never been  published,  demonstate that by  means of the grooved
 sound we will always be sure of incising  the  same parts.  It was
 after having adopted his advice that F. Jacques, in 1701, was enabled
 to operate upon 38 calculous patients, at Versailles, without losing  a
 single one, and also upon the 22 patients collected by the Marechal
 de Lorges, at his hotel in 1703, and it was also by this operation that
 he obtained such brilliant success in Holland, and again upon his re-
 turn to France.*  However this may be, public attention having for
 a time been diverted from  its legitimate object during the first half
 of the last century, was not enabled to comprehend  at first all the
 importance of the grooved sound, and of the oblique operation, prop-
 erly so called.
   B. Process of Garengeot and Perchet.—Garengeot, who discov-
 ered  it while making with Perchet, a surgeon of La Charite, trials
 upon the dead body, and put it into execution in the case of a child eight
 and  a half years old, in  1729, while Alorand had  gone to London to
 learn it of Cheselden, is the first person who appears to have re-estab-
 lished the oblique operation for lithotomy upon  the principles which
 Hunault had first laid down.   The sound  being introduced into the
 bladder is consigned to an assistant, who presses it towards the left
 side of the perineum.  The surgeon makes an oblique incision from the
 raphe to the middle of the space which separates the ischium from the
 anal opening, with an ordinary bistoury or lithotome.   This incision,
 which ought to commence at about an inch in front of the anus, com-
 prises the integuments and  the sub-cutaneous layer.   The left fore-
 finger afterwards serves as a guide to the cutting instrument, while
 we divide the other tissues, layer by layer,  and  open into the ure-
 thra.   The lithotome, glided from above downwards or from before
 backwards upon  the groove of the sound, penetrates into the bladder
 while cutting  through the  prostate obliquely outwards, backwards,
 and to the  left; after which the surgeon makes use of this knife to
 enlarge the whole wound  while withdrawing  it,  and by making
 pressure upon it with a greater or  less degree of force.   In  order
 to favor the  entrance of the lithotome as  soon  as the membranous
 portion of the urethra is laid open, the operator directs the assistant
 to depress a little the plate of the sound or depresses it himself, in
 order to elevate its concave portion behind  the  pubes, at the same
 time that he more or less inclines the wrist of his right hand down-
 wards.   By this means we run no risk of making a mistake, and the
 bladder escapes from any danger of being wounded.
   C. Process of Cheselden.—Morand, in  describing the process of
  * F. Jacques did not die in  1713, as is asserted by Sabatier. Having arrived from
Rome at L'Etendonne, or, according to Normand, at his native town of Arbagne  in
June, 1714, he went to pass several months at Besan<;on, and afterwards remained a suf-
ficiently long time among the Benedictines to build there a small house, which he sub-
sequently abandoned in order to reside with his friend L. Depart, where  he died, aged
69 years, and consequently in the year 1720, since he was  born in the year 1651. 
LITHOTOMY.
905
Cheselden, conveys nearly the same idea that Garengeot does, of the
lateralized operation;  except that it would appear that his principal
object after having divided the prostrate, was to respect to a consider-
able extent the other tissues, and to make a wound from the bladder
to the perineum, similar to a sort of oblique canal, from behind  for-
wards.  Cheselden, moreover, has frequently modified his process of
lithotomy.  His first method is the one which I have above described,
while speaking of the  lateral operation, and his second method is the
one which Morand made known.  The third, or the one which he
finally fixed upon, is very different from the ideas that are generally
entertained of it in France.   The English surgeon  gave in  every
case an extent of from two to four inches to his external incision, an
incision which was made to fall between the bulbo and ischio-caver-
nous muscles, and to lay bare the urethra as far up as to the apex of
the prostate.  The second stage of the operation comprised the inci-
sion of the deep-seated parts, exposed to view by the first.  To ex-
ecute this, Cheselden pushed the anus with  force to the  right,  and
backwards, by means of his left forefinger placed in the posterior an-
gle of the wound, then glided upon the nail of this finger a bistoury
which was slightly concave, penetrated up to the neck ofthe bladder,
while following the anterior side of the rectum, and came down upon
the groove of the sound, when he divided from behind forwards,  and
from below upwards the whole extent of the prostate gland, by draw-
ing his lithotome towards him, the cutting edge of which was turned
towards the  symphysis pubis.   The  method of Cheselden is,  as we
perceive, very distinct from the oblique  or  lateralized operation,  fol-
lowed by the French  practitioners.   It is true  that it  divides  the
same parts that Garengeot's does, but while it apparently puts him
better on his guard against any injury to the rectum, it in  reality
creates only greater difficulties in the manipulation.
  D. Boudou, who also performed the lateralized operation, and even
before perhaps any person had described it at Paris, made a process
from it which does not differ  from that of Mery, except in the  direc-
tion which he gave to the wound.   De la Faye  in fact says,  in the
additions  he has made  to the  treatise  of Dionis, that Boudou inclined
the plate  of his sound towards the right groin,  and that after having
incised the membranous portion of the urethra,  he  plunged in  the
lithotome along  the groove of the director, which was then raised up
in the direction of the pubes,  until he reached beyond the neck  of the
bladder, and  that  he divided the prostate obliquely to  the left, by
bringing back towards him the cutting instrument.
  E. Process of Le Dran.—Le Dran also was desirous of having his
own process.  After having incised the urethra, he introduced a large
grooved sound into the bladder, and immediately withdrew the cathe-
ter, and terminated by dividing the prostate with  a convex bistoury,
which was a sort of a buckler-shaped instrument (rondache) guided
upon the sound, and which was about six lines  in  breadth.  Though
almost insignificant in  itself, and calculated rather to  embarrass than
to simplify the operation, this  modification, nevertheless, has had its
partisans.  Schmucker (Bibl.  Chir. du  Nord, p.  39,) says  that  no
patient will die from this operation if it is well performed.  A.  Burns
adopts the principle of this process, with this difference, that a bistoury 
906           NEW ELEMENTS OF  OPERATIVE SURGERY.
or ordinary lithotome appears to him to be preferable to the rondache
of Le Dran.   M. J. Bell, who is of the same opinion, incises from the
prostate towards the first opening of the urethra, like Cheselden, in
the place  of directing his  bistoury from before  backwards, in the
manner  of Le Dran ; and M. Allan, who, like his countryman  also
directs the point of the  bistoury upon the sound, by passing behind
the prostate, prefers  to  withdraw the two instruments at the same
time,  by holding them firmly against each other in the  same way,
as is  very frequently done  in the operation  for  fistula in  ano.  It
would be difficult to discover in what manner lithotomy is rendered
more  convenient, or less  dangerous, by these various modifications of
the principal process.
  F.  Process  of Lecat.—A mode of  performing the oblique or late-
ralized  operation, which made some  impression in its time, was  that
of Lecat.  The sound of this operator terminated in a handle instead
of having a plate.   The instrument he made use of to lay bare and in-
cise the urethra, had a lateral notch near its back, and received from
its inventor the name of uretrotome.   Lecat conducted, by means of
this last, another instrument terminated in a blunt extremity, into the
groove of the  sound, in order to cut  through  the  prostate, nearly in
the same manner as in the second process of Cheselden, that is to say,
in the one described by Morand.   The cutting edge of this second
bistoury, however, which was called a cystotome, was never to go be-
yond  the vesical bourrelet, which is found at the entrance of the ure-
thra, for which reason precisely the name of cystotome was in no way
applicable to it.   Finally, the surgeon of Rouen had at one time the
idea of replacing his cystotome by a concealed lithotome. which he
denominated a cystotome-gorget.   His axiom was a. small, deep inci-
sion, and a large exterior incision.   It is perceived  that  he already
foreshadowed the dangers of going beyond the limits ofthe prostate,
and that he preferred dilating rather than incising the  entrance  into
the bladder.   His  method, which has not been  generally received,
though  he  obtained unquestionable  advantages  from  it, neverthe-
less, continued  to be adopted  by some practitioners.   Pouteau, who
had slightly modified it, obtained such decided success from it, that in
the hospitals of Lyons it is still employed quite frequently.
  A surgeon of Venice, AI. Paiola, who has complicated it still more
by adding  another  instrument to  those of Lecat, has, it is said,  em-
ployed this process in 500 cases, and  without losing a single patient!
This assertion is so extraordinary, that had not Langenbeck spoken
of its  author  in  terms of eulogy, it would  not  have deserved the
slightest attention.  We  perceive in the thesis of AL Dumont, that at
the hospital of Rouen, AL Flaubert also adopts the axiom laid down
by Lecat, and  that in his opinion a small  incision with free dilatations
is a precept which the surgeon should never lose sight of.   Delpech
also thinks  that there is less danger in dilating or even lacerating the
neck  of the bladder than in  incising it extensively, and that in this
respect  Lecat's rule ought  to be retained as a law.  There is  under
this precept an important truth, which could not  be properly appre-
ciated until in these latter  times, because  the anatomical fact con-
nected with it had not been clearly indicated : it is this, that lithotomy 
LITHOTOMY.
907
confined within the limits of the prostate is infinitely less dangerous
than that in which the incisions are extended beyond this gland.
  G. Process of Moreau.—Moreau, a surgeon of the Hotel Dieu of
Paris, rejected all these complications and performed the lateralized
operation in the following manner.  His lithotome  resembled, to a
certain extent, the ancient  lithotome of Collot.  He made an extensive
incision into the skin and sub-cutaneous cellular tissue ; laid open the
membranous portion of the urethra ; elevated the sound behind the
pubis at the same time that he plunged the bistoury into the bladder;
strongly elevated the wrist of the right  hand, in order to incise the
prostate obliquely, and afterwards depressed it, in order to replace the
cutting edge of his knife backwards at the moment when he brought
it out to the exterior.  Moreau's object was to have a large opening
at the neck of the bladder, in order to extract the stone  from it with
facility ; an opening still  larger at the integuments, in order to prevent
infiltration or atjscesses; and to incise but to a very small extent the
intermediate parts, in  order that he might avoid the arteries of the
perineum, which  are chiefly found in that part, and in order also to
respect the rectum ; so that the wound in his operation would repre-
sent a  double triangle, the strangulated  portion of which was  at the
middle of its length.
  H. Process of F. Come.—A  modification  of the lateralized ope-
ration, which warmly interested the  surgical world, is the one of
which Frere Come gave himself out as  the inventor  in  1748.   This
ecclesiastic had contrived an instrument which, being introduced
closed, through  the incision of the urethra, into  the  bladder, was
opened by the pressure  made upon  a movable piece at  its outer ex-
tremity, and divided the prostate from within outwards, at the mo-
ment it was withdrawn.   This  instrument,  which has  since  been
known under the name of  the concealed lithotome, was at  first sup-
posed to possess numerous advantages.  Its handle, cut into faces, and
numbered by the figures  5, 7,  9, 11, 13, 15,  was arranged in  such
manner, that by turning either of these figures towards the movable
piece, we were sure of having a corresponding opening in the  direc-
tion of its vesical extremity.  We thus know in advance before in-
troducing it, and in a positive manner, that it will incise the neck of
the  bladder, to  the  extent of 7, 9, 11, 13, or 15 lines, according as
we  have selected  one or another of  the  dimensions indicated.
Franco speaks of an instrument of the same kind, and the concealed
bistoury of Bienaise does not differ materially from  it.  The  objec-
tion made to it was, that it was liable to escape from the groove  of
the  sound, to slip between  the bladder and the surrounding parts, to
wound the rectum at the  moment when it is withdrawn, to  divide
the  pudic vessels, and especially to perforate the  bladder itself as
soon as this has emptied itself through the wound in the perineum.  It
was  to remedy this last inconvenience  that Caquet, a surgeon  of
Rheims, gave it a blunt point.  Moreover as it has, when rigidly ex-
amined, the advantage only of incising  to a  determinate extent the
same parts that are divided with the other lithotomes, it has in turn
naturally been both praised and rejected, and apparently  with reason.
Those surgeons who are little practised in great operations, who are
not sure of their hand, and  who are not perfectly acquainted with the 
908           NEW ELEMENTS OF OPERATIVE  SURGERY.

anatomical relations of the perineum, but who nevertheless  dare  to
perform  lithotomy, may,  and even  ought  to give it the preference.
The lithotome gorget, formed of two pieces, which are movable on
each other, and which Bromfield proposed  to substitute for it, is infi-
nitely more defective. As to the modifications which have been given
to it by M. Evans of London, and sundry operators  in  France, and
which relate almost exclusively to its handle and movable piece, they
are of too little importance, and too evidently matters of mere taste to
render it necessary that I  should describe them in this place.
  I.  Frere Come, down to the incision of the membranous portion of
the urethra, proceeded in the same manner as in the ordinary lateral-
ized  operation.  The  lithotome, directed on the nail  of the left fore-
finger into the groove of the sound, was immediately to be introdu-
ced, shut up, into the bladder.  The surgeon then himself seized the
sound with his left hand, in order to depress its plate and to elevate its
concavity behind the pubis, while with his right hand he pushed for-
ward upon the  groove of the  sound, the point of the concealed
bistoury, which  by this means was conducted into  the bladder.
The sound  being now no  longer necessary, was immediately with-
drawn from the urethra.   After having again satisfied himself of the
existence of the  calculus, which may be readily touched with the ex-
tremity of the lithotome, the operator seizes the  stem of this  instru-
ment with his left hand, between the thumb and  forefinger, in  a state
of semiflexion;  opens it  by making pressure with his right hand
upon the movable piece ;  pushes its  back firmly, and a little to the
right, against the symphysis  pubis ;  directs its  cutting edge back-
wards and  to the left; withdraws it by elevating moderately  its han-
dle, until its blade has passed through the  prostate; loosens  at this
moment  its movable piece ;  allows it to  shut up again  by degrees;
and depresses it  more and more, and in  such manner that, from the
neck of the bladder to the integuments, its cutting edge shall to some
extent have circumscribed the half of a circle, the convexity of
which would be turned forward very nearly in  the same way as  in
the process of Moreau.
  J. Process of Guerin.—F. Come is far from  being  the only per-
son who has proposed a particular kind of instrument to diminish the
dangers of lithotomy.  Since his time there  have been also a great
number of others contrived, the object of some of which has been to
give greater certainty to the opening into the  urethra, and that of the
others to incise the prostate or neck of the  bladder with less danger.
Among the first  are to be found various sorts of sounds, that,  for ex-
ample, of Guerin, which is constructed  in such manner that  when it
is once introduced, its outer  extremity is depressed to such extent
as to face  directly  towards  its most  convex portion, that is  to
say, the groove  of its urethral half.  This sound, moreover, termi-
nates in a sort of head which is pierced with a hole, through which a
long  trochar  grooved upon its lower side, may be  introduced, and
which being  directed upon  the perineum necessarily  falls into  the
groove of  the sound itself without any danger of deviating. It is
perceived that the incision of the external soft parts then becomes a
matter of extreme facility, and that the laying open of  the urethra is
no longer attended with the  slightest degree of difficulty.  In other 
LITHOTOMY.
909
  respects the operator proceeds in the same manner as has been men-
  f10nf,  "?• JPea^ing °f the median operation.  An instrument which
  hardly differs from that of Guerin except in being formed of two
  halves, which are articulated by a hinge outside, has been introduced
  into practice in England by M. Earle, to effect  the same object as
  that of  the practitioner of Bordeaux.   Deschamps proposes a third
  which also belongs to the same description, and M. Smith (Baltimore
  Med. and Surg. Journ., April, 1832,) has  contrived a  fourth which
  does not differ materially from that of Guerin.  If the opening into
  the urethra were really the difficult point in the operation, these kinds
  of sounds  would perfectly carry out the intention.  But though the
  operator may have ever so little  knowledge or skill, this is never the
  stage in lithotomy which embarrasses him.   Consequently the instru-
  ments of MM. Guerin, Smith, and Earle will continue  to be, like so
  many others, a matter of taste and personal convenience.   The ordi-
  nary sound, in which AL Chas. Bell has placed the groove upon the
  side, in order  to be enabled while leaving it upon the median line, to
  incise obliquely to the left  on reaching the prostate, is, in fact,  only
  calculated  to  increase  the difficulties  of the  operation.  As  to the
  straight  sound extolled by AL Zaviziano,  (Mem. sur F Usage de la
  Sonde Droite, 1832,) or the one which  is but slightly  curved back-
  wards to the extent of half an inch near its  point, like the one em-
  ployed by  M.  Key, this also  does not  appear to me  to possess any
  real value or decided advantage over the others.
   K.  Lithotomy with the bistoury.—The instruments  devised with
 the view of rendering the  opening into the bladder more easy and
 secure are  of  two kinds.  There  are those, in  fact, which differ only
 by slight modifications from ordinary bistouries,  while  others, in
 reality, constitute special instruments.   Thus the lithotome of Ches-
 elden, which  is slightly  concave on its back, was modified by A.
 Dubois into a small knife  with a fixed handle, but which in other
 respects  scarcely differs from the convex  bistoury.   In England,
 Blizard made use of a long narrow bistoury with a fixed handle, like
 that of the French surgeon, and the point of which  terminates on the
 back by a kind of blunt probe.   Klein, Langenbeck, Kern and Graefe
 in Germany each, also, have  their own lithotome, which, like those
 above, are to be  ranged in the class of simple knives or  modified  bis-
 touries ; but to whoever shall examine  this matter  attentively it will
 appear evident, that all  this is a  mere optional affair, and that it is
 almost a matter  of  indifference whether we adopt one or the other
 of these instruments, all of which might, if necessary, be  advanta-
 geously replaced by the simple or blunt-pointed bistoury.  It is now
 a long time also since Dupuytren, M. Mott and  a number of  the
 London surgeons made this remark, viz., that the  ordinary straight
 bistoury is full  as well adapted  as  the most complicated lithotomes
 for penetrating into the bladder, and for dividing in  a proper manner
 the prostate as it comes out, provided  it is conducted  by a skilful
hand.   Dupuytren even has  performed lithotomy  by plunging  the
straight bistoury by puncture down to  the groove  of the sound and
then  into the bladder, in such  manner as to divide  at the same time
while withdrawing it, both the prostate and the entire mass of tissues
Which form the perineum.   This process, which assimilates lithotomy 
 910          NEW ELEMENTS  OF OPERATIVE SURGERY.

 to the simple opening of an abscess, is more easy than is supposed.
 I have frequently made trial of it upon the dead body while going
 through the operations before the  students:  but as it cannot have, in
 reality, any other advantage than that of abridging the operation by
 the space of about half a minute, I do not think that prudence would
 allow us to establish a manipulating display of this kind as a law in
 surgery.   If, however, we  should decide upon using  a simple bis-
 toury, we should open  the urethra in the ordinary mode, and after-
 wards glide the  instrument  upon the groove of the  sound, by pro-
 ceeding in the same way as  with  the other kinds of  lithotomes.  It
 would be  in such cases that my  double sound with an eye would
 be applicable.  The special instruments which remain to  be  spoken
 of are known under the common title of gorgets.
   L.  The process of  Hawkins.—The first gorgets employed in
 lithotomy were nothing more than a simple  gutter terminated at one
 end by a probe  or button, and at the other by  a kind of  handle.
 They were made use of to replace the sound, and are also employed
 in almost every kind of lithotomy  in order to give greater facility to
 the introduction of the tenacula.   Under this  form they have blunt
 rounded borders,  in order not to incur the risk of wounding the parts.
 It was not until about the middle of the last century that Hawkins,
 an English surgeon, suggested the idea of  transforming the  gorget
 into a lithotome, that  is to say, to give one of its borders a  cutting
 edge near the point.   This instrument, wiiich most English surgeons
 adopted, is employed  in the following manner:  As soon as the sur-
geon has opened through the membranous portion  of the urethra, he
 seizes the gorget  by its handle and applies its button into the groove
 of the sound and  pushes it into the bladder, taking care that  it  does
 not let  go its  hold upon the last mentioned instrument, which,  by a
 vibratory  movement, is to be raised up  behind  the pubis, in propor-
 tion as the gorget divides the left side ofthe prostate.   The apparent
 simplicity of Hawkins's gorget did not prevent its partisans themselves
 from noticing its defects.  Bell, perceiving that its blunt portion was
 too large, made it small  in order to  prevent it from lacerating or
contusing the parts.   Desault dispensed with its concavity, placed its
 button altogether to the right and  upon  its blunt border, and in other
 respects adopted the modification of Bell.  Blicke,  fearing  that it
might escape from the sound  and get in  between the rectum and
 bladder, instances of which MAI. A.  and S.  Cooper state  that
 they have frequently been witness to,  arranged the button in  such
 manner that it could  not   escape  until it had  arrived  near the
 extremity of the groove  of  the sound.   That of Abernethy, so to
 speak, resembles a triangular gutter, as  is noticed  also in the  gorget
of Cline, or a semi-cylindrical  canal  like that of Hawkins.  Dorsey
 has given the figure of one, the blade of which, which can be easily
 detached, has  in every part of  it the same  width, and  the  free
 extremity of which, cut obliquely like that of Desault's kystotome, is
the only part which  has an edge.  Finally, Scarpa, who avowed
himself a partisan of the gorget, has gone to a great length to demon-
strate that it ought to have a very narrow cutting  edge of the extent
of two  lines near its  button, becoming gradually  wider until it has
acquired a transverse diameter of about seven lines, and that this 
LITHOTOMY.
911
 cutting edge ought to be bent into an angle of sixty-nine degrees  to
 the border  which constitutes its back, in order that while cutting
 through  the prostate,  it may make in this  gland a wound, whose
 angle should also be sixty-nine degrees, in relation to the axis of the
 urethra.   Some English surgeons,  among others Dease and Mair,
 supposed that there would  be greater security given in  the employ-
 ment of the  gorget by making use of Le Dran's sound for its director;
 but this proposition has not  had  and could not have any advocates.
 In France the gorget has found but a very small number of admirers,
 and AL Roux is almost the only person who makes use of it in Paris.
 The most  simple reflection  will be  sufficient  to  show the little
 importance, I  might  say almost the insignificance, of  the various
 modifications which it has undergone.   It is  the  gorget  as a special
 instrument, and not the gorget in particular, which is  the important
 one  to be examined ;  and  I am surprised that authors of so much
 repute should  have wasted  so much time in discussions relating to
 this subject.  It is certain that with the  gorget we never can wound
 the rectum or pudic artery, unless there should exist some anatomical
 anomaly; and also that we cannot go beyond the limits of the pros-
 tate.  But as the only reason of these advantages lies in the small
 extent given to the incision,  it is clear that we could obtain the same
 result from any lithotome whatever, provided we restricted ourselves
 to a wound  of from six to seven  lines.   Its inconveniences are that
 it always  makes a passage of the same width whatever be  the vol-
 ume of the stone;  that it exposes more than any other instrument to
 the danger  of wounding the posterior wall of the bladder, or even
 transfixing this organ, as M. Earle says  he has seen, and especially
 of dividing the tissues by pushing them  before it, and by separating
 the different layers of the perineum from one another,  of relaxing
 them to some extent in the place of stretching or pressing them from
 above downwards, in the way for example it is done by the con-
 cealed lithotome, and by almost  all the  cutting  instruments  made
 use of by different surgeons in this second stage of the operation.
 Finally, that it dilates and contuses at the same time that it  divides,
 that  it obliges the operator  to have several of different dimensions,
 and that  it does not allow of an incision of more than eight to nine
 lines in extent.  One of its  advantages, perhaps,  which is the most
 positive though it has not been noticed, is to be found in the direction
 which it  gives  to the incision of the prostate, an incision which is
 semilunar, the  convexity of which is turned  backwards  and to the
 right, and the arc of which having a cord of about seven lines, may
 be enlarged  without laceration to the extent of two to  three lines,
 when we  proceed  to  elongate  it  while  extracting  the calculus.
 Under this point of view the gorget of Desault is evidently the least
 convenient of all; for to attain the object in view  it would be neces-
 sary, while increasing its breadth at the cutting part, to preserve its
 primitive gutter-like or semi-cylindrical form.  In this respect, more-
 over, it would no longer be  applicable  to the lateralized or oblique
 operation,  properly so called.  The incision would be rather trans-
 verse than in the direction  towards the left ischium ;  from  whence
 would arise  another  inconvenience, since we should incise upon  a
segment of the prostate, which  would  be less in length than that 
912           NEW  ELEMENTS OF OPERATIVE SURGERY.

which would have been incised in the process of Frere Come, Che-
selden or Garengeot.
  M. Process of Thompson.—The deviation from the line originally
contemplated for the lateralized operation, is however  not  the only
one which has  been proposed.  In  1808, Thompson also, with the
view of avoiding the rectum and  perineal arteries, suggested that we
should incise with the ordinary lithotome, not downwards, but in fact
upwards, and  a little to the outside, provided an  incision  of some
lines backwards should not be found to be sufficient to allow of the
extraction of the stone.   Nearly about the same time, Dupuytren, for
the purpose of avoiding the same  organs, deemed it advisable to car-
ry his incision almost directly upwards ;  that is to say, having arriv-
ed into the bladder, he turned the cutting edge of his bistoury, or of
the lithotome of F. Come, upwards, and a little to the right, and par-
allel to the ischio-pubic branch of the pelvis, as if for the purpose of
reaching up to the  symphysis.   M. Pantaleo, (Gaz.  Med.,  1834,
p. 411,) who incises  the prostate posteriorly, and to the left, and then
in front and to the right, has in reality done nothing more than to repro-
duce  the suggestion of Thompson.   These modifications have had
to be abandoned, even by their authors themselves, since in  such
processes we divide the prostate in that direction where it has the
least diameter, and that we almost unavoidably go  beyond its limits,
and for the still greater reason, that we  are obliged to extract the
calculus at a narrower part  of the lower strait than in  the posterior
oblique operation.
  N.  Process of Boyer.—Boyer, who almost always used the  con-
cealed lithotome,  and who was considered very fortunate in his ope-
rations for  stone, did not make his incision in the direction of any of
those lines  which have been above indicated.  In place of resting the
back of his instrument against the symphysis, he held it firm against
the right ischio-pubic branch, so as to be enabled to direct its cutting
edge almost entirely transverse and  to the left while withdrawing  it,
and to divide the prostate from within outwards, in  the same way as
every person does.  When we proceed  in  this  manner, we run no
risk of wounding  the rectum or pudic artery, any more than we do
the transverse artery, whose course  is nearly parallel to that of the
incision, so that the superficial artery is in reality the only one which
could be in any danger.   A modification  of this kind would be free
from all objection, if we  were  not obliged  to divide the prostate  in
the direction of  one of its shortest  diameters,  or  if it were possi-
ble to give an extent of more than 7 or 8  lines to this division with-
out going beyond the  circumference of the gland.  The lithotome
directed  in this manner,  presents in  fact all the advantages of the
gorget, without being attended with its inconveniences.
  O.  The Author.—If it be  true, that the question to be solved in the
oblique operation for stone, is that of dividing as extensively through
the prostate as possible, without passing beyond its periphery, the incis-
ion directed downwards and outwards, is evidently the only one which
ought to be adopted.  According to this hypothesis, the process  of
Thompson, and that which Dupuytren was desirous at one time of in-
troducing into practice, would no longer be worthy of any consider-
ation.  The rule  adopted  by Boyer, which  allows  the  cutting  edge 
                          LITHOTOMY.                        913

of the bistoury to be inclined a little towards the ischium, is infinitely
preferable.   For the extent of a line  perhaps, that it  makes  us lose
at the place where the prostate would be opened, we procure in com-
pensation incontestable advantages in  relation to the rectum and ar-
teries.  As to the incision made after  the manner of Boudou, Garen-
geot, Morand, Le Dran, Moreau, Dubois, and J. and Ch. Bell, or after
all those in fact who prefer the bistoury to particular lithotomes, and
whose object is to make a large opening into the neck ofthe bladder, it is
a matter almost  of indifference whether we imitate one or the other, so
long as we take care to give a sufficient extent to the incision through
the integuments and the other tissues composing the perineum.   The
method of Lecat presents two points  for consideration: 1st, the in-
struments which the  inventor made use of,  and which may  be re-
placed by an infinite number of others ;  2nd,  the suggestion that we
should make only a small incision in entering into the  bladder.   It  is
under this point of view only, that the operation of Lecat is worthy
of being distinguished.   De la Motte had already maintained  that
there is less  danger in dilating or even lacerating, to a certain ex-
tent, the entrance into  the  bladder, than  by incising it.  More-
over, the justice of this position can scarcely be called in  question.
The error of those  who have defended it, is that of not having  com-
prehended its fundamental principle, and of having given too extrav-
agant an extension to it.  In fact the small incisions mentioned by
Lecat have  no  other advantages  over the great  ones, except  that
they enable us to restrict  ourselves to  the periphery of the prostate,
from whence it  follows that the  other operations would not expose
us to any more  danger, provided that we did  not go beyond the con-
tour of this gland.  I have mentioned' above,  what estimation is to be
placed on the gorget and its different varieties.  There remains to be
considered, the  instrument of Frere Come, which, it cannot be denied,
offers in reality  a great degree of security, an extreme simplicity in
its  construction, and  the  advantage that it can be employed with
more facility than the  bistoury, by the greater number of operators.
As the principal dangers of the oblique operation are the lesion of the
rectum, ofthe pudic artery, and ofthe transverse or superficial arte-
ries, all the  instruments, with the  exception of the  gorget, are under
this point  of view attended  with nearly the same inconvenience.
Provided we can satisfy ourselves in  respect to the condition of the
intestine, by introducing our finger into it,  and that we have  taken
care not to give too great dimensions  to  the deep portion  of the
wound, and have conducted the lithotome with some adroitness, we
shall not wound it.   As  the  pudic artery is always situated  upon
the contour  of  the pubic arcade, and consequently considerably be-
yond the limits of the prostate, it does not  in reality  run any risk
of being wounded.   As  the  superficial artery has its  seat  in the
sub-cutaneous layer,  it could  be too easily  seized, twisted, tied or
cauterized to make its division a  matter of any apprehension.   The
transverse  artery of  the perineum, which  is ordinarily quite  small,
will not be  avoided with certainty, unless the incision of the  ure-
thra should not  commence  too  near the bulb or too far from the
prostate.  Fortunately the hemorrhage which results from it is rarely
sufficiently abundant to be  a  matter of serious importance.   It can
                              58 
914          NEW ELEMENTS OF OPERATIVE SURGERY.

only be, therefore, in cases of anomaly  or deviation in the  direc-
tion of these vessels, or of their preternatural size, where any danger
can exist under this point of view, in practising the lateralized opera-
tion.  A more serious difficulty by this method, is that of being only
enabled to obtain an opening at most of from ten to twelve lines,
and which is  consequently too small to allow of the extraction  of
large sized calculi.  It was with a view  of remedying this real  in-
convenience, and  independently of  all processes and all operators,
that the following method has been warmly  approbated.

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

  Another interpretation of Celsus has given rise to a new operation
in lithotomy.  In speaking  of the  extraction of calculi, the Roman
author recommends that we should  make juxta anum, cutis plaga
lunata,  usque  ad cervicem  vesica, cornibus ad coxas  spectantibus
paululiim, and then that  the instrument must be brought back to the
bottom  of this first wound, in order  that  we  may  make another,
which is to be  transverse, and which opens the neck of the bladder
in penetrating  down to the  calculus.  Now it is this passage, hitherto
explained in such manner  as to refer to  it the  origin of the lateral
operation, and the lateralized  operation as well as the little one for-
merly described by the  Greeks and Arabs, which,  when brought
back to its legitimate  signification, has'suggested the idea of the new
method.   The expressions  plaga lunata and plaga transversa had,
it is true, in more than one  instance  embarrassed the commentators
of Celsus ; but in  putting the  singular in place of the plural, and by
translating ad  coxas as towards the thigh  (vers la  cuisse), they sup-
posed that they had overcome the difficulty. It was in vain that Davier
made Cochu sustain, on the 15th April, 1734, at the Faculty of Paris,
that in the operation of Celsus, we are to make upon the skin near
the anus an incision  in  the form  of a crescent, the  extremities of
which are to be turned  towards the thighs; that Heister made Ils-
mand repeat the  same  phrase, in November, 1744;  that Normand
de Dole, who complained, in 1741, of the  little attention paid to the
reading of the  ancient authors, recalled to mind that in the operation
of Celsus, the incision, which wTas of a crescent  form, should have  its
horns turned slightly  towards the thighs of  the patient, and that the
same  interpretation  was again given  by  Alacquert in  the  thesis
which he  supported  in April, 1751.  by Portal in his Precis de Chi-
rurgie, published in 1708, and by Deschamps himself, in his treatise
on stone ; nobody took the trouble to derive the slightest profit from
it.  A second difficulty which Bromfield  had in vain  endeavored  to
remove, had undoubtedly been the reason.  This was to ascertain if
the words cornibus spectantibus paululiim ad coxas ought to be un-
derstood to mean a  semilunar wound, whose extremities should  be
turned forwards rather  than  backwards.   All  the authors whom I
have just quoted have,  as we perceive,  adopted  the first version.
Bromfield alone inclined  to  the second, which appears  in fact to  be
the true  signification, inasmuch as  the word coxas  among the an-
cients was generally applied to the large  bones of the pelvis, and to
the ossa ischia in particular.   However this may be, it was not until 
LITHOTOMY.
915
 at the beginning of the present century that the question was exam-
 ined in a correct point of view.
   In the year 1805, M. Morland recalled in his thesis the trials made by
 Chaussier on this point, essays by which it was proved that a semilu-
 nar incision, with its concavity posteriorly, would enable us to enter into
 the bladder and to extract the calculi from it.   Nevertheless, it was
 still labor lost.  Chaussier himself had forgotten his own researches,
 when in 1813 Beclard reproduced them  almost  in the same terms as
 M. Morland, and  with full as little  success.  The cogent and en-
 tirely conclusive arguments adduced in  1818, by M. Turck, in  favor
 of the same  principles, did not any more succeed in changing the  di-
 rection of the public mind.   But in  1824, Dupuytren, whose atten-
 tion was  occupied with the subject of rendering lithotomy less  dan-
 gerous, having had the same idea as Chaussier,  Beclard, and M.
 Turck, and  almost immediately  making an application of it  upon
 living man, was soon convinced that this method contained a precious
 process  for  the operation  of stone.   Beclard, without attaching  so
 much importance to it, and who  moreover  had never overlooked it,
 but, according to M. Olivier d'Angers, had occasionally already  used
 it in practice, again  described its advantages before the Academy,
 while Dupuytren, at the  Hotel Dieu, demonstrated its extreme value.
 Since that epoch, a great number of surgeons have adopted it, and it
 is now reckoned among  the best methods.
   A. Process of Chaussier.—We perceive by the thesis of M.  Mor-
 land, that Chaussier, after the mode of M. Ribes, began by incising
 all the soft parts between the anus and the bulb of the urethra,  with
 the point of a scalpel;  that  he  had had the idea of a sound  with
 a double  groove, one on the right and  the other  on the left, in order
 to be enabled to divide the membranous and prostatic portion ofthe
 urethra, on one side only, or on  both sides in succession, should the
 volume of  the stone appear  to require  it; that  in  his  opinion a
 grooved sound could replace this instrument, provided that by intro-
 ducing it into the wound, it would be easy to incise  upon  it to the left
 and then  to the right; that he also had had the  idea of a  concealed
 lithotome with a double blade, and of the sheathed  scalpel  of Louis;
 but that he took care to make the remark, that in such cases, the best
 of instruments was the mind, guided by an exact knowledge of the
 situation and nature of the part.
  B. Process of Beclard.—The  instrument  which Beclard selected
 is a sort of gorget of some breadth, slightly concave, cutting  upon
 its two edges, and terminated in a tongue in  the direction of its  con-
 vexity.   He also speaks of the  double lithotome, leaving every one
 at liberty to adopt it or to dispense  with  it. He  finally had made,
 in order  to carry  out the same indication, a  knife  of  a sage-leaf
 form, and nearly similar to the lithotome of Cheselden.   He incised
 the skin  and the  other  tissues, moreover,  in the  same manner  as
 Chaussier.
  C. Process of Dupuytren.—Dupuytren,  for  the purpose  of per-
 forming  the  transverse  operation, contrived two  particular instru-
ments ; first, a fixed bistoury, or sort of scalpel with a cutting  edge
on both sides near its point, to the extent of some lines; second, a
double lithotome, which might have been suggested by  a  phrase  in 
916           NEW ELEMENTS OF  OPERATIVE SURGERY.
Franco, and which is very accurately represented by the 'cutting te-
naculum of Tagault, figured at  page 366 of the additions of Joubert
to the work of Guy, printed in 1649 ;  one which Fleurant  had men-
tioned,  in speaking of  lithotomy  in  women, of which  Lombard,
(Thomassin,  Corps Etrang., &c, p. 103, 1788,) has given the  de-
scription and figures, which Chaussier and Beclard had also thouo-ht
of, hut which  it was  reserved  for Dupuytren  to  bring into repute
and to render as simple as possible.  M. A. Stevens and AL Amus-
sat, finding it  still too complicated, have  proposed to employ in its
place a sort of scissors, with cutting edges on  their borders when
opened, but which are blunt when shut;  but these scissors are  not
capable  of fulfilling all the indications which we have  in view in
making use of the double lithotome.   It is not in fact a simple trans-
verse incision which the surgeon ought to think of making, but this
incision should at the  same time be  oblique in  the  direction back-
wards and outwards on each side, in order that it may embrace at
once the  two largest portions of the  prostate.   Dupuytren,  who had
early felt the necessity of this, has found everything that he  could de-
sire in this respect, in the modifications which M. La Serre,  and espe-
cially those which the ingenious cutler AL Charriere has given to his
original lithotome. Finally, in place ofthe ordinary sound, Dupuytren
has contrived one which is dilated, as it were,  at its greatest convex-
ity, in order that it may make greater distension upon the urethra, and
the groove of which is more flaring and has less depth at its extrem-
ities, than in its middle portion.   The patient is arranged in  the same
manner as in all the other operations for lithotomy.   The  surgeon,
placed in front of the perineum, stretches  the integuments with  his
left hand.  With a scalpel in his right hand, he makes the semilunar
incision;  commences it near the right ischium ;  extends  it to  six
lines in front of the anus, and terminates it on the inner side of the
left ischium, in order that its horns may fall on the middle  point of
the space, which on the right and on the left separates the anus from
the tuberosities of the ischium.  He thus divides  in  succession the
different  layers which present themselves, keeping rather on the me-
dian line, until he arrives near the membranous  portion of the ure-
thra, which he divides longitudinally.   Then  laying aside the scal-
pel,  he takes the  lithotome, whose handle  has been  previously
fastened  at the proper degree,  and directs the point of it  upon the
conducting instrument, with its concavity turned upwards,  in order
to introduce it into the bladder  in the  same way as when we make
use of the instrument of F. Come.  Before  opening it, it is to be
made to  circumscribe a half circle, in order that its concavity, which
was turned upwards, may now look downwards towards the rectum.
It is then to he opened, after which it is  to be withdrawn  in the di-
rection of the external wound, after having embraced it  with the
thumb and  forefinger of the left hand  a little beyond its handle,
while with the right hand we keep it open, in  order  to divide from
within outwards the prostate and the soft parts, which had  been  re-
spected by the scalpel.
   There can be no doubt that  the  ordinary bistoury might  in this
operation be made to answer perfectly well in place of the scalpel;
that the lithotome of F. Come, directed first to the left and afterwards 
LITHOTOMY.
917
 to the right, may serve to incise the same parts ;  and that the double
 cutting-edged gorget, which  Physick had already made use of in
 1804, which M.  A. Cooper also sometimes  employs, and which  Be-
 clard has  proposed, might also  be very well adapted  to effect  this
 double incision;  even the  simple strait probe-pointed bistoury might
 in a case of necessity be substituted for all those instruments for divi-
 ding the prostate.   But we cannot deny to  the double  lithotome the
 advantage of terminating the operation with a single cut, that of ef-
 fecting a more certain tension  of the parts in proportion as it divides
 them, of giving a greater degree of regularity to  the wound, and es-
 pecially that of  making an actual  curved instead  of a simple V inci-
 sion, which latter is the only one which can reasonably be expected
 if we use the bistoury or other lithotomes.  Reason immediately sug-
 gests to us the  important character of  this method.   Should each
 blade ofthe lithotome be separated to the distance only of four lines,
 there would evidently result from this a wound of at least 8 lines, or
 even 10 lines, if  we include the  calibre of the  urethra.   Now since
 each oblique posterior portion of the prostate has nearly 10 lines in
 diameter,  it is perceived  that we  may thus give to the wound as
 much as 20 lines in dimension.   Moreover, if the  incision accurately
 represents a  curve, the  tractions  made  upon it in our efforts to
 straighten it, will elongate it still more; and the posterior portion of
 the prostate being  crowded back with the rectum, while we  are  en-
 deavoring to extract the  stone, will be readily  transformed  into a
 second curve parallel to the first, so that a calculus of 20 to 24 lines
 in thickness, and from 5 to 6 inches in circumference, might, strictly
 speaking, pass through this opening without causing any laceration.
 None of the ancient methods of perineal lithotomy can be compared
 in this respect with the transverse  operation.  As it incises the  tis-
 sues to  the outside, and slightly backwards, it cannot endanger  the
 intestine, except  in cases where  this latter is  enormously distended
 on each side of the bas fond of the bladder, and then only when  we
 are obliged to open the lithotome  to a very great extent.   The  pu-
 dic artery is also protected from  any kind of lesion.  The same may
 be said ofthe superficial artery in all cases where  it occupies its nor-
 mal position.  So also with the transverse artery, which can  be   but
 rarely wounded,  for the most advanced point ofthe incision must be
 behind the bulb of the urethra* to which part it  is  found  to be princi-
 pally distributed.   The only arteries therefore that  can  be wounded
 are the posterior  branches  of this last mentioned  vessel, when they
 are larger than usual near  the anus, and the anterior divisions  of  the
 hemorrhoidal  artery.  As  the  first incision comes down upon  the
 membranous portion of the urethra, and as the  two blades  of the
 lithotome are first obliged to act  towards the outside, the verumon-
 tanum and the ejaculatory ducts are necessarily protected from every
 kind of danger.   Nevertheless, it is not to be forgotten,  that in some
 persons,  the lower dilatation of the rectum is prolonged to below the
 prostate, and that if we should make the  incision  too near the anus,
 we might readily perforate this intestine at the first stage ofthe ope-
 ration, as it is  said happened in  one instance to Dupuytren  himself.
 A danger which reason would have enabled us to  have apprehended,
is that of a urinary fistula.  It would seem  at  first view that so ex- 
 918           NEW  ELEMENTS OF OPERATIVE SURGERY.

 tensive a wound of the posterior and inferior wall of the urethra,
 must be little calculated either for immediate or consecutive reunion.
 Experience, which is the only competent judge in such matters, has
 not confirmed these  apprehensions.  On the  contrary, it goes to show
 that as a general rule, the urine resumes its natural  course more
 speedily after  the bilateral operation than  after any other.  They
 count at the Hotel Dieu  as  many as  26 patients operated  upon by
 this method, without a single one of them  terminating fatally ; out of
 an aggregate of 70 mentioned by Dupuytren, there  were but 6 that
 perished.   If, in respect to the accidents, it is not better, it  must at
 least  be confessed that it is full as good as the other processes.   To
 derive all the advantages possible from it, the incision, it would ap-
 pear to me,  ought to fall upon the base of the uretro-anal triangle, in
 such  manner as  to  avoid, at  the same time, both  the  anus and the
 bulb,  and  afterwards to arrive at the posterior part  of the membra-
 nous  portion of the  urethra,  a little in  front of the prostate, after
 having divided  through the integuments, the  sub-cutaneous layer, the
 mixed fibres ofthe sphincter ofthe anus, the bulbo-cavernous and trans-
 verse muscles, as well as those of the aponeuroses at the point where
 they are blended  together.   It is necessary also that the horns of
the incision  should be sufficiently prolonged  in the direction towards
the ischio-rectal cavities, to prevent their presenting any obstacle to
the escape of the discharges externally.   If the bilateral  operation
 did not admit of as prompt a cicatrization as the incision on one side
 only ofthe prostate, it would  without  doubt, as Beclard considered
 it and as Scarpa maintains  in his  letter  to M. Ollivier, constitute
nothing more  than  an exceptional method, useful only in cases
 where the calculi were exceedingly voluminous  ; but since the con-
trary is the  fact,  I  cannot see what should prevent it from being
 adopted as a general method.
  D.  Process of M. Senn.—M. Senn, a surgeon of Geneva, has en-
deavored  to prove, that in  place of performing the transverse ope-
ration with the  double lithotome, it  is better,  by means of the  straight
 probe-pointed bistoury, to divide at first  only  one of the  oblique
 portions of  the prostate, and that should  the stone seem  to be  of
too large a size, we should then incise this gland transversely to the
right, with a second  cut.  Upon the strength of geometrical data, he
asserts  that  the triangular  flap thus circumscribed at the expense
of the urethra  and the gland through which it  passes, and the base
 of which  flap is  posterior,  and to  the  right, procures when it is
 stretched or pushed  back towards the  rectum, at the time of extract-
ing the calculus, a greater opening than  by the process of Dupuy-
 tren.   The process of  M. Senn differs from that which Thomson re-
 commends in cases  of large  calculi, in this particular, that one of
 his  incisions is to the   right,  and  the other to the left, while the
 English surgeon  made them on  the same side,  one above  and the
 other below.   In my  judgment it possesses the inconvenience of
 being more tedious, and  somewhat less certain than the operation
 by the  double  concealed  lithotome, without  having any real advan-
 tage  over  this  last.   Martineau, of  Norwich, had already laid it
 down as a rule, and  Louis himself had also recommended it, that we
 should, when we  experience  any  difficulty  in extracting the stone 
LITHOTOMY.
919
 introduce the finger into the bottom of the wound, for the purpose
 of ascertaining the point which  makes resistance, and then proceed
 by means  of the bistoury to enlarge  the incision either backwards,
 upwards or  outwards,  as was practised with so  much success  by
 Saucerotte ;  from whence it  follows that there is no portion of the
 prostate which will not  have been incised by either one or the other
 of the processes, for the lateralized  or oblique, or  transverse opera-
 tion, as the same have  been modified by  Louis, Martineau, Boyer,
 Thomson, Dupuytren and M. Senn.   From this  circumstance even!
 there has originated a new mode of performing lithotomy.

               §  V.—The Quadrilateral Operation.

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

advantage in making use of the four-bladed lithotome which  M.
Colombat has had made, rather than to make the four incisions in suc-
cession with an  ordinary bistoury, and  this for the  same reasons
which render the double lithotome preferable in the simple  bi-trans-
versal operation.   It is important  moreover not to forget that AI. Vi-
dal incises the prostate in the direction of its oblique portions, and not
from  before  backwards or transversely,  as  has been  erroneously
staled.

     § II.—The  Operative  Processes in Perineal  Lithotomy.

   A.   The different Articles.—Before  commencing the operation
the surgeon ought to arrange in order all  the articles which may be
needed, whatever may be the process upon which he has  decided.
These articles are : 1st, silver catheters and sounds, or such as are of
gum-elastic  should they be  required; 2d, a common straight and a
convex bistoury, the curved bistoury of Pott, a straight probe-pointed
bistoury, one or  more cutting  gorgets,  and one  of  the  lithotome
knives mentioned above, if we have the  intention of using them ;
3d, the concealed lithotome of F. Come, opened at number five or
seven for children, and  at nine or eleven, but rarely thirteen or fifteen
for adults ; 4th, the stem and the button scoop having a crest on  its
flat side ;  5th, a simple gorget;  6th, straight and curved tenacula of
various dimensions ; 7th, long polypus forceps, dressing forceps, dis-
secting forceps, and straight and  curved  scissors;  8th, the needle
having a handle used  by J. L. Petit, or that of Deschamps,  together
with  common ligature needles;  9th, a simple  canula  of metal  or
gum-elastic,  another canula  provided with its  cover,  rolls of lint
encircled  at  their middle portion by a noose of  strong and  well
waxed thread; and 10th, small balls of lint and coarse lint, a few
bandages  and compresses,  lithotomy bands, water, sponges,   some
styptic liquid, a strong syringe, and finally, one or more wax candles
if the natural light does not appear to be sufficient.
   I. Sound.—Among these articles there  are some, the selection  of
which requires particular attention, viz.: the sound and the tenacula.
All other things being  equal, the sound should be rather large in size
than too small.  The  more  volume  it has the better it distends the
urethra, the easier is it to feel it at the bottom of the perineum, the
more advantageous does it become as a director of the other instru-
ments, and the less danger will the patient have of being wounded.
Its groove ought to be at the same time wide and deep; otherwise
the finger will have difficulty in distinguishing it through the  walls
of the urethra, and the lithotome will be unable to be directed  by it
with a sufficient degree of accuracy.  It is a matter of little import-
ance afterwards  whether we give its transverse portion the  semi-
lunar form which  it  formerly had,  the triangular shape  which  is
generally  preferred by the English surgeons, or the square  shape as
recommended by Dupuytren.  As the  cul de sac which terminates
it is but of doubtful utility, and must be calculated to  interfere with
the movements of the  point  of the lithotome, it ought to be  divested
of it, but  in  a gradual manner, in order to preserve a rounded and
blunt arrangement to the sound.  Were it prolonged to the extremity 
LITHOTOMY.
921
of the instrument it would possess no advantages except in the pro-
cesses where the sound is to remain fixed, and not to be raised up
towards the pubis before the division  of the  prostate,  because in
such cases  the  point of the bistoury  is more firmly secured by it.
The curvature of this instrument moreover need not extend as far as
its extremity, which latter ought to go  an inch or two beyond the
axis of the  handle, if we do not wish  to run the risk of its receding
into the urethra when we suppose it to be still in the bladder.  It is
unnecessary to add that the form of its plate is a mere matter of
taste, and that in terminating it in this direction with a ring in the
manner of  Pouteau, or by a  stem provided with  a  wooden  handle
like that  of Lecat, &c, we render  it  neither more nor less con-
venient.
  II. Tenacula.—The ancient tenacula, which were  articulated  like
scissors and very near their branches, possessed the double inconve-
nience  of opening more extensively in the wound than in the bladder,
and of grasping the calculus with difficulty.   It did not prove suffi-
cient to place the rings on the outer side of the handles ; hut in order
to remedy this defect  these last were  arranged in  such manner that
they more or less cross  each other inwardly, and that before going
past the axis of the instrument outwardly  they allowed the branches
to open to a considerable extent.  Those whose  branches  remain
parallel in  the place of separating, while diverging  when they are
opened, and which are articulated laterally, like those found  at M.
Charriere's, have moreover the advantage of not losing their  grip so
readily, and of adapting themselves better to the form of the stone.
  III. Position of the patient and of the assistants.—An  ordinary
bed is too large and soft, and in general too low to take the place in
private practice of the operating table, used in public establishments.
Nevertheless, I am not friendly to those mechanical contrivances
that certain persons are  so much in the  habit of transporting to the
chambers of the sick ; under this point of view, the  table of AI. Heur-
teloup, that of AL Tanchou, AL Rigal,  &c, however ingeniously con-
structed they may be, do not appear to  me to be any more indis-
pensable than AL Rouget's bed, or the lithotomy table  of the ancients.
A commode, or an ordinary table, a stump bed firmly fixed and prop-
erly prepared, are less repulsive and will always suffice for those  sur-
geons,  who do not wish  to appear  over nice by exacting  special
contrivances.  What is  necessary  is, that the patient, placed on his
back, should have his head and chest in a flexed position, and slightly
raised, that  the pelvis should not be allowed to sink into the mattress,
that the perineum may come  beyond  the  edge of the bed, and  that
the  assistants mav have room to place themselves around.  We hear
no more to-day of seating him doubled up upon the knees of one or
two strong  men, as at the  time of Celsus,  nor after he is laid on his
back, of lashing him down by means of cords passed under his arm-
pits, and then around the upper part of his thighs, and upon his  feet
and hands, as was  prescribed by  the AInemonists.   The  straps  also
of the figure of 8 employed by Le Dran, are ho longer found neces-
sary.   When it  is recollected that no  kind of cords has ever been
prescribed for the  operation of hernia or aneurism,  we  cannot too
clearly perceive  what can make it so very urgent for lithotomy, ex- 
922           NEW ELEMENTS OF OPERATIVE SURGERY.
cept it be in children and in individuals devoid of reason.   Hitherto
I have dispensed with their use without having any cause to regret
it, yet the operation, nevertheless, in one of the patients confided to
my care, the one from whom I extracted an enormous stone in  the
month of October,  1830,  at La Pitie, was one of  the most  severe
character.   Upon the supposition, however, that we  decide upon
having recourse to cords, either as a matter of prudence or necessi-
ty, we are to have a bandage of woollen, or should  that be wanting,
one of pliant linen, three fingers' breadth in width, and  two or three
yards long.   With this bandage, which is to be doubled in the direc-
tion  of its  noose, we make a running knot, which is to be  applied
and fastened on the wrist of the patient, and  which is then  immedi-
ately to include his heel, while leaving the thumb on the fibular side,
the fingers below and the radial  border  of the hand in front.  The
two heads of the bands are then seized by the surgeon, who separates
them  and passes them, one  inwards and  the other  outwards, then
crosses them upon the instep, and carries them to the plantar surface
of the foot,  brings them  back above, and then behind, and finally in
front, at which place he  fastens them by a bow-knot, taking  care to
leave its  free extremity to the outside.  The foot  and the  hand on
each side  thus  tied, are  confided  to  two assistants, who are  placed
one on the  left and  the  other  to the  right, outside  of the limb,
while their  backs are slightly turned towards the  head of the bed,
which assistants would  have the same duties to perform if we did
not make use of bands.
   While with the hand which looks towards  the pelvis, each of them
grasps the corresponding knee, as if for the purpose of separating it
from the axis of the  body, he makes  use  of the other hand, while
turning it in pronation, to embrace the foot  on its inner border and
dorsum ; if he had placed his hand underneath, the patient might find
in this a point d'appui, which he might use in trying  to  raise  up  his
pelvis, which ought to be particularly avoided.  This disposition to
raise  up the pelvis, which  is observed especially  in  infants,  and
combined with  a movement  to  the right and to the left, or of rota-
tion, is so difficult to control, that it requires the  intervention of a
third assistant, who should be stout and strong, and  place himself on
the left.  In applying the palm  of the hands on each corresponding
iliac crest, with the thumb extended upon the front part ofthe antero-
superior spinous process  down to the fold of the groin, he  regulates
these  movements by the  simple effect of pressure, and is not in gen-
eral  but very little fatigued.  A  fourth aid, seated  upon  the table
or bed, watches the movements of the head, and keeps the  eyes ol
the patient   covered  with a  compress.  A fifth is placed upon the
right and opposite to the side, to keep in the sound and  raise up the
scrotum.  Finally, to the sixth is assigned the duty of handing to the
surgeon all the  different objects which he may have  occasion for du-
ring the course of the operation.
  IV. Introduction and  adjustment of the  sound.—Before  proceed-
ing to the division of  the tissues, the operator introduces  the  sound
into the bladder, where he does  not fix it until after having again
recognized the presence of the calculus, and corroborated the fact by
some  of his  assistants.  It has been for a long time adopted as a rule, 
LITHOTOMY.                        923
 to incline the plate of the  sound  towards the right groin, in order
 that  its  convexity may press the perineum  more or less to the left
 of the median line, and obliquely backwards towards the ischium;
 but  it is doubtful if this rule has any great value or any thing else to
 support it than long usage, or at least, when our intention is to open
 the prostate with the gorget or  concealed  lithotome.  This inclina-
 tion in fact  does not change the direction of  the walls of  the urethra
 in its relations with the axis of the canal.   Of what importance is
 it after all, whether we open the urethra upon the  side or upon the
 median line, so long as we have nothing to do  but with its membra-
 nous portion,  or the making a passage  for  the  other instruments 1
 The only argument that may be adduced in  favor of a practice of
 this  kind, is the greater facility, perhaps, by which we may thereby
 avoid the bulb, by crowding  hack to the left the  urethral  portion
 which this dilatation conceals, and by thereby removing this imped-
 iment to  the  subsequent steps of the operation.   It is  therefore a
 matter  almost of indifference, whether we  place the sound  to  the
 left as is generally  done, or on  the  median  line  as Scarpa  and A.
 Cooper prefer to  do, even though we are performing the  lateralized
 operation.   Almost all surgeons  of the  present  time, in place of
 holding the  sound themselves with the left  hand, with the view of
 following its movements better or more  advantageously varying its
 position, according to circumstances, as  is  the practice  of various
 operators after the  advice of  Pouteau, hand  it, as  soon as its  loca-
 tion is clearly decided upon, to the  care  of  an  intelligent assistant,
 who ought to  be well acquainted with its character and uses.
   B. Operation.—I.  Incision.—The surgeon with a bistoury which
 he has selected and holds in his right  hand, stands up, or  if his sta-
 ture in respect to the position of the patient appears  to  require it,
 rests his right knee on the  floor without the  necessity of a stool or
 bench to support him, and then divides first the integuments, which he
 stretches with the thumb and fingers of his other hand, without pay-
 ing any attention to the scrotum, which the  assistant charged with
 the care of the sound, gently raises up with his  right  hand.   This
 incision should commence on the left side of  the raphe, at about an
 inch in front of the anus, and should be carried obliquely backwards,
 terminating nearly at the middle of the space  which separates the tu-
 berosity of the ischium from the  opening of  the rectum, and should
 be from three to four inches long.  If it were nearer the  scrotum it
 would expose to  the danger  of infiltration,  and  could have no ob-
 ject.   Its prolongation towards the sacro-sciatic ligament is useless.
 If it  were too short  it would interfere with the extraction of the
 stone, and would not give sufficient facility to the  flow of the urine.
 If it  were nearer the median line, it would frequently  fall  upon the
 rectum ;  and if, after the manner of Roux, it should be made very
 near  the ischio-pubic branch, it could not preserve its parallelism with
 the incision of the deep-seated  parts.  The bistoury being now re-
 applied into the upper angle of the wound, is then  to  divide the
 suh-cutaneous  layer, the posterior border  of  the transverse muscle,
 and in succession  all the other  layers which  separate the skin  from
the urethra, with this precaution, that it should rest much more upon
the median portion, than upon the two extremities  of the solution of 
924           NEW ELEMENTS OF OPERATIVE  SURGERY.

continuity.  Rather than  continue this manipulation until we come
down upon the directing instrument thus laid bare, it is better at this
time to seek through the tissues which have not yet been divided,
the groove of the  sound by  means of the  left forefinger,  and  to
place the right edge of  this groove between the nail and the pulp of
the finger, the radial border of which finger should be turned down-
wards.  The surgeon, without stopping, glides  the  point  of the bis-
toury, which is held like a pen, upon the nail which remains fixed,
then pierces the lower  wall  of the  urethra  a  little in front of the
apex of the prostate, and  now arrives into the  groove  of the sound.
The guiding finger is then immediately brought round upon the back
of the bistoury, the point of which  latter the operator  pushes to-
wards the gland,  to the  extent of three or four lines, while  with
the other  hand  he raises up its handle  and continues to press the
point against the groove  in which it is lodged.  If it should  escape
from  it, we  should be  exposed  to  the risk of  perforating the rec-
tum.   Uretro-cutaneous fistulas  have been  produced  in  this man-
ner ;  one  instance  of which I have  seen, while another has been
mentioned by Dupuytren  and AI. Begin.  The forefinger resumes
its fixed position on the edge  of the sound, after which the right
hand  withdraws  the knife, at the same time that it presses its heel
by a vibratory movement, in order in this manner to enlarge the
opening through the tissues that are  in the nearest proximity to the
urethra.
  II.  The  moment of introducing the lithotome,  whatever may be the
description selected, is now arrived.   If it should be that of F. Come,
the operator seizes it by the handle,  and  without touching its mova
ble piece, glides its beak upon  the nail  in the urethral opening,  in
such manner as to fall perpendicularly upon the groove of the direc-
tor, and makes wit*h it a few movements backwards and forwards, in
order to satisfy himself that it has been properly introduced.   When
he has positively recognized  the metallic contact of the two  instru-
ments, he  raises  himself up if he has been resting on his knees ; dis-
engages his  forefinger  from the wound; seizes hold  of the sound
and depresses its plate ; and gives it a vibratory movement with his
left hand,  while with his right he glides  the point  of the lithotome
along its groove into the bladder, when the escape of a small quan-
tity of urine soon shows him that it has entered into the organ.
  III. The employment of the gorget exacts the same precautions.
Prudence  does not permit us to proceed in a less methodical manner
when we  give  the preference to the tongue or  probe-pointed bis-
toury, or to the small  knives with fixed handles, whether straight  or
convex.   If the vesical  extremity of the  sound  had not been pushed
back  towards the  symphysis pubis  to give room to  these  instru-
ments, they would not, it  is  true, therefore divide  the  prostate, but
their  point or their cutting edge would almost  unavoidably come in
contact with  the trigonus  vesicalis, or frequently cut entirely through
it.  In following, on the contrary, its groove, at the time of making
this elevation, they place the point of the instrument in relation with
the vertical axis of the bladder, and penetrate without danger  to such
depths as  may be desired, and in such manner that we  may, while
withdrawing them, give to the incision all the extent required. 
LITHOTOMY.
925
  IV. The object of the sound having been effected, it is to be with-
drawn.  The hand which  holds the handle of the  lithotome places
some of its fingers  below its movable piece and opens it; the other
hand is  placed upon its back on a  line with the  articulation of the
sheath with its blade, the thumb being upon the right side, the fore-
finger semiflexed  upon the left side, with  its radial  border turned
towards the pubis.  Its  cutting edge being inclined in the  direction
of the exterior wound, or in any other manner, should it be  preferred,
there is nothing more for the two hands to do  than to withdraw the
instrument by their combined efforts.  The office of the left hand is to
see that its sheath, while the instrument is being withdrawn, does not
become separated from the point on the pubic arcade, against which
its concave  or  dorsal border had  been  first  made  to rest.   The
right hand, which is charged  with the duty of withdrawing it to the
outside, has  to  guard against two  difficulties.   If the wrist were
raised up  too much, it would  give  greater  depth to the incision at
the  base than at the apex of the prostate; too great a depression
would  produce a  contrary effect,  and moreover would  expose to
the danger of wounding the  rectum.   If it was not made to rest
against the osseous arcade, it would  have no  fixed  point, and  the
dimensions of the wound would vary according as  its blade should
be directed with a greater  or less degree  of force downwards;
this is one ofthe inconveniences of  the gorget and of bistouries.
  V. Moreover, whatever  may be  the instrument by which the de-
bridement is effected, we would find no other advantage in  avoiding,
as Moreau recommended, the  layers situated immediately underneath
the prostate, than that of respecting the rectum with greater cer-
tainty, for it is not at  this  point that we find the transverse artery
of the  perineum; but a dangerous difficulty would result from it for
the  passage of the urine.   As on the other hand the intestine is suf-
ficiently protected by the obliquity of the incision, it behooves us not
to follow this practice.   The more the  axis of the wound approaches
to a  perpendicular position, that is  to  say,  to the axis of  the body,
the  more  chances  there  are  against infiltrations and abscesses.   In
conclusion, as the deep incision has  for its object the enlargement of
the entrance of the urethra to as great an extent as possible, without
going beyond  the  contour  of the prostate, it ought to be made upon
the  largest diameter of this  gland, not only from the centre to the
circumference, but also from  before backwards, and in such manner
that the circle of its base alone shall  be respected.  Here lies the
problem to be solved in the lateralized  operation.  Now the slightest
reflection.shows that to  effect this object, the division of the urethra
in its membranous  portion is attended with no advantage ;  and that
all that is necessary is to open this passage posteriorly, quite near the
apex of the prostate, and consequently near the horizontal aponeurosis
of the  perineum.   We  see, for the same  reason, that  it  is wholly
useless to prolong  the incision of  the other tissues  forward in the
direction of the pubes, since its only object is to form a sufficiently
large passage for the  calculus, and that in respect to the consequen-
ces of  the operation or  the  effusion of urine, the posterior  direc-
tion especially is the one in  which the incision should be enlarged.
  VI.   The lithotome being  now  no longer required,  is handed 
926           NEW ELEMENTS OF OPERATIVE  SURGERY.
back to the assistant, and in its  place  is immediately substituted the
left forefinger, which in order to enter  into the bladder must be intro-
duced from below upwards, and from behind forwards, and by which
we ascertain: 1st, the interior condition of the organ ; 2d, the  posi-
tion, and sometimes the  size, form, and  even  the  number of stones
contained in it;  and 3d, the dimensions of the wound.  Precautions
should be taken to prevent it, while penetrating, from lacerating either
the intestine or prostate, by blundering between the rectum and this
gland.  Before withdrawing it, we introduce upon it the probe-point-
ed bistoury, to enlarge the incision either of the prostate or perineum,
or in this or that direction, should it be found too narrow.  The fin-
ger may be then used as a director for the bouton, or for the  gorget,
or even for the tenacula.   It is better, in order to carry out this indica-
tion, to place the finger in the lower angle of the wound, with the nail
turned backwards, than to place it above, and for this reason, because
the instruments which it  is intended to guide have more tendency to
escape between the tissues  posteriorly than in  front.   The  bouton
being longer, and of less  size than the gorget, passes with greater fa-
cility around the entire vesical cavity, and comes down better upon the
stone, whatever may be its position, but it is afterwards attended with
a little more inconvenience as a conductor ofthe tenacula.   We may
moreover dispense with  either in a  great number of  cases,  and in-
troduce the tenacula immediately upon the finger.  As soon as  they
have performed their exploring duties,  they are to take the place of
the finger in such manner as to be enabled to depress by this means
the posterior angle of the wound.
  VIL The operator with his right hand now become free, presents
the tenacula above, one of the branches to the right, and the other  to
the left, and gliding them into the gorget, or embracing the crest of
the bouton at their edge which is opened, he pushes them in the same
manner as he had done with the finger, and in this manner penetrates
into the bladder, at the same time that  he disengages the conducting
instrument from them.   Before thinking of grasping the calculus, he
again endeavors to touch it by various movements of the instrument.
This being done, we, have now finally arrived to the last stage ofthe
operation, which is frequently the longest, sometimes  the  most diffi-
cult, but usually the most simple and rapid.  The surgeon  then opens
the tenacula by making traction upon each of the rings, by means of
the thumb and forefinger of the corresponding hand.  When their
branches are sufficiently separated apart, he makes a sudden move-
ment with the instrument from right to left, to the extent of a quar-
ter of a circle upon  its  axis, in such manner that  one of its  scoops
is immediately placed below and the other above, and that the  branch
below grazes, so to speak, the vesical wall, and may glide underneath
the calculus.  If this first movement does not succeed, it is to be re-
peated, either in the  same direction, or  from left to right, or by eleva-
ting or depressing the wrist  still  more.
  VIIL The stone being once seized, may widen the handles of the
tenacula to a greater extent than had  been supposed, which arises
from its being too near the joint of the instrument, from its not  hav-
ing been embraced by  its smallest diameter, or from our having been
deceived in respect to its volume.   It is an inconvenience which  may 
LITHOTOMY.
927
be remedied in the two first cases, by pushing back the calculus be-
fore the tenacula by means of a sound, without entirely relaxing our
hold upon  it,  or by  making  such movement upon it, that it  may
present itself  at its smallest diameter.   In the third case,  there is no
other resource than to enlarge the prostatic opening, should it not ap-
pear to be of sufficient dimensions.  In conclusion, it is better to let it
fall out and to seize it again, than to persist in attempting to change its
position between the branches which retain it; it being well  understood
that if it is not very large, all these precautions  are  in general  un-
necessary.  If the stone should  be  flattish, and much  longer in.one
direction than in another, it might, though seized by its smallest diam-
eter, be necessary to relax our  hold  upon  it, and  then to grasp it
again, should  it have become placed transversely in the wound.   The
same would be the case with any elongated stone whatever, or with
the cylindrical or cucumber shaped calculus,  &c.  These peculiari-
ties are indicated by the resistance which is suddenly perceived at the
moment when the tenacula are upon the point of being entirely with-
drawn from the bladder.  Even without being opened, they may, from
their leaving  between their branches a certain space, which prevents
them from compressing the organ,  have got the calculus lodged and
confined between them, should it be small and flat, and this without
the operator  being aware of it.   We may, however, presume this
to be the  case, when, after having touched  it,  and endeavored to
grasp it, we  can  feel it no more.  In a case of this kind, we with-
draw the  tenacula, in order to be certain of the  fact.   Aloreover,
it not unfrequently happens that small calculi make  their escape with
the flow of urine, or become arrested in  the track of the wound, and
thus for a moment give rise to doubts as to their existence.  I  will
now suppose  that  the stone has been finally  seized.   The tenacula
being now replaced horizontally, the  surgeon seizes their rings with
his right hand, and fixes them as near  as possible to the branches, by
means of his  left hand, turned in  supination, with  the thumb above
and the fingers below.  He then commences the tractions, after hav-
ijig thoroughly convinced himself that the stone is free, and the  only
thing embraced.   For that  purpose  he confines himself  to making
pressure on the tenacula from above downwards, with the thumb of
one hand, in order that the instrument may rest chiefly against the
posterior angle ofthe wound, while the other hand makes  such efforts
as are suitable.   These movements are  made to the right and left,
and above and  downwards, rather than  in a direct  line.   We  take
care, however, to make them follow the axis of the  pelvis in the same
way as for extracting the head  of the infant by means of the forceps.
   IX. Should the straight forceps constantly pass above the stone,
without being enabled to embrace it with its  scoops, or, in  fine,
should the stone have escaped from it in consequence of being turned
aside, or too much depressed in i.ts position, or from being situated in
too deep  a  cavity,  the  curved tenacula would then be indicated
Being  introduced  like the others, they should have their concavity
turned in  the direction  in which  the calculus is  situated,  in order to
seize it, and in order to extract it, be brought out in  an opposite direc-
tion.  The forceps tenacula, contrived by F.  Come,  can  scarcely be
necessary except for large sized stones  completely embraced by the 
928           NEW ELEMENTS OF OPERATIVE SURGERY.
bladder, being of that class of calculi which Ammonius (Dujardin,
Hist, de la Chir., p. 340,) recommended should be  first  broken
up, in order afterwards to extract  their fragments with facility.
The branches of these forceps tenacula are to be placed in succession
by making them glide gently between the walls ofthe organ and the
foreign  body; we then  lock them together in the same manner, pre-
cisely, as when we are manipulating with the obstetrical forceps.
   X. After the calculus has been extracted, we are to examine its ap-
pearance.   If it is rounded off and of an elliptical, oval, or elongated
form, but destitute of angles or facets, we are justified in supposing
that  there are no others  in the bladder.   Calculi which are covered
with asperities would lead to the  same conclusion, while those which
present facets indicate  the  contrary.  This  examination,  however,
which can  give nothing  but  probabilities, does not allow us  to  dis-
pense with further researches.  The finger or the bouton, therefore,
is  to be reintroduced  into the cavity of the organ, in order to ascer-
tain  positively what we have to depend upon.  Some bladders more-
over contain a  considerable number  of calculi.  The bladder  in a
person who had been operated upon three times was found still to
contain 300 calculi when the autopsy was made by AL Ribes.   The
journals have spoken  of a patient in whom M. Roux extracted near
100;  while  Murat, (Arch. Gen. de Med., X. VIIL, p. 131,) in another
patient, counted 678.  M. Souberbielle has shown me sixty-six that
he extracted from  a  bladder after the operation for lithotomy.  I
found 160 of them in a patient, in 1836.   It is important that none
of these calculi should remain in the bladder, or even  in the track
of the wound.   As they are ordinarily small, many of them may
become easily lost in the midst of the  tissues.
   XL  The volume of the calculus may also become a source of em-
barrassment.  If they exceed two inches in their smallest diameter,
it  is  frequently  impossible to extract them even  by the recto-vesical
operation.   It was in  a case of this kind  that Dupuytren laid open
the anterior wall of the intestine, after having  performed the bilateral
taille.   Various instruments have  been proposed, under such circum-
stances, to break and reduce them into fragments.  That of F. Come
has two pyramidal teeth on  the  interior of the branches, which are
filed  down flat.   The stone-breaking tenacula of B. Bell are also pro-
vided with teeth, and a quick screw going through their handles.  The
forceps  contrived  by AL Sirhenry to  break up  the calculi by pene-
trating through the urethra,  the  virgule forceps of AL Heurteloup,
the friction forceps of M. Rigaud, the jointed noose of AL Jacobson,
and almost all the lithotritic forceps might also effect the same pur-
pose.  These last mentioned instruments would also have the advan-
tage of enabling us to  perforate the calculus, should their ordinary
construction not be found sufficient to break it, and they ought there-
fore, in  my  opinion, to be  preferred;  but  the  stones which  render
such manipulations indispensable are so voluminous and difficult to
embrace, that we  generally prefer having recourse immediately to
the hypogastric operation, and thus to extract them above the pubes.
M. Mattuizzi, (Bull, de Fer., X. X., p. 277,) in  a patient who after-
wards recovered, was enabled to extract a stone of eighteen ounces
through the perineum.  A debridement of two  lines, performed on 
LITHOTOMY.
929
the fifth day, enabled AL Alaman (Bull, de Therap., X. XIIL, p. 169,)
to extract a calculus of the weight of six ounces, and which, after hav-
ing resisted his efforts, had become spontaneously lodged in the wound.
  XIL No person at the present day is alarmed to so great  a degree
at  finding  the calculus, when it is very friable, crushed between the
branches of the forceps, as to think of employing  the quadruple for-
ceps of Bromfield, the graduated tenacula of Lecat, the filet-en crin
of Has, the forceps of Home  with a  circular  development, or the
triple tenacula with eyed branches,-as made by the cutler Cluby of
Sheffield.  Should  this accident happen, it is found to be more con-
venient  to seek in succession for all  the fragments by means of the
same forceps,  and to extract  their  particles by  means of  emol-  *
lient injections.   I have, however, operated successfully on a patient
who suffered a great deal from this accident.   The stone, which was
broken up into an infinity of angular fragments, and which, moreover,
had the appearance of a mural calculus, had  become glued in frag-
ments to the walls of the bladder, like patches  of concrete mortar
upon wet rumpled linen, so that it became necessary, so to speak, to
scrape its interior with the scoop and finger in order  to extract them.
   XIIL The fixed condition of the calculus  has given  much  more
embarrassment to  operators.  Before  wasting  our time in useless
efforts we endeavor to recognize with the  forefinger what is the
nature of the difficulties which present themselves.   If the foreign
body appears to adhere only upon one of its sides, it is probable that
fungosities or vegetations have become  introduced or grown  up
between its bosselures.  In  this case the process of Lapeyronie, as
employed by Marechal, Le Dran and Boyer, and which consists in
making methodical traction on the stone as soon as  it is grasped, in
order to tear it out, is the only one which  is  applicable  in  all  those
instances in which we have not been enabled  to  detach it by jogging
it  with the finger,  scoop or  bouton.   If it should  be encysted and
adherent at the same time, the breaking down the cyst with a grooved
sound, as recommended by Littre, would amount almost to  nothing.
We  should scarcely  succeed  any  better, by mashing  it with the
branches  of the tenacula,  as  is also recommended by the  same
author; the tearing of it out  then also is the only remedy.   When it
is  merely arrested by a bridle or retained in  an  open cyst, but  with-
out any adhesion, the cutting  instrument will not always  be  unat-
tended  with  advantage.   Garengeot, Leblanc and Desault  had
recourse to it with success.   A  probe-pointed  bistoury should  be
cautiously directed upon the free border of the cyst, and then inserted
flatwise between its inner surface and  the calculus, in such manner
that in bringing its cutting edge outwards it may incise the accidental
pouch to a convenient extent from its summit  to its base, in the same
way nearly as would  be done in a  hernial  debridement.   Nothing
would prevent our repeating this incision on other points of the bridle,
if  the first should  prove insufficient, or should  it have appeared to
have been attended with too much danger to carry it to the distance
desired.   The tonsil  kyotome or  bridle  cutter used by  Desault,
is certainly not as good as the bistoury of Pott,  and  ought not  to be
adopted.  The ordinary straight bistoury used by Garengeot has two
disadvantages:  1st, its point is constantly in danger of wounding the 
930           NEW  ELEMENTS OF OPERATIVE  SURGERY.
walls of the bladder; 2d, it neither glides nor is introduced with as
much facility as the probe-pointed bistoury between the cyst and the
surface of the stone.   The  surgeon however ought  not to forget
that the bridles formed by a mere partial contraction of the bladder,
and the abnormal sacs developed external to this organ in place of
projecting into its interior, would  not allow us  to make incisions of
this kind, except with extreme caution, since from their acting in  such
cases on the  walls of the bladder  itself, they would  rarely fail to
wound  the peritoneum.   There would  however be an exception to
be made in favor of calculi fixed in the urethra by one of their ex-
tremities.   As the orifice of this canal traverses very  obliquely the
tissues of the bas  fond of the bladder, it might, in fact, be incised
separately to the extent of several lines without any danger. Finally,
if the  calculus was in  the form of a gourd, for example, and was
arrested by one of its portions, either in the urethra or an accessory
pouch of the  bladder, we should have to  resort again to  various
movements  and tractions, and not  attempt incisions except  as a
desperate remedy.
  XIV. The foreign bodies, which are  sometimes designedly intro-
duced into  the urethra, such  as  sounds,  bougies, &c, sometimes
escape either as fragments or entire into the bladder.   Their extrac-
tion  should then be effected as soon as  possible.  AL Ferrier, (Rep.
d'Anat. et de Phys., X. IV.,) by having fixed the lower end of the piece
of a sound against the arc of the pubes by making compression upon
the perineum,  was enabled to extract by means of a turrel; and M.
Tyrell reached one in the bladder and ultimately extracted it by means
of the forceps of Weiss, (Encycl. des Sc Med., 1836, p. 241.)   In a
similar case M. Haime (Prec  Med. d'Indre et Loire, 1820, 1st trim.)
also succeeded without recurring to  a bloody operation.  Duse and
M. Segalas have extracted them by means of the litholabe with two
branches.   But it quite frequently happens that we are obliged, under
such circumstances, to have recourse to  the operation.  A patient of
M.  Roux, (Dubourg, Journ.  Hebdom., X. IV., p. 11 ; Andral, These,
No. 293, Paris, 1837,) who was operated upon  in this manner for a
sound which had  escaped into the bladder the day before, died on
the seventh day.  Those of MAI. Viguerie (Journ. Hebdom., 1S31,
t. I., p. 183) and Moulinie, (Bull. Med. de Bord., 1833,  p. 41,) on the
contrary, were perfectly  restored.   Dupuytren, it is stated, has per-
formed the operation five  times, and  Beclard (Bull, de  Therap.,  X. I.,
1832) once for this description of accidents.  Certain is it th;it a great
number of practitioners, with Lesage, M. Duval, (Bull, de la Fac. de
Mid.,t. VL, p. 420,) &c, have made mention of sounds that have be-
come broken off in  the  urethra or escaped  into the  bladder.   Sup-
posing then that the foreign body could not be seized in the  urethra
by means of the processes mentioned in  the paragraph on calculi, nor
in the bladder by means of the forceps already described, it would then
be  necessary  to have recourse to  cystotomy.  In  such  cases the
perineal operation,  which is  the  most  simple, would evidently  be
found sufficient, since it is unnecessary to make a large incision into
the  parts.   The  finger,  a blunt  hook, or a  polypus, urethral  or
lithotrity forceps would  then be found  sufficient to  remove the
•ound or the broken portion of it in the bladder. 
LITHOTOMY.
931
  XV. The operation in two stages.—The difficulties  attending the
grasping or extracting of the stone, and  the danger of occasioning
too much suffering to the patient, by tedious explorations, have sug-
gested the idea of performing lithotomy in two stages, that is to
say, to confine ourselves at first to the  opening of the bladder, and
to defer to another period the extraction of the calculus.  The Arabs
had already entertained the same idea,  for Albucasis says, that  if a
hemorrhage should supervene, the surgeon ought to dress the wound
with vitriol, and then wait.   Franco, who revived this practice, wait-
ed from three to five days.  Maret de Dijon, however, is the first person
who endeavored to generalize it.  This principle has also been support-
ed by Kamper and by T.  Haaf, which last did not undertake to search
for the  stone  until at the  expiration of 8 days, and  more  recently
by Guerin, of  Bordeaux.   No doubt that in adopting it, it  has been
hoped that the foreign body would of itself have  escaped through the
wound, or come out upon the dressing, or at least approximate the
passage which had been made for it, and be no longer attended with
so much difficulty in  reaching it.   But  in opposition to these ad-
vantages, we have the restlessness of the patient, the irritation wiiich
the presence of the calculus constantly causes, and  the acute pains
which are necessarily produced by the tenacula in passing through
a wound; in a word, we have two operations instead of one.  Modern
practitioners, therefore, have rejected this modification of the opera-
tion, and  do not come to the  alternative of leaving the stone in the
bladder, when they have made the division of the soft  parts, except
it  be  impossible to act otherwise.   As  to a transverse incision, as
Paul and  Avicenna (Theses de Haller, X. II., Fr. trans.,) recommend,
or to the right rather than to the left, as  is advised by Tarin, (Ibid.)
in the lateralized operation, these are precepts which at the present
day are lost sight of in the  methods established.
   XVI. Injections.—From the apprehension that particles of gravel
may be left behind in the bladder, most operators are in the habit
of washing it  out  freely, by means  of injections of tepid water  or
emollient decoctions.  If these injections are methodically made, they
can never do  any  injury.   As they have the advantage of cleansing
out the clots of blood and the flocculi of mucus,  as well as  the frag-
ments of calculi, which frequently escape the most minute exploration,
we do not  see  how  they could be dispensed  with.   In  order to
make  use  of them  we should be provided with  a large, or injection
syringe, which would contain a litre of liquid.   W thout  this pre-
caution the amount of contained fluid  would not possess  sufficient
force  to drive out  the matters that we wish to expel.   In order not
to  wound  the  organ  we  may make  use  of a syphon, which termi-
nates in the manner of the spout of a watering-pot, and is made either
of tin  or  gum-elastic.   With a little address, however, and in trac-
table subjects,  the simple  syphon does not expose to any risk.  After
the first injection we usually make use  of a second, and even of a
third,  in order to be sure  of detaching  all the foreign substances.
The patient is then to be immediately cleansed with a sponge and
tepid water; after which we unloose the cords, or other confining
means which the operation had rendered necessary.  We then place
him on his back in bed, with the head and chest slightly elevated, 
 932           NEW ELEMENTS OF OPERATIVE SURGERY.

 and with his lower limbs brought together and  semiflexed, and sup-
 ported  by a sheet, rolled in the form of a cylinder, or by  a trans-
 verse bandage passed  under his hams.   It is unnecessary to tie his
 legs or  thighs,  as was still done  in the  last century, in order to
 prevent them from being separated  apart.  Nor  is it necessary to
 keep him permanently even in a dorsal position.   It is necessary that
 the patient should incline to one side  or the other,  and  that he should
 not confine himself to his first position only to the degree that it does
 not become too fatiguing for him.
   XVIL  Canula in the wound.—For a long time since, the sound
 has no longer been left in the urethra  to re-establish the course ofthe
 urine.   The same nearly may be said ofthe  canula, which a consid-
 erable number of operators considered it proper to leave in the wound
 a certain number of days after the operation, and which was intend-
 ed to prevent infiltrations by conducting all the  effused liquids out-
 wardly.   This canula,  which was  disapproved  of  by Schmucker,
 (Bibliot. Chir. du Nord, X. L, p. 39.)  but which some  practitioners,
 and AL J. Cloquet in particular, still make use of, irritates the wound
 and neck of the bladder, and even the interior of this organ.   It be-
 comes a  foreign body, which interferes with  the  salutary efforts of
 nature, fatigues the patient to a greater or less degree, and of itself
 alone may give rise to serious accidents.   I have seen it used in an
 old man 84 years of age, who was soon seized with adynamic symp-
 toms, and died at the expiration of 11 days.  The whole extent of
 wound was covered with a grayish  colored concretion; pus  had be-
 come infiltrated into the neighborhood, and traces of purulent inflam-
 mation had extended even into the interior of the  pelvis.  Should it
 ever be deemed necessary to present  any obstacle  to the approxima-
 tion of the lips of the wound, it would  be better to place in it a meche
 of ravelled linen,  or a simple tent of lint, than a canula.

            § VIL—Accidents of Perineal Lithotomy.

  It is perceived  that the perineal operation must be one of a painful
and serious character.   Instances however are cited, in  which the pa-
tients have performed it upon themselves.   The blacksmith mentioned
by Tulpius, (Bonet, Corps de Med.,  t.  III.  and t.  IV., p. 42,) and the
physician Clevel  (Bull,  de Fer., X. III., p. 59)  must  have been exam-
 ples of this kind.   The  truth may not resemble the truth!  Perhaps
 also in these cases the calculi had come out of the bladder and pro-
 jected at the  perineum.
  A. The first accident which we have to fear in the lateralized ope-
ration, and in perineal lithotomy in general,  is  hemorrhage, which
 may show itself in three different ways:  at the time itself of making
the incision  into  the tissues, in the course of the first twenty-four
hours which succeed to  the operation, or only after the  expiration of
a certain number of days.  In the first case, it may depend, as I im-
agine, upon a lesion of the superficial artery, of the  transverse artery
ofthe perineum, ofthe hemorrhoidal, or ofthe trunk ofthe pudic, of
the prostatic venous plexus, or as I presume of some  anomalous artery,
like that which passed through the prostate in the  patient mentioned
by Shaw, (Bull,  de Fer., t. VIL, p. 269.)   The  hemorrhage  comes 
LITHOTOMY.
933
   from the superficial branches, if the blood escapes from the upper angle
   of the wound, or from the sub-cutaneous layer; and from the trans-
   verse artery, on the contrary, when the finger introduced at a certain
   depth, arrests it by making pressure on the external lip of the wound
   opposite the bulb and the membranous portion of the urethra.   The
   hemorrhoidal will  be the source of it, if the  blood escapes by the
   lower angle of the  wound.  The hemorrhage will also be found pos-
   teriorly and to the outside, but at  a great  depth,  in those  cases in
   which the pudic artery itself shall have been  wounded.   The hemor-
   rhage which arises from  a division of the veins, or which is caused
   by the section of an artery situated around the prostate, will,  from
•  having its source at a greater depth than any other, be distinguished
   from the  preceding by the color of the blood in the  first case, and in
   the second case by the fact that the pressure  made  by the finger on
   all the  points of the perineal wound will be found insufficient to sus-
   pend the flow of blood  even momentarily.   So long as the flow of
   blood does not take place per saltum, and  that  it does not flow in
   such considerable  quantity as to occasion much  debility  in the pa-
   tient, we need not  make any effort to arrest  it.  In many cases it is
   a salutary bleeding, which may prevent a number of serious  acci-
   dents.  If, on the contrary, it threatens to be abundant, and to con-
   tinue, and if the patient is enfeebled or at an advanced  age, it is ad-
   visable to check it  as soon as  possible.
      The most efficacious,  and at the same time  most simple means, is
   the ligature, when  it shall be found practicable.  When the divided
   artery can be seen  in the interior of the wound, it is to  be seized
   with a dissecting forceps, or if it is not sufficiently isolated, by means
   of a tenaculum, after which we immediately pass the ligature around
   it. If the artery in question should be the pudic, and  its  extremity
   could not be seized without too much difficulty, we should, I conceive,
   imitate Physick, who wounded it in his first  operation for  lithotomy,
   and pass  between it and the ischio-pubic ramus  a double thread,
    bv means of J. L.  Petit's curved needle with a handle.  This needle
   w'ould be introduced through the interior ofthe wound, and pass on the
   outer side ofthe artery behind its division, in order to re-enter into the
    solution of continuity, where  the thread would be disengaged from its
    point in  order to  enable us  to withdraw the needle, and the liga-
    ture then knotted  intermediately on  the tissues.   I  do not  think
    in such cases, that we should ever think of passing a ligature through
    the obturator foramen in order to encircle the ischio-pubic ramus at
    the same time with  the artery, as is recommended by M. Caignon,
    (Arch. Gen. de Med., X.  IX., p.  137,) nor that we should apply a liga-
    ture upon the vessel at the point where it passes through the sciatic
    ligaments, as is advised by M. Travers.   This wound, moreover,  is
    so rare, and one which  it would  be so difficult to  make, unless we
    deviate from  all the rules of  sound surgery, that the means pro-
    posed to meet its dangers cannot possess any great degree of value.
    It is probable,  moreover, that a deception has in more than one in-
    stance arisen  in  this matter,  from the  hemorrhage  being caused
    by abnormal  branches,  or  by secondary ramifications that are
    somewhat more largely developed than usual.  Upon the supposi-
    tion that the artery could be seized and isolated with sufficient ease, 
934           NEW ELEMENTS OF OPERATIVE SURGERY.

but that it was too high up to surround it with a ligature without being
attended with considerable difficulty, we should not hesitate to make
torsion upon it by means of the forceps with which we had seized it.
Finally, if neither torsion nor  the ligature are practicable, and it should
become necessary at every hazard to put a stop to the hemorrhage, there
are various other means that  may be made trial of.  The solid sound,
arranged in such manner as to fill up and press against the whole extent
of the wound, as was still  practised not more than half a century since,
had  the inconvenience of making stronger compression towards the
skin  than towards the prostate, and  of frequently forcing the fluids
to be effused into the bladder.  Boyer, like Richerand, (Mem. de la
Soc, Med. d'Emulat., X. IV., p. 275,) appears to have frequently made   «
use with advantage of a roll of lint introduced as far as into the blad-
der,  and secured by means of a ligature whose two heads were after-
wards knotted at the outside, upon another roll, which was inserted as
deep as possible in the direction towards the urethra; but the little ap-
paratus of Dupuytren evidently deserves here the preference over all
the others.   It consists of a canula opened on its summit and sides,
around which there is attached a piece of fine linen in the form of a sac.
It is introduced to beyond the neck of the bladder, after which we glide
between it and the linen, by means of  a dressing forceps, a quantity
of soft lint, until the wound is completely filled up with it, and in such
manner that it makes a suitable degree of pressure upon its entire cir-
cumference, and with a little more force near the bottom than towards
the skin.   The whole being fastened by means of a T bandage, pre-
sents no impediment to the flow of urine, and moreover allows of our
increasing or diminishing the  pressure in this or that direction, as may
seem advisable.   After the lapse of two or three days, the surgeon
gradually withdraws the  small balls of lint, and soon  after removes
the remainder of the dressing.
  If the  hemorrhage does not make its  appearance  until after the
expiration ofthe first few hours, it is rarely sufficiently alarming to ren-
der the interposition of instruments necessary.  It is not because the
contact of the air had temporarily contracted the vessels, nor from
a  supposed  spasm of their  calibres,  that the  blood,  which  now
appears, did not show itself at the time of the operation, but because
the general circulation, which is usually very gentle when the patient
is on the bed of sickness, soon undergoes a strong reaction and an
increased augmentation of power  in its  propulsive  energies ; from
whence it follows that the disease  then quite frequently becomes its
own appropriate  remedy, and that these kinds of hemorrhages may
be suspended under the influence of cold applications or by revulsive
means, which have the tendency to repel the fluids into another direc-
tion.  Thus we should  commence  in  such cases by applying cold
water over the hypogastrium, upon the upper part of the thighs and
to the perineum, and by injection even  into the wound ; should there
be fever and hardness of pulse, a small  bleeding by the arm would
evidently  be  indicated.   In  the contrary cases, mustard manulu-
via,  dry cupping  followed by scarifications  between the shoulders.
and  cataplasms of mustard to the same regions, should be made trial
of before proceeding to look for the wounded vessels or to having
recourse to  tamponing, unless the  hemorrhage should be extremely 
LITHOTOMY.
935
copious.  When it does not show itself until after the first days, it is
almost  certain that it does not  depend  upon a mere wound of  an
artery,  but that it is occasioned by a pure exhalation  either from the
wound  or from the cavity of the bladder.  To admit the contrary,
we should have to suppose that there had been an eschar, which had
become afterwards detached from the walls of the vessel; or that
there was, as in fact we sometimes find to be the case, a general state
of exhaustion, and  a marked  dissolution  in the fluids, which has
brought about the  fusion of the  sanguineous clots, and all other de-
posits which  had been  interposed against the  escape of the blood.
We thus perceive that this must be of  the most dangerous kind.  It
does not, however, exact a different kind of treatment from the other.
A patient who had been operated upon by the perineal process, by
Dussaussoy, (Soc.  de Sante de Lyon, 1798, p.  145,) was  seized  an
hour afterwards with a considerable degree of hemorrhage from the
interior of the bladder.  A similar accident took place at the expira-
tion  of several days, in a patient  operated upon by Guerin, (Ibid.,
p. 158.)  On forcibly introducing the finger through  the wound, the
bladder was found to be filled  with clots.  Injections  and frictions
put a stop to the sanguineous exhalation, and both patients recovered.
  B. Spasm of the  bladder.—An accident, which up to the present
time has scarcely been  noticed, viz., spasm of the bladder, existing
to such degree as to present difficulties in the extraction of the cal-
culi, appears to have been frequently met with in children, especially
by  M.  Riberi, (Journ.  des Conn. Med.-Chir.,  1838,  p. 164,)  who
treats of it by means of  tepid  water thrown up freely into the wound
with a  large syringe.
  C. Wounds ofthe intestine.—If, as I have seen  in one instance,
the rectum  is wounded in the first stage of the operation, or in any
manner whatever, before the bistoury has reached the neck ofthe blad-
der, the wound will be found to be underneath the prostate.  As this
accident most  usually happens while we  are withdrawing the litho-
tome, the perforation is then made on a point more elevated and above
the sphincters, even though we should make use of the plate contrived
by M. Caignon (Arch. Gen. de Mid. X.  IX.,) to crowd back the pros-
tate.  The  making traction upon the penis while we  are incising the
prostate, as recommended by  AL Huguier, (These,  Paris,  1834,)
would  scarcely be  attended with any greater advantage.  In quite a
considerable number of cases, we are not at first aware of the  acci-
dent.  It may even happen that there has not been  a complete per-
foration, but that the wall of the rectum, already greatly attenuated
by the  cutting instrument, has been contused and mortified  during
the extraction of the stone, and that the fall of the  eschar is alone
chargeable  with the production of the accident.  It was in this way
that the accidents appeared to have taken place in a patient whom I
saw at the Hospital of St. Louis, in 1822.  In the first case, that is to
say, where we immediately recognize, either by  the gases or the pas-
sage of foscal  matters or urine, that the  rectum  has  been wounded,
if the division has been so extensive that we have reason to apprehend
that it may be transformed into a fistula, the most certain means of pre-
venting this termination consists in laying open completely the extrem-
ity ofthe perineum and  intestine as far as to the anus.  As the con- 
 936          NEW  ELEMENTS  OF OPERATIVE  SURGERY.

 traction ofthe sphincters do not now present any obstacle to the free
 passage of the matters, the wound will  in general cicatrize with the
 same rapidity as if  nothing particular had happened.  In the second
 case, that is to say, when some days  have  elapsed, whether there
 may or may not have been loss of substance,  the recto-vesical fistula
 is already established, and inasmuch as instances are known in which
 they have disappeared spontaneously, we ought to wait for the ordi-
 nary term of the cure, and afterwards treat it in the same way as we
 would a fistula wiiich might result from any other cause.
   D. Though urethral fistulas, properly so called, are quite rare at
 the present day, they are still, nevertheless, sometimes noticed ; but
 whether they communicate  directly to  the exterior,  or  only reach
 there through the medium ofthe anus, their treatment being the same
 as that of  urinary fistulas in general, will  be  considered in  another
 article.
   E. Paralysis  of the  bladder,  and retention of  urine,  which are
 sometimes caused by clots of blood, and also  the tumefaction of the
 wound and inflammation of the neck of the bladder or prostate, with
 syncopes,  convulsions, incontinence of urine, and  inflammations  of
 every description, which may manifest themselves during, or a short
 time after, the operation for lithotomy, do not require other attentions
 than those which are generally known and indicated in the treatment
 of those affections.  The wound requires more or  less time to close
 up.  The urine usually passes exclusively through it during the space
 of two, three, four, or five  days ; after which  the patient from time
 to time experiences a  desire  to pass it.   Finally, he expels some
 drops through the urethra.  It gradually enters  into this canal and
 in larger amount; and finally, from the fifteenth to the thirtieth day,
 passes through it exclusively.   At this period the perineal wound has
 completely cicatrized.   Nevertheless, it  is not rare to find the urine
 take another mode in  its passage outwards.  In certain  patients it
 continues  to make its escape during two, three, and even four, five,
 and six months, in such manner  that the wound  may, in  reality, be
 looked upon in the light of a fistula.   In  others, on  the contrary, the
 perineal opening closes tip  immediately, or ib the space of from eight
 to twelve  days.   A patient of AL Laugier recovered  in this manner
in twenty days, though he had extracted  from  him a calculus of more
than eighteen lines in diameter, by the bilateral operation.  Physick,
 Dorsey, and Copeland, in America, have  each  noticed an instance of
this kind, and Beclard mentions several as  the result of the  bilateral
 operation.   There are but few distinguished  operators, in fact, who
 have not noticed a certain number of these cases: but no person has
 published  so great a number as  AL Clot, (Gaz. Med.,  183:), p. 176,)
 who relates eleven instances, either after the lateralized operation or
 Vacca's process of median lithotomy.

                § VIIL—Recto- Vesical  Lithotomy.

  The anxiety that operators have evinced at every epoch to avoid
wounding  the intestine while performing lithotomy, proves of itself
how far they were from wishing to create this incision into an estab-
lished method.  Hence it happens that it was not until within these 
LITHOTOMY.                        937
latter years  that  a suggestion of this kind presented itself to  the
minds of practitioners, and that AL Sanson, who  first ventured to
broach this subject in 1816, (Des Moyens de parvenir a la Vessie par
la Rectum, Paris, 1821, in 8vo.) found in this ancient prejudice one of
the greatest obstacles to the adoption of his opinions   Nevertheless,
it has been  since ascertained  that the extraction of urinary calculi
through  the  rectum was not altogether a new process.   According
to M. Clot (Gaz. Mid., 1830, p. 167,) tradition  speaks of  it as a me-
thod  which had existed in Egypt.   Vegetius, a veterinary surgeon
quoted by Haller, had already said, a century before, in his work
published at  Bale: Jubet per vulnus recti intestini et vesica aculeo
lapidem  ejicere.
  An observation  made by F. Come, relative to a  patient in whom
the recto-vesical fistula was kept up by the presence of a calculus,
and who recovered after the extraction of this body through the in-
testine, might have served  also as a  foundation for  M. Sanson's the-
ory.  The fragment of wood extracted  from the bladder by Cam-
per, by enlarging the fistula ofthe rectum, was another proof, which
might also have been adduced  as an authority.   Aloreover it is well
known that recto-vesical fistulas were frequently cured at the Hotel
Dieu by Desault, by incising the sphincter in such manner as to form
it into a  wound which should extend as far as to  the perineum.  How-
ever this may be, no person among us had laid it down as a princi-
ple that  we should pass through the rectum to search for vesical cal-
culi, and AL  Sanson ought in reality to be considered as the inventor
of the  recto-vesical  operation.  His method, which never  found
many partisans  in France,  Germany, or England, was almost imme-
diately  adopted in Italy by a  certain number  of distinguished sur-
geons, among others by Vacca, and AIM. Barbantini, Farnese,  Gi-
orgi, Giudetti, Giuseppe, Lancisi, &c.  The advantages which were
ascribed to it are that of being an easy operation, and but little pain-
ful, of opening the bladder at the widest part ofthe pelvic cavity, of
not exposing to  the risk of wounding any artery, and of enabling us
to extract the largest sized calculi.   But the fear of having the com-
munication of the rectum with the bladder continue after the  cure,
has been a sufficient •reason among us to outweigh ail these probable
advantages.   The fact is, that  even at the present  day, this process
of lithotomy  has scarcely ever been performed in our country except
by MM. Sanson, Dupuytren, Pezerat, Castara, Willaume, Cazenave,
Dumont, Taxil,  Castel, (Acad.  Roy.  de Med., 25th Nov. 1824; Arch.
Gen.  de  Med., X. II.,) and some others, that is to  say, about thirty
times.
  A.  Operative  process.—M. Sanson saw  at the beginning that recto-
vesical lithotomy might be performed by two distinct processes ;  the
one  in which the  prostate, urethra  and the  lower extremity of  the
rectum are alone divided ; the other, which attacks at the same time
the bas  fond, or rather the trigonus vesicalis,  together with the in-
testine, and in such manner as to respect  the two  anterior thirds of
the gland.  In Italy, Vacca and M. Barbantini adopted the first more
especially, and  to  so great an extent, that they in some measure ap-
propriated it to themselves.   Geri, Giudetti, &c,  adhered, on  the
contrary, to the second, which is the one that  M. Sanson had given 
938           NEW  ELEMENTS  OF OPERATIVE SURGERY.

especial preference to.  The manner of performing both, however,
differs but in a very  slight degree.
  I.  First process.—The sound held by an assistant, should press ac-
curately upon the  median line,  and in such manner as to depress the
anterior wall of the rectum.  The surgeon  introduces the left fore-
finger into the anus to the depth of an inch; turns its nail backwards
and pulp forwards; glides in flatwise upon this finger a sharp-pointed
bistoury, and after having  turned its cutting edge upwards, inserts
its point into the groove of the sound;  then elevates the wrist of the
right  hand, and divides the recto-urethral triangle from behind for-
wards, that  is to say, from the  intestine towards the urethra; and
afterwards endeavors to find, at the bottom  of this wound, the pros-
tate, and through the membranous portion of the urethra  adjusts his
finger, whose  ulnar border should look towards the symphysis pubis,
and its nail towards the left ischium, on the groove of the sound.
The same bistoury, held as  a writing pen, is then inserted  into the
groove of the directing instrument, and afterwards glided along this
groove into  the bladder.   It is then withdrawn while depressing the
hand  a little in order to  divide  from before backwards, almost the
entire prostate, together with the other soft parts which might possi-
bly have escaped  at the time of the first incision.  In this  process,
we divide the external sphincter,  the intercussating fibres  of the
transverse and bulbo-cavernous  muscles, the point of union of the
different fibrous laminae of the perineum, the prostate from its apex
to its  base, and the front part of the rectum underneath the  trigonus
vesicalis.  One of the ejaculating ducts is also comprised in the inci-
sion, for it could only be by accident alone that the bistoury could be
conducted with such precision upon  the median line as to enable us
to fall exactly between the two ducts.  If, as  might very readily
happen, the  incision should  deviate too much upon the side, it would
soon reach upon a point remote from this  canal, or  might even fall
upon  the termination of the vas deferens, and finally upon the lower
extremity of the corresponding vesiculum seminale.   As to  the rest,
no important artery  presents itself, not even the abnormal branches
mentioned in speaking of perineal lithotomy.  In place of the opera-
tive process of M. Sanson, Vacca proposes that  .the  right forefinger
should be applied in  such manner upon one ofthe sides ofthe bistou-
ry, whose handle is grasped by the same hand, that in slightly press-
ing its pulp  against  it, it may cover the whole point of  the instru-
ment ; that the whole is to  be introduced in this  manner to the depth
required; that having reached there, the cutting edge of the  bistoury
is to be turned forwards, in order that the finger may be  placed be-
hind it upon  its back, and that the section of the tissues should  be made
by a  single cut, as has been just described;  the left forefinger, which
had remained free, is immediately to be  placed  upon the groove of
the sound, in order that the bistoury, whose edge is then to be turned
downwards, may be  directed upon  the membranous portion  of the
Virethra, and thus divide the prostate and border ofthe vesical orifice
from  before backwards, that is to say, in a direction opposite to that
which it  had followed up to that moment.
   II.  Second process.—The first incision, which commences a little
higher up, does not terminate as near the bulb of the urethra  in the 
LITHOTOMY.
939
second as in the first process.  It is  no longer the apex, but in fact
the base ofthe prostate, that the left forefinger re-introduced into the
wound now endeavors to find, and it is on a line with the posterior
border or at most at the point of union of the two lower thirds with
the upper third of this gland, where  the  bistoury should be plunged
in to reach  the groove of the director; it is afterwards to be pushed
into the bladder, in order  to lay open its lower wall to the extent of
about  an inch, withdrawing  the  instrument from behind forwards,
and slightly from  above downwards.  The solution  of continuity
when we adopt this method falls, in so far as regards the first incision,
upon the same parts as in the  preceding.  The second stage of the
operation, on the contrary, avoids those portions of the urethra and
prostate which receive and are traversed  by the seminal ducts, and
attacks the  trigonus vesicalis in its place, while approximating in a
greater or  lesser degree to the  recto-vesical  cavity.   Should  the
incision not be made precisely  upon the median line, it might wound
the ejaculating ducts, the vesiculas seminales and the vasa deferentia,
and even the urethra.   It is also  perceived  that the  peritoneum is
exposed to  a very  considerable degree of danger, and that it  could
not be avoided should it descend  a little lower than usual.   It is also
to be  remarked  that in consequence of the  direction given to  the
bistoury while  it is being withdrawn from  the bladder, the w.ound
must fall to a much greater extent upon the last organ than upon the
intestine, and that it is consequently prolonged  much  higher on  the
inner surface of the bladder than upon that of the intestine; so that
the mucous membrane and a great portion even ofthe muscular coat
of the rectum will  descend in  the form of a projection or valve, to
the distance of several lines below the wound in the bladder.   Some
Italian surgeons  have supposed that  AL Sanson's process might  be
improved by placing a dilating instrument in the interior of the rec-
tum.  It was with this view that  AI. Geri, for example, had proposed
a large  gorget.  At first view  a modification of  this kind would
appear to possess the advantage of  diminishing the mobility of the
tissues, which AL Pezerat had so much  difficulty in overcoming in
the  recto-vesical operation as performed by him, and to have the
advantage  also of actually  giving  greater  facility to the  incision.
Vacca, however, has vehemently opposed this modification.  It must
be readily  perceived, in  fact, in reflecting  upon it, that it would
increase the difficulties of the operation instead of diminishing them.
However, it is not in respect to its mode of execution that objections
may be raised against lithotomy by the rectum.  All the ameliorations
proposed in reference to  this point are not in reality of  a character
to deserve any particular attention.
  B. If  we should  be disposed  at the present  time to  form  a just
appreciation of the value of recto-vesical lithotomy, we could do so,
as it appears to me, without any  difficulty.   Its first  advantage, and
the most indisputable of all, is that of  protecting us from hemorrhage;
the  second  is that of possessing an  extreme degree  of simplicity.
We should not however  deceive  ourselves  on this  point.  The
division  of  the mucous membrane of the anus, of the walls  of the
intestine, and even  of the posterior  portion  of the perineum, is  at-
tended in certain patients with all those difficulties which are pointed 
I
 940          NEW  ELEMENTS  OF OPERATIVE SURGERY.

 out  by AI. Pezerat, whatever  may be the  precautions we  adopt  to
 stretch the tissues.
   In opposition to those who accord to it the advantage of affording
 so easy an egress to the urine that we have no cause to fear infiltra-
 tion, it may  be  stated that the recto-vesical septum, drawn upon by
 the  instruments or by the stone during the operation, is sometimes
 liable  to  be  lacerated, and  that in such cases we  cannot  perceive
 what would  prevent the effusion of some drops of urine into the sur-
 rounding cellular tissue.  There is another objection, which is this,
 that from the infiltration taking  place above  the pelvic aponeurosis,
 it would very quickly spread to  the sub-peritoneal  cellular  tissue of
 the'pelvis.   The advantage, which  it is alleged to have, of  allowing
 of a large incision and  the extraction  of enormous calculi, may also
 be contested.  It  is a grave error, in  my opinion, to refer the diffi-
 culties in such cases to  the degree of distance existing between the
 bones.  I cannot  conceive any more than  Scarpa how, in  any pro-
 cess of lithotomy whatever, the  lower strait, should it be of regular
 conformation, could  present an obstacle to the extraction of  a stone.
 It is at the opening  made into the bladder where all the embarrass-
 ment lies.  When this  opening  is directed exclusively upon the bas
 fond, we are not enabled to give it  more than from  twelve to fifteen
 lines, because there is" only this  distance between the  prostate and
 the cul de sac of the peritoneum.   Whence then is the advantage,
 since in bilateral lithotomy, for example, we may obtain an  opening
 of from fifteen to twenty lines ?   If we limit ourselves to the incision
.of the prostate with the expectation of not going beyond its limits,
 the division can have but from eight to  twelve lines, even supposing
 we give it its greatest extent.   If we give it a greater extent we
 necessarily go beyond the border of the gland, because in this direc-
 tion there is  only from six to seven lines of it to divide; if we should
 unite the  two processes, the opening might be extended to  an  inch
 and  a  half or two inches; but up to the present time this has been
 proposed by no one.  Bilateral lithotomy, moreover, could  also fur-
 nish us as extensive a division.   Finally, if  we no longer adopt the
 rule which directs  us to  confine ourselves to the  periphery of the
 prostate, it is evident that we might, by the bilateral method, incise
 the neck of the  bladder upon each side, in such manner as to obtain
 a wound of two or two and a half inches in extent; which would not
 be possible in the recto-vesical operation but by voluntarily  exposing
 ourselves to  the risk of wounding the  peritoneum.   It would appear
 that in speaking of this process some importance has been attached
 to the division of the perineum and membranous portion of the ure-
 thra.  The same error  also is found in  almost all  the discussions in
 relation to the other kinds of cystotomy.  Nevertheless, it is easy to
 perceive that in regard  to the passage of the stone, there is nothing
 else but  the enlargement  of the  posterior opening of the urethra
 which can be taken into the account as of any value.   Thus enlarge
 it directly backwards and  you will never obtain  any more than  an
 opening of seven to eight lines unless you  go beyond  the  prostate;
 whether the exterior incision be confined to  the perineum, or whe-
 ther it includes at the  same time the extremity of the rectum.   In
 prolonging this incision an inch or an inch and a  half farther, you 
LITHOTOMY.
941
will traverse  the whole extent of the trigonus and will give to the
wound a length of only about two inches, while at the same time ex-
posing yourself to the risk of wounding the peritoneum.  The double
oblique incision, on the contrary, enables us to go to the extent of
twenty lines or more without encroaching upon the apex of the blad-
der, and if you are not afraid of going beyond the prostate you will
evidently be enabled still to increase the dimensions of the wound to a
much  greater extent than by the posterior method.  As to the lesion
of the  arteries, the point to ascertain is, whether this can counterbal-
ance the danger of recto-vesical fistulas.
  In transversal lithotomy it is almost certain that hemorrhage can-
not take place in one case out of 100 ; while  the  recto-vesical ope-
ration is followed by a urinary fistula, at least in one case out of
every four or five.   The hemorrhage also is far from being always
fatal,  while the fistula is a disgusting  infirmity, which is in most
cases  incurable.  The  recto-vesical operation has furnished, up to
the present time, almost as great a  proportion  of deaths as the pro-
cesses of perineal lithotomy.   It possesses in  a special manner  the
disadvantage  of unavoidably wounding one of the ejaculatory ducts.
Experience has shown that it  frequently causes enlargement  of  the
testicles, and serious affections of these organs.  In one of the  pa-
tients  of M. Geri, (Arch. Gen. de Med., X. XIL, p. 236,) the duplica-
ture of the perineum was laid open.   AL Janson,  (Mem. de la Soc
Med. de Gand., 1835, p. 93,) lost two patients out  of six cases. The
intestine was found to  be inflamed to an  intense degree.  Alany  au-
thors  show that the bladder has  been  frequently inflamed by  the
passage of stercoral matters into this organ.   Scarpa states that it
gangrened in  two  cases noticed by him.  The vesiculas  seminales
have also been laid open, and purulent collections in the interior of
the pelvis have been met with in a great number  of instances.   Fi-
nally,  out of about  100 operations of this kind, which appear to have
been performed up  to the present time, by MM. Sanson, Dupuytren,
Camoin, Pezerat, Wiliaume, Cazenave, (Bull. Med. de Bordeaux,
1833,  p.  121,) Dumont, Castara, Urbain, Janson, Taxil,  Barbantini,
Vacca, Geri,  Orlandi,  Gallori,  Mansfredi, Guidetti, Farnese, Giorgi,
Guiseppe, Cittadini, Mori, Lancisi, Castaldi, Cavarra, Regnoli, Ban-
diera,  (Bull,  de Fer.,  X. IL, p. 156,)  Heihg,  (Ibid.,  X. I.,  p.  346,)
Fasoti, (Ibid., X. L, p. 352,)  Meli, Clot, (Compte rend, de FEcole de
Med.  d'Abou-Zabel, Paris,  1832, in 8vo,) Wenzel, (Bull, de  Fer.,
t. VI., p. 280,) Dawson, (S. Cooper, Diet., p. 15, 7th edit.,) and Lal-
lemand,  Lafosse, (Ephem. Med.  de Montp., Dec, 1828,) we count
about  20 deaths, the same number of fistulas, and  a variety of acci-
dents which have placed the  life  of  some of the  other patients in
danger.   The following  table  moreover, (Extrait  du Journ.  des
Chir.  von Graefe  und Walther, achter band, scite 540, par M. A.
Belin,) will furnish a complete detail of these cases. 
RECTO-VESICAL   OPERATION   FOR    STONE
                First.   Cases followed  by  Complete  Cure.
CO
Operators.		Age
Camoin,		20
Pezerat,		17
Dupuytren,	3	11
Vacca,	3	38 '
Vacca, Vacca,	4 5	74 38
Vacca,	6	2
Vacca,	7	60
Vacca,	8	46
Vacca, Vacca, Vacca, Vacca,	9 10 11 12	11 12 15 65
Vacca, Vacca, Vacca,	13 15 17	8 6 14
Vacca,	20	H
Operative
 process.
1st process,

   ditto.  \
2nd process,
■f
Size and weight of the
      calculus.
weight, 2 ounces,

Length  21 lines,  breadth
  1 inch,
medium size,

size of a  pigeon's egg,

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

sized of a pigeon's egg,
very large,
19 lines in its long diame-
  ter,
length 1J inch,
breadth  11 lines,
 Escape of fecal
matter through the
     urethra.
frequent,

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

30 days,

25 days,
1 month,

14 days,
60 days,

4 months,

22 days,
1 month,

22 days,

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

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


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

Vacca,
Vacca,

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

Giorgi,

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

Janson,
Orlandi,
Bandiera,
21	16
22 24	10 3i
2 3 4 5 6 7	1 12 24 5 9 4
8	12
9	53
10 1 4 1 1	4 12 65 50 50
1	75 yth.
1 2 3	3 30
5	
<f	6
—	y.rn.
2nd
process.
lst& 2d proc
2nd  process
2nd  process

2nd  process
    ditto
2nd  process,
   ditto
 1st process,
   ditto
   ditto
   ditto
small, fragile,

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

very large,
size of a pigeon's egg,
larger than a pigeon's egg.
         ditto
2 calculi, each the size of
  an almond,
size of a hen's egg, weigh-
  ing 2 ounces,
weight, 6  ounces,
the size of a nutmeg,
medium size,
weight, 1 ounce,
breadth,  3 inches, 3 lines,
  length, 2J inches,

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

tolerably  large size,
3 calculi, the  largest of
  which  was the size of
  a small nut.
small calculus,
a small quantity
  of liquid faecal
  matter,
45 days,

36 days,
12 days,

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

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


45 days,
  Some drops of urine only issue through the wound, a few daya
before the ordinary time.
Unequivocal symptoms of a diseased bladder
The stone was extracted by means ofthe fingers.
The urine was turbid, sanguinolent, purulent, and of an infected odor.

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

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

Cavarra,
Cavarra,

Cavarra,
Cavarra,

Cavarra,
I   8
1  73
60
62
lst&2dproc.
2nd  process,

    ditto
    ditto
In his first 5
casesCavarra
modified  the
 2nd opera-
tive process.
2nd process
Vacca,	2	5	2d process,
Vacca,	23	2	ditto,
1 Gioigi, 1 Cittadini,	1 3	28 7	1st process, 2d process,
3 calculi,
the size of a large nut,
3 calculi each  an inch in
  diameter,
10 calculi, the largest of
  which was the size of a
  small nut,
shape and size of a small
  nut,
size of a small nut,
the calculus was broken
  into several pieces,
2 large calculi,
large,  and  was  broken
  into pieces,
2 calculi  of  2 inches  in
  their great diameter,
matter passed,
40 days,
a little over
  month,
14 days,
12 days,
in the space of
about a month,

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

about 20 days,
19 days,

25 days,
  The calculus was adherent on one side.
  The patient had vesical fistulas and strictures of the urethra, which,
after 15 days  caused  the urine to  flow anew through the intestine;
the use of an elastic bougie soon made all right again.
  The operation could not be performed in consequence of deformity
of the pelvis.
  This patient had been operated on by the first process.   A fistula
which had been the result of it was cured on this occasion.
Second.    Cases followed by Fistula.
medium size,

     u
small calculus,
some escape,

    ditto,
none,
48 days,

18 days,

27 days,
  The fistula was almost closed on  the  day that the operation was
published.
  The escape of fecal matter through the urethra in this case might be
attributed to the too prompt re-union ofthe sphincter ami.
  Some drops of urine escaped through the fistula.
  A few drops of urine escaped by chance. 
Second.    Cases followed  by  Fistula.—Uontinuea.
Cittadini,
Mori,

Cliet,
Geri,
Dupuytren,

Dupuytren,

Cavarra,
I  57

2  -

 1  70
2nd  process,
  combined
with the first,
   ditto,

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


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

no matter obser-
  ved to escape.
quite frequent,
30 days,
25 days,
   ------     about a month,

Third.  Cases followed by Death
The patient died of tubercular phthisis 3 months after the operation.
  This patient had already been twice operated upon for stone, and
there remained a fistulous opening after the first operation.
  This was the preceding case, after an interval of six months.  This
operation must have succeeded like the first.
  Frequent contraction of the urethra.
 Operators.

Dupuytren,


Vacca,

Vacca,


Vacca,
70

 6


55
Operative
 process.
2nd  process,

   ditto,


   ditto,
Size and weight of the
      calculus.
2 inches 4 lines,
1   "   8   "
1   "   4   "
very long,

size of a pigeon's egg,


medium size,
Time of death.
on the 36th day,    There was a vast abscess between the rectum and bas fond ofthe bladder.
               i

        4th day, |    Inflammation ofthe lower belly.  Gangrene ofthe internal surface ofthe bladder
               [  to which the stone adhered.
        8th day, I    During the night following the operation, pain in the hypogastric region; fever
               j  came on, and went on constantly increasing.  The post-mortem examination showed
               I  traces of inflammation in all the organs contained in the pelvis.
About 2 months    At the time of his entrance the patient  was very thin.   A diarrhea set in, and a
  after  the ope-  short time after there was jaundice  to a certain extent, but death occurred without
  ration         being preceded by distinctly developed evidences of the disease.  The  examination
                 after death showed the bladder  and  organs contained in the pelvis in  their normal
                 condition.  The wound ofthe neck ofthe bladder and of the prostate had healed ;
                 only that of the membranous portion of the urethra remained  uncicatrized.  The
                 two ejaculatory canals were entire;  either they had not been divided, or had healed.
                 The substance of the liver had been transformed into tuberculous and scirrhous mat-
                 ter ;  this organ was atrophied, whilst the gall bladder was much larger than usual. ^ 
Third.  Cases followed by Death.—Continued.
Vacca,
Vacca,
Cittadini
Barbantini,
Geri,
Janson,
Janson,
Janson,
Regnoli,
Martini,
Meli,
Cavarra,
19
56
55
quite ad-
 vanced,

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

1st process,
2nd  process,
ditto,
adult,
2 lines in diameter,  on the 11th day
  and  by  which the
  stone was extract-
  ed,

2 calculi of consider-  6 hours after,
  able  size,          !
extraordinary size.
very large,
the size  of a hen's
  egg, 31 ounces,
40 hours,

24 hours,
24 hours,
15 days,
3 days,
10 hours,
  Robust constitution, sanguine temperament, extraordinary  embonpoint.  On the
16th day there was fever and delirium, and three exacerbations of fever daily.  The
autopsy showed that the intestines, peritoneum,  and the other abdominal and pelvic
organs were without traces of inflammation or any other  lesion.   The wound was
situated between the seminal ducts, neither of which had  been touched.
  This patient was of a robust constitution; he was in the habit of taking opium.
Shortly after the operation and again a little later, 8 grains were given him.  There
followed irregular movements ofthe muscles ofthe face, with paralysis of the extre-
mities and coma.  By the autopsy, the prostrate, which was found much larger than
in its normal condition, projected about an inch into the bladder, and separated the
fundus from the neck of that organ in such a way that the  fundus had quite the ap-
pearance of a sac which could have contained two stones.
  This patient died during an attack of epilepsy ; an effusion of blood was  found
within the cranium.
  Subsequently to the operation, all hope was lost, in consequence of an internal
pain which showed itself in the bladder.   The urine contained fecal matters.  Peri-
tonitis took place afterwards.
  The peritoneum was wounded.

  Intense peritonitis.

  An ulcerated bladder, and its internal surface covered with gravel.
  The stone could not be extracted in consequence of its size and adhesions.
  Died in consequence of the incessant and obstinate reproduction, in spite of every
remedy, of a large quantity of worms, which  terminated in  a slow and obscure
pneumonia.  The lymphatic ganglions,  especially  those  of the lower belly, were
hypertrophied.
  A short time after the operation, inflammatory svmptoms appeared.  Autopsy: The
prostate projected  like a uterus.  The ureters wefe four times the natural size, and
full of pus.  The kidneys presented the same appearance, having their tubular and
cortical portions destroyed.
  A strong constitution and sanguine temperament.  The operation was easily per-
formed.  On the night  after the operation, there was intense  pain  in the bladder,
fever, suppression of urine, black vomiting.   Autopsy: The bladder large and in-
durated, somewhat cartilaginous, the bottom of the wound  mortified, the right ureter
and kidney inflamed. 
LITHOTOMY.                        947
              § XL—The Hypogastric Operation.

  We do not find in the ancient authors any definite expression in re-
lation to the  operation of opening into  the bladder above the pubis,
in order to extract calculi from it.   It appears certain that Philagrius
in recommending that we should  incise superne juxtd  glandis mag-
nitudinem, merely intended to speak of calculi arrested in the urethra,
and that in opening into the dorsum of the penis, his only object was
to prevent fistulas, which were much more to be  apprehended when
the incision was made in the lower wall of the urinary  passage.  On
the other hand, we cannot find what grounds M.  S.  Cooper has for
supposing that the operation performed  by Collot in 1475, had refer-
ence to  the hypogastric operation rather than to nephrotomy, or to
any thing else  we please.   It  was unquestionably Franco to whom
we are indebted for  this process ; and this  practitioner  also was led
to it, so  to speak, in spite of himself, and-is  careful to warn others
against imitating his  conduct.   Rousset, who gave a detailed descrip-
tion of it in 1581, 20 years after the publication of Franco's work, is
therefore the first person who  positively recommended  it, and who
endeavored to have it adopted  as a.general method.   Nevertheless,
the manner in which he mentions it, would induce us to believe that
other physicians also at his time had spoken of it.  However this may
be, Rousset, in consequence of the death  of Henry III., who had
promised to assign to him three or four criminals, in order to make
trial of it, was not enabled to perform  it upon the living body, and no
person appears to have thought of it since his time up to the epoch at
which Mercier undertook to defend it  at the faculty of Paris, in  a
thesis of N. Pietre, in 1635.  Some surgeons finally adopted it, and
Collot relates that in 1681, Bonnet, ofthe Hotel Dieu, had performed
it with complete success, in the presence of Petit.  Some years sub-
sequently, Proby, from finding himself unable to  extract a calculus,
through the usual routes, also had recourse to it, and Groenvelt, in a
work published at London in 1710, declared himself its  avowed
champion.   Nevertheless, it was  still  so little known, that Douglas,
in 1718, at one moment supposed himself to have been the inventor of it.
The successful  results which this last surgeon obtained from it, having
finally opened the  eyes of practitioners, hypogastric lithotomy soon
became  a subject of  investigation with Cheselden, MacGill, Thornill,
Middleton, Bamber,  and  Pye,  in England.   Morand, who made trial
of it at the Invalides on the 27th May, 1727, on an officer 68 years of
age, saw it performed on the 10th December following, by Berier, at
St. Germain-en-Laye, on  L. Amon, who was four years of  age.   It
was also performed  by J. Robert, Sermes, Kulm, and  Heuermann,
and especially by  Heister, who defended it in a thesis, supported by
Weise, at Helmstadt, on the 8th September,  1728, and who  cited in-
stances of it from Runge  and  Prsebisch, so that it appeared to be on
the point of being generally adopted.   In 1727, Cheselden, who had
performed it on 6 patients, had yet lost but one, and Douglas also one
only, out of 9 cases.  Out of  12  cases,  Thornill  lost only two, and
MacGill but one out of 4.   Nevertheless, the great excitement pro-
duced  by the appearance of F. Jacques, soon caused it to  fall  into
disuse, and there was scarcely anything more said of it until F. Come 
948           NEW ELEMENTS OF OPERATIVE SURGERY.
in his turn undertook to bring it into repute, in 1775.  From that time,
Le Blanc and Bazeilhac declared themselves its partisans.   Lassus,
as well as Deschamps, Dupuytren, Boyer, M. de Guise, and  several
others, also occasionally had recourse to it, but only in the character
of an exceptional method.   Notwithstanding all the justifications that
had been employed in its  defence, and  the  numerous successful re-
sults which had been obtained from it in France, by M. Souberbielle,
the inheritor of the principles of F.  Come  and Bazeilhac, the high
operation had again fallen into disrepute, until in consequence of the
improvements proposed  by Scarpa, Dupuytren, Everard Home, and
Gehler, it was a third time attempted  to  demonstrate its advanta-
ges, and to substitute it  for the perineal methods.   It consists of an
incision into  the anterior wall of the bladder, through the parietes of
the abdomen.
  A. Examination of the methods.—The high operation has not pre-
sented as many methods as perineal lithotomy, and  the processes
which belong to it can scarcely be considered in any other light than
as modifications of  each other.   In order to analyze  them  with some
degree  of method, I classify them under three different heads. In
the first, we operate without the previous introduction of  a director.
In the second it is directly the reverse ; while the third is distinguished
from the two others in this, that we make an accessory opening below
the pubis.
  I. Method of Rousset.—The first method of performing hypogas-
tric lithotomy, is the one recommended  by Rousset.  We begin by
injecting barley water, tepid water, milk, or in fact any  vulnerary
decoction into the bladder, in order to distend it, and to oblige it to
project above the pubes.   In order that the liquid  may not escape
contrary to the intention ofthe  operator, a ligature is placed  around
the penis of the patient, or  an assistant is  directed  to  compress it.
The integuments, and the aponeuroses are incised upon the median
line by means of a  razor.  A bistoury  which is slightly concave, is
then introduced obliquely downwards and  backwards between the
symphysis and the bladder, with  its back turned towards  the bones,
in order to open into this organ with  considerable caution.  Should
the puncture be very large, the bladder would  be immediately emp-
tied.  It is necessary that it should be sufficiently so only  as to ena-
ble  us to introduce a lenticular bistoury, by which the wound is to be
immediately enlarged from below upwards, but in such manner how-
ever, as not to go as far as the  peritoneum.  The  stone finally, is
extracted by means of the fingers alone, or by the  fingers wrapped
in linen, or by the scoop  or tenacula.
  a. Douglas has modified the process of Rousset in two respects.
He recommends that the organ should  be but moderately distended
by the injection, in order that it may not incur the risk of  having its
fibres paralyzed, and because its excessive distension is in most cases
insupportable.  He substitutes a convex bistoury for  the razor.  The
straight bistoury, which  he employs in preference to the curved, en-
ables him at  the same time to make the puncture into the bladder,
and  also to enlarge this wound immediately without having recourse
to the probe-pointed bistoury.
  b. Cheselden. who also does not like any great distension of the 
LITHOTOMY.
949
bladder, recommends the  patients to retain their urine as much as
possible, and that we should inject only a quantity of liquid equal to
that which they ordinarily discharge.  When he has laid  bare the
aponeurosis with a  convex bistoury, and divided  the linea alba with
a straight bistoury, he  prefers a  concave bistoury, and not probe-
pointed, for opening  into the bladder from above downwards, and
no longer from below upwards,  as is recommended by Rousset and
Douglas.   The  curved scissors, recommended by MacGill in place
of the  bistoury  at this last stage of the operation, would expose us
too much to the danger of  wounding  the  peritoneum, to allow of
their adoption, and are in every respect of too little advantage to ren-
der it necessary that  we should examine a modification of this kind.
  c.  Morand scarcely modified the process of Rousset except in this,
that he made his patient lie  down in the opposite position, with his
head and chest  lower than the pelvis, and  his legs secured to  the
posts of the bed.   He also insists  upon the danger of forced injec-
tions, and  endeavors, moreover, to show their inutility.   With  him
the straight bistoury for  the incision of  the abdominal walls, and the
concave bistoury for the bladder, were found quite sufficient.   It is
to him  we owe  the suggestion of making use of the left forefinger,
bent into a hook, in order to retain the bladder at the upper angle of
the wound, while we completed its division,  as had also been  recom-
mended by Heister.
  d. Others, and Le Dran in particular, considered that in place of
incising the bladder from  above downwards, it would  be  better to
divide it transversely, and that by  acting in this manner, we should
run less risk of wounding the peritoneum.   Winslow  alleged  that
we might dispense  with  injections by making the  patient drink freely
of a diluent ptisan for some weeks before subjecting him to the ope-
ration,  and pointed out  to Morand that the  position chosen by this
last  was  but little suitable.   According to him, Thibaut, of  the
Hotel Dieu, had suggested the idea of returning to the incision from
below upwards, and recommended, like La Peyronie, that we should
plunge  the bistoury  into the bladder with one  movement, in such
manner as to  divide  the whole  thickness of the  tissues while with-
drawing the instrument.   Lecat followed this advice in the two pa-
tients upon whom he performed the high operation.  His cystotome
bistoury introduced by puncture, with  its back turned downwards,
enabled him to divide the bladder above, and then to retain this organ
momentarily suspended  by means of a projection on the convex bor-
der of  the bistoury,  and which was suddenly turned  round in  this
direction  until the surgeon had replaced it by  a suspensory hook.
  e.  In these latter times  the process of Rousset has again under-
gone some modifications.  M. Baudens says  he  has done very well
without introducing  any liquid into the bladder,  and in laying  bare
this organ a little towards  its side, as  had already  been recom-
mended by Pietre, Solingen, &c,  also in introducing the left fore-
finger  down to the posterior side of the pubes,  in order to crowd
back the peritoneum from below upwards, and to make tension upon
this membrane at the same time as upon the bladder; then to plunge
the bistoury into the cavity of this organ  from  above downwards,
and immediately to  introduce the finger into it  in the manner of 
950           NEW  ELEMENTS OF OPERATIVE  SURGERY.
Morand, continuing the incision in the same  direction without stop-
ping, down to near the neck of the bladder.  M. Baudens (Bull, de
Fer., X. XX.,  p. 224) also thinks that we should  incise laterally the
rectus muscle as well as the lips of the wound  of the bladder, as
had  already been done  or  recommended by MacGill and Le Dran,
when  any difficulties presented  themselves  in regard to the  extrac-
tion  of the calculus.
  f.  M. Tanchou  has supposed that he could render  this process
more easy by using  a  species  of flattened  trochar  with a  sheath,
grooved on one  of its borders, and a joint at a certain distance from
its extremity, and the rod in which, having a cutting edge, tranforms
it  into a bistoury.  The operation is  performed  in the  following
manner.  The operator  incises  upon the median line down to  the
front ofthe peritoneum, by means of a convex  bistoury.   By means
of the left forefinger  introduced into the bottom  of  the wound,  he
recognizes the fluctuation of the  bladder, which has been moderately
distended by an  injection of tepid pater; then plunges in his instru-
ment from above downwards and  from before  backwards  ; with-
draws its  cutting blade  by means of a spring ;  when its  sheath
immediately  bends into  a right angle, forming a  suspensory hook
developed  in the  interior, and upon the lower border  of which a
probe-pointed bistoury is to be  conducted, in order to enlarge  the
wound.
  g.  Finally, M. Verniere (Bull, de Fir., X.  XX.,  p.  224) has con-
sidered that  he has introduced an  advantageous  modification into
practice, in proposing a previous operation, which consists in incising
the hypogastric wall in order to introduce between it and the front
part  of the bladder a plate which is  destined, by acting from  behind
forwards, to compress the peritoneum against the inner side of the
recti  muscles during the space of several  days.  The adhesions
which result from this compression will enable us, he says, to open
into the bladder without the slightest danger of penetrating into the
cavity ofthe  abdomen.   A suggestion similar to that of M. Verniere
has been communicated to me by M. A. Vidal.   This surgeon pro-
poses to perform the operation  in two  stages, with  an interval  of
several days  between.  The first,  which  consists of  an incision
through the tissues, which separates the bladder  from  the external
surface, has for its object to render  the cellular layers impermeable
by inflaming them.  The second consists in opening into the bladder,
which, according  to  the author, will  by this  means be no  longer
exposed to urinous infiltrations.
  h.  Appreciation.—There is  not  one of  all  these modifications
which in reality deserves an absolute preference over the  others.
That of Morand, so far as regards the operation properly so called,
is, as it appears to me, the most prudent.  To make the patients re-
tain  their urine  in  order to distend their bladder, is  a  thing which
may  be  more easily  recommended than carried  out.   All  that is
necessary to convince us of this is to recall to mind how frequently
calculous patients  have  an inclination  to urinate.  The  injections
could not, in fact, be supported if we persisted in throwing them up
in such quantities as  to  make the bladder project  above the  pubes.
But  in the majority of  cases we have no  difficulty  in giving  it a 
LITHOTOMY.
951
 moderate degree of distension by the injection of an emollient liquid,
 which is sufficient to enable us easily to recognize its presence behind
 the pubes by means of the finger introduced  through the wound at
 the linea alba.   As to the nature ofthe liquid  to be injected, milk, to
 which Middleton appears  to  give the  preference, and  of  which
 Rousset  himself had already spoken, is evidently, on account of its
 tendency to decomposition, less suitable than mallows or barley water,
 or better than all these, a certain quantity of  tepid water.  Air, the
 suggestion of which  is  ascribed  to  Solingius, (Thises  de Haller,
 French transl., t. II.,) though already mentioned  by Rousset, when
 he says that it was recommended in his  time  to fill the bladder with
 wind,  would possess no advantage over any liquid whatever, and
 merits the little  importance that was given to  it.   As to  the precept
 of Bamba, who  recommends that the injection should not be thrown
 up until  after the incision made through the linea alba, and that of
 Middleton, who  thinks  that we should at least then throw up a little
 more than  before  commencing the operation, they have been long
 since rejected.   The incision  from below upwards  with a straight
 bistoury, as in the process of  Douglas, or with  the probe-pointed
 bistoury, according to Rousset, would enable us, if necessary, to take
 a point d'appui  against  the pubis and  to  proceed with a certain
 degree of security; but  it is undeniable that we  would in this way
 incur too great a risk of perforating the  peritoneum, and of opening
 into the  belly, as was  remarked by  Cheselden.   In  adopting the
 incision from above downwards  it is almost a  matter of indifference,
 provided we are sure of our hand, whether we  prolong it with the
 scissors or with  the probe-pointed, straight or curved bistoury, or
 with  the ordinary straight bistoury.  The transverse  division  of
 the bladder would  have  the inconvenience, as Winslow remarks, of
 presenting  a wound which would be  perpendicular to the direction
 of the external  incision, and which, by retracting  behind  the pubes,
 would peculiarly expose  to the danger of urinary  infiltrations.  It is
 also  very evident that the lateral incision of the recti  muscles, as
 practised by Pye. and at  another time  by Dupuytren, and which
 Gehler in our time has proposed to establish  as a rule, is not  appli-
 cable except in  those rare  cases  in  which spasmodic contractions
 take place in so violent a degree as to prevent  the introduction ofthe
 fingers or tenacula into  the bladder  through  the  wound, as I saw
 occur in a patient operated upon by M. Roux  at La Charite in 1827.
 The  process  of M. Baudens would have the serious inconvenience,
 by detaching the peritoneum  of causing too  extensive a laceration
 of the cellular tissue.  There can be no  doubt that in those cases in
 which  the bladder has entirely receded  to the bottom  of the pelvis,
 the operation would be attended with very considerable  difficulty if
 no injection was used.    The bare mention of the suggestion of M.
 Verniere is  sufficient of itself, as I consider, to enable every one to
 appreciate it at its just value.  That of M. Vidal is more simple and
 more rational.  As to the combination of M. Tanchou, its prudence
 cannot be  questioned;  only as  it exacts a  particular instrument
 which has no other advantage than that of enabling us to introduce
a hook into the bladder, at the same time  that we penetrate into it by
the puncture, and as the puncture into  this organ, by means of a 
952          NEW ELEMENTS OF OPERATIVE SURGERY.

bistoury, enables us almost always immediately to introduce into it
the finger or any suspensory instrument whatever, this process I pre-
sume will not be  adopted by practitioners.  Some  ancient authors
had already however  seemed to have felt the necessity of  such a
process, for Heister recommends that we should  make the puncture
into the bladder by means of a grooved  trochar, which could after-
wards serve as a director to the bistoury.
  II. Method of Franco.—Dionis and Toilet consider that the surgeon
might confine himself to the method adopted by Franco, that is to say,
to introduce two fingers into the rectum,  in order to raise up the cal-
culus towards the hypogastrium, so that we might cut down upon it
a little to one side of the linea alba.   They find  this method easy and
simple, and more  certain than  that mentioned by Rousset.  If the
stone were of such small volume, the symphysis of such inconsidera-
ble  height, and the aggregate of the parts of so little thickness, as to
enable the fingers to push the foreign body in this  manner to as far as
above the  pubes, this  process would  possess  real advantages, and
would deserve to be adopted.  Proby used it, and it was by this pro-
cess that Lassus, M. De Guise, and some others were enabled to re-
move from the bladder calculi, which they had  found it impossible to
extract through the perineum.   It is nothing more in fact, than the
little operation of the ancients transferred to hypogastric  lithotomy,
with this difference, that above the pubes there  would be less incon-
venience in cutting down upon  the  stone, than  if we had to extract
it through the lower strait.   As to the manipulation of the operation,
it is altogether useless to give it in detail.   Franco merely says, that his
patient was operated upon " on the mons veneris, a little to one side, •
and over the stone, while he raised up this last with his fingers, which
were in  the  fundament, and keeping  it  moreover under his con-
trol  by means of the hands  of an  assistant, which  made  compres-
sion on the lower belly."   It is well to remark, en passant, that Franco
had not previously incised the perineum  in the  infant, two years of
age, mentioned by him, as has been  repeated in a great number of
works, and that it was only after having found that all his efforts to
depress the stone were useless, that he decided upon " cutting the
said infant above the ossa pubis."
  III. Method of F.  Come.—Hypogastric lithotomy appears to have
undergone in its successive modifications, almost  all  the varieties of
the  perineal operation.   In the same way, as for  a long time it was
the  practice to make the stone descend towards the neck ofthe blad-
der, in order to incise the parts over it, so also  has it been with the
high operation.   In this latter, however, they soon adopted the  pre-
caution of distending the organ  by means of injections.   In the last
century Bamber, Cheselden  and Foubert suggested the  same  course
for the purpose of avoiding the employment  of the conducting sound.
Finally, if it was thought that this last  instrument was indispensable
in all the processes of the low operation, so also have a great number
of authors recommended its employment in  the supra-pubic method.
Rousset refers to it without being an advocate of it.  It  appears that
at his time it was a hollow and grooved sound,  w7hich could be used
at the same time as a catheter for making the injections, should they
be deemed advisable, and also '• as a sound for  directing the incision 
LITHOTOMY.
953
 in the manner  of the Marianists ;" that is to  say undoubtedly, that
 we could turn  either its  groove  or  its  convexity forward, which,
 however, would not be an  easy matter.  At a  subsequent period the
 sound was recommended  fey Pie tre, Heister, &c. ; by some for the
 purpose of distending and raising up the bladder, while several others
 had a groove running along  its concavity, for the purpose of direct-
 ing the point of the bistoury.  But the instrument which has attracted
 most  attention in this respect is the one contrived  by F. Cdme, and
 which gave this ecclesiastic so great a predilection for the high ope-
 ration, that from the year 1758  to 1779 he  had  already made use of
 it in 100 cases.   This  instrument is known under the name of  the
 sonde-d-dard.   It is introduced in  such  manner that its extremity
 may glide from below upwards, behind the symphysis, and reach above
 the pubes while passing against the  anterior region of the  bladder.
 The walls of the belly having been incised, the point of the instru-
 ment  is made to project  slightly into the wound, by making a slight
 pressure on its  plate outside, as if for the purpose of pushing it back
 and depressing  it.   The surgeon  seizes it  through the walls of the
 bladder by its projecting  extremity, with the thumb and forefinger of
 his left hand,  or he applies  in front of it a sort of canula which
 flares open like a  funnel.   The  dart  (le dard) being pushed  from
 below upwards, perforates the  bladder in  escaping from its sheath,
 in order to  come to the outside.  Whether the extremity of this
 dart shall have  been unscrewed, in order that we may leave its stem
 only in the wound, or whether  it  consists  only  of a single piece, the
 bistoury is to be guided on the groove of its concavity, then from above
 downwards, and from before backwards, in order to  incise the walls
 ofthe bladder to such extent as may be deemed advisable.  Nothing
 more  remains to do than  to withdraw it into its  sheath, the projecting
 point  of which had not left  the bladder, and which itself is to be im-
 mediately removed.   The other stages of the operation are the same
 as in the  process of Morand.
  a. We perceive that the sonde-d-dard enables  us  to dispense en-
 tirely with injections, that it stretches the parts to a proper extent, and
 that its grooved stem becomes an excellent conductor when we wish
 to enlarge the opening into  the bladder with the bistoury.  With the
 view of giving it still greater efficacy, Scarpa and  M. Belmas have
 made  some modifications  in it.  Thus, it has been frequently objected
 to it, that it may wholly escape through  the puncture made by the
 dart,  and allow  the bladder to retract  before  it was possible to .
 open into it with the bistoury.
  The surgeon of Padua remedies this inconvenience in  the follow-
 ing  manner.   His catheter  is not grooved  except  at  some lines dis-
 tance  from the extremity, which  latter   consists of a beak  dila-
 ted  into  an  olive shape.   This groove is  moreover very wide and
 deeply excavated, in order to  leave on  each  side of the stilette a
 furrow of sufficient depth to enable  the point of a bistoury to glide
 upon it.   The perforating stilette, intended to pass through  it, sepa-
 rates  from it by degrees, and  goes beyond  it  to the distance  of
 two or three  lines in advance of its extremity, which latter in this
manner is retained in the  bladder, and cannot escape from it to  fol-
low  the stilette.   Scarpa  also alleges that the nail can always distin- 
 954          NEW ELEMENTS OF OPERATIVE SURGERY.

 guish its borders through the walls of the bladder, and  that the  bis-
 toury may be conducted upon it without  any danger by passing on
 one side of the stilette.  The sound of M.  Belmas, however, is so
 complicated that it will not be adopted at least in its  essential points.
 Other conducting  instruments have also been  proposed  at various
 epochs.   Cleland, for example, proposed in the last century a sound,
 which after being introduced into  the  bladder, opens like a forceps
 and enables us in this manner to make  a greater or less degree of
 tension upon the walls of the organ.  Kulm, L'Heritier,  &c, have
 produced nothing better, and the very complicated apparatus which
 M. Rouget wished  to bring in repute some years since, and the  ob-
 ject of which was to enable us with one movement  to  make an  im-
 mediate perforation of the entire thickness of the walls of the belly
 and bladder, also does not deserve to be revived.   M. Leroy d'EtiolIes,
 (Cystotomie Epipubienne, Paris, 1837,) has contrived  aponeurotomes,
 (Oper. Cit., fig. 1, 2, 3, 4, 5, and p.  9. 10,11.) suspensory cystotomes,
 (Ibid., op. 18, 19, fig.  7, 8, 9, 10, 11, 12, 13,) dilating hooks,  (Ibid.,
 pp. 22, 23, fig. 14, 15,) &c, the use of  which also in my opinion do
 not appear to promise  any great advantage.  The only question to
 be determined would be, if the conducting instrument was exclusively
 designed to stretch  the organ and  to prevent its retracting, or if it
 was at the same time intended  to perforate  this cavity  from  within
 outwards, in order  to serve as a more certain guide for the bistoury,
 destined to complete the  incision.  In the first case,  an ordinary
 catheter would sufficiently carry out the views of the  surgeon ; in the
 second, the sonde-d-dard, whether simple, or such as it has been mod-
 ified by Scarpa, leaves certainly nothing to be desired.
  b. Button-hole Incision.—The employment  of conductors has not
 been the only change made in hypogastric lithotomy.  Various sur-
 geons have proposed to make  an opening underneath the pubes.  This
 opening, which had already been performed by the Dutch surgeon,
 Serines, who on that account was even pursued by the tribunals and
 defamed by envy, sometimes consisted only of a simple puncture, and
 at others resembled in some respects the lateralized operation.  Ser-
 ines recommends that we should  use it for conducting the suspen-
 sory  sound.   Palluci  made  a  puncture  with  the  trochar  at  the
 same point, and left a canula  remaining  in the wound.   Deschamps
 recommends that  the  puncture should  be made at  the rectum, in
 order that it may give passage to the instrument which has been pro-
 vided with its arrow, (fieche.)  It is, however, to F. Come that  the
 supplementary incision chiefly owes the reputation which it has  en-
joyed.   This lithotomist, who commenced his operation with it, inci-
 sed the membranous, and also  in part the prostatic portion  of  the
 urethra upon a grooved sound, and then made use of the  wound to
 introduce  through it the sonde-a-dard into the bladder.   After  the
 operation, a large short canula, left  to remain in the  solution of con-
 tinuity, served by giving egress to the urine, to prevent its effusion
 towards the hypogastrium.   The arguments presented, and the suc-
 cesses obtained by F. Come, for a moment led to deception on  the
 importance to be attached to an incision of this kind ; but some persons
 soon asked themselves  the question, if this process  could  in reality
 possess any advantages for the high operation, or whether it would 
LITHOTOMY.
955
not, on the contrary, complicate it in a  dangerous manner.   It was
easy to perceive—1st, that the wound of the perineum did not prevent
the urine from getting into the hypogastric wound; 2d, that it is not
required  for the  introduction of the sonde-a-dard; and  3d, that it
must add almost all the dangers  of the lower  operation to those of
the upper.  Thus, Scarpa in 1808, and  Dupuytren in 1812, endea-
vored to  reject the modifications of F. Come, by demonstrating that
the instrument contrived by this practitioner, could,  if introduced
into the bladder through the urethra, be  made  to  manipulate full as
well as through  the  perineum.   Nevertheless,  the  process of  the
Feuillant ecclesiastic continued to be followed, until Home, abandon-
ing this method,  performed in two instances, in 1819  and 1820, the
hypogastric  operation according to  the  principles laid down in  the
dissertation of Dupuytren.   Some years  after M. Souberbielle him-
self renounced the precept of his ancestor, and which precept he had
no longer followed since the year 1825;  so that at the present day
the question is definitively adjudged, and no longer requires discus-
sion.
  B.  Operative   Process.—The  processes  which  have  just been
passed in review, notwithstanding they are different,  present rules
which they have in common.  These rules relate either to the posi-
tion of the patient, to the incision of the tissues, or to  the means of
passing off the urine and dressing  the wound after the operation.
  I.  The position of the patient  ought  to be  that which  is recom-
mended for the operation of hernia,  with this difference only, that it
would be advisable to have the pelvis slightly  elevated.  If  the legs
were allowed  to hang from  the table  or bed, they would increase
the tension of the abdominal muscles, and expose, in  this manner, to
a variety of  inconveniences.  In folding  them upon the thighs as in
the perineal operation, they would interfere with  most of  the move-
ments of the surgeon.   If necessary, the operation might be made
on an  ordinary bed; but  a narrow  table of an  appropriate height
renders the position of all parties infinitely more commodious.
  II. Injection of the bladder.—When  we propose  to distend  the
bladder by means of liquids, we must begin by introducing  an ordi-
nary catheter through the urethra.  The syphon of a syringe filled with
tepid water is  then attached  to the  pavilion of the  catheter. The
injection  is to be thrown up gently, and in such manner as  to make
as much of it penetrate into  the bladder as the patient can  support
without experiencing any pain.  No one  at the  present day would
think of using the urethra of an ox, the trachea of a turkey, or a lea-
ther catheter, as is recommended  by Douglas,  Cheselden, Middleton,
and Solingen, as a medium of communication between the  catheter
and syringe, in order thus to prevent all kind  of  concussion.  As
soon as the  injection is  terminated  an  assistant is directed  to com-
press the urethra, for  the purpose  of preventing the liquid from
making its escape before it is time for  it to do so.  It is true that
many persons do not need  this precaution, but as it is not the same
with others,  prudence would  not  allow of our neglecting it.  As to
the compressor of Nuck, Winslow, &c, the fingers may be perfectly
substituted for them.
  III. Incision of the external parts.—The  surgeon being placed 
956          NEW ELEMENTS OF  OPERATIVE SURGERY.
upon the right rather than  between  the legs of the patient, as M.
Belmas recommends,  proceeds  to lay open the  hypogastric wall.
It would be absurd to discuss the advantage of this or that form of
bistoury for this stage of the operation ; whether it be  a razor, the
convex or straight bistoury, or the small ordinary knife,  is  a matter
of little importance, provided it has a good cutting edge.  It is to be
held in the first position, that is to say, in the manner of a table-knife,
and after having stretched  the  parts with the  left hand, we divide
from above downwards, to  the  extent of  three or four  inches, first
the integuments, then the cellulo-adipose tissue, and thus  in  this man-
ner come down upon the aponeurosis.  It  is better,  whatever Zang
may say to the contrary, to  have this incision a little too long ra-
ther than too short, and there will be an advantage, notwithstand-
ing the contrary opinion of Winslow, in prolonging it upon the front
part of the  symphysis  to a  half  an inch below the  superior border
of the  pubes.  The incision  of the aponeurosis  is not made in  the
same way by all surgeons.   Though there may be some who make
it with the same instrument which they have used up to this point of
the operation, there are others, and Scarpa is of  this  number,  who
recommend, that after having incised into it very low down, we should
glide underneath it  a  grooved  sound which is  made  to pass be-
tween  the peritoneum and the  wall of the  abdomen,  from below
upwards, in order  that we may  conduct upon  it a bistoury in the
same direction, to  divide through the whole thickness of the fascia.
F. Come employs for this purpose an instrument which terminates in
a triangular point at one extremity, and in a handle  cut into facettes
(taille a-pans)  at the other, and which contains a cutting blade, hav-
ing a  plate  at its free  extremity, and opens from the heel  towards
the point, and consequently  in a  direction which  is the  reverse of
that of the concealed lithotome.   This trochar is plunged in from
before  backwards, and from above downwards, until it  arrives be-
tween  the symphysis and the front part of the bladder.  The sur-
geon with  his right hand fixes  its  stem  against  the  bones ; seizes
its plate with the  thumb and forefinger of his left  hand,  separates
this plate from the  handle from  below upwards,  and  divides in the
same  direction the linea alba as well as the entire thickness of
the other tissues  which  lie beneath  its  cutting  edge.   Having
withdrawn the trochar, F. Come introduces in its place a bistoury
terminated by an olive  point, with a cutting edge upon its concavity^
and fixed upon its handle ;  then incises from below upwards  with
this second instrument held  in his right hand and protected or sup-
ported by the first  fingers of his  left  hand, all the layers which may
have at  first  escaped  him, taking  care  to make  its button point
pass between the  bladder  or  between  the peritoneum itself and
the deep-seated surface of the aponeuroses.  At first  sight, the pro-
cess of F. Come would appear to be  more dangerous than any other.
It is calculated to cause alarm  to see the edge of  his  trochar bis-
toury acting  in  this manner from below upwards, and  from before
backwards.   As it cuts however by pressing, rather than  by a saw-
like movement; and as  at  the greatest degree possible at which it
may be  opened,  its blade  represents a line strongly oblique  from
the integuments  towards the bladder, it rarely happens that the peri- 
LITHOTOMY.                        957
 toneum is actually wounded.   The only  reasonable objection that
 may be made to  it, .is that it is  not  indispensable, and  that  any
 person  practised in the performance of  the great operations will
 manipulate  with  full as much security with an ordinarv  bistoury.
 Under  this  point of view  the  improvement which M. Belmas has
 made upon it, and  which  consists in making it concave on the
 back, and convex  on the cutting edge, does not appear  to me to
 possess  any great advantage.
   As to the probe-pointed bistoury of F. Come, I have, while making
 my pupils manipulate on the dead  body, a thousand times  perhaps
 replaced it by the  ordinary  probe-pointed  bistoury, and have never
 felt the  necessity of employing one  of a particular kind.  Almost all
 surgeons of the present  day  recommend that the incision  should be
 made directly upon the  linea alba ;  M. Baudens, however, recurrin»
 to the advice of certain  authors, has endeavored to prove  that it is
 better to go outside of this fibrous line,  alleging that if the wound is
 placed between it and the inner border of the rectus muscle, we ex-
 perience less difficulty in enlarging it. and  in separating its  lips to
 come down upon the front part of the bladder.  This, however, is one
 of those recommendations which may be followed or omitted without
 any  inconvenience.   The important point is to penetrate between the
 two muscles, and not through  their fibres.   Whether the linea alba
 after that remains intact on one of its sides, or whether it has in  real-
 ity been separated into two equal portions,  is a matter that we  need
 not trouble ourselves about.   I  will  remark, that the reason why we
 ought not to make the bistoury pass through the muscular fibres, is not
 so much owing to the danger of incising them, as it is in consequence
 ofthe greater thickness  that  we should have to cut through before
 arriving at the sub-peritoneal cellular tissue, and because the serous
 membrane is found more closely applied  to the deep wall of the hypo-
 gastrium, upon the outside ofthe median line, than  it is upon the cen-
 tre itself.  The ordinary straight bistoury, held  like a knife or  pen,
 is full as good as any other, to incise from above downwards, and in
 succession, the skin, adipose layer, and aponeurosis.   Having arrived
 to this aponeurosis, the surgeon should proceed with caution and di-
 vide  it layer by layer, taking care to press with much more force while
 approaching the pubis than at the upper half of the wound.  As we
 unavoidably come down upon the pubeo-vesical triangle, on the me-
 dian  line, and inasmuch  as with a little attention we may always re-
 cognize  that we have reached this point, the  peritoneum does not in
 reality run  any risk during  this part of the operation.   Upon the
 supposition that more intimate  adhesions above should  prevent our
 opening  into the aponeurosis  on this side  to a sufficient depth, the
 probe-pointed  bistoury  should  then be  substituted for the  straight
 one.   Its extremity should  be  applied  to  the triangle above men-
 tioned, immediately above the symphysis, against which the operator
 might for greater security hold its back supported with his right hand,
 while with the forefinger and thumb of his left hand, he would grasp
 its blade at its sides, to draw it  from below upwards, and to oblige
 its button to glide on the anterior surface of the bladder, or the lower
portion of the  peritoneum itself, between those parts and the deep-
seated side of the linea alba, to the extent of about two inches.   It is 
958          NEW ELEMENTS OF  OPERATIVE SURGERY.

true that the opening into the bladder is made with less danger below
than above ; but in the first case, we have to direct the cutting edge
ofthe bistoury towards the umbilicus, which would expose to consid-
erable risk of wounding the peritoneum : while in the second case, if
th.s membrane has not been wounded at first, we are almost sure of
avoiding it afterwards.  It is unnecessary to seek for the origin ofthe
urachus, or the middle point which separates this cord from the pubes,
as Middleton and some others have suggested.  The important mat-
ter is to come down on the anterior wall of the organ, on some point
which is not covered by the peritoneum, and this constitues the whole
matter.   This puncture is made with a straight bistoury, guided upon
the nail  of the left forefinger, and inclined from above downwards,
full as well as writh the little  concave knife of Cheselden or Rousset.
In withdrawing the instrument,  we  should  take care to enlarge the
wound rapidly, in order to enable us to immediately introduce a sus-
pensory instrument into the  bladder.   The forefinger turned above,
in the manner of a hook, performs  its office at first.  If,  after that,
the walls ofthe belly should appear to be too thick, and seem to pre-
sent a difficulty in reaching the bladder, we might follow the  recom-
mendation  of Zang, and  separate the  lips  of the wound apart with
two small blunt hooks.  The finger crooked above, again  serves to
direct the bistoury, which is to be had  recourse to for enlarging the
wound in the bladder, and prolonging it towards the neck, to the ex-
tent of an inch or more,  according  to  the presumed volume of the
calculus.  In ordinary cases the  same bistoury, that is to  say, the
straight bistoury, will  also answer for this purpose, and is better even
than the probe-pointed bistoury in  this respect, that  its pomt more
thoroughly divides the tissues when it is withdrawn.  If, however,
on account of the embonpoint of the  patient, its employment should be
attended with any difficulty, the concave  bistoury of Pott might be
advantageously substituted for it, and  would render wholly useless
the concave bistoury proposed by the ancients.  As  to the scissors
that are curved on their border, I know of no circumstance that can
render their employment  necessary.  If the finger should appear to
take up  too much room during the time of introducing the tenacula or
of extracting the  calculus, or if it  should  be apprehended that it
might be wounded during these last manipulations, an instance of
which was seen by Deschamps, we ought, whether it be the finger
of the operator or that of an assistant, to  replace it by a special in-
strument for this purpose.  The  blunt  hook of  F. Come would then
answer perfectly well. The species of gorget, however, with a han-
dle, and bent almost into a right angle near its extremity, like the one
constructed by M. Belmas, would be evidently preferable.   In fact
this suspensory instrument, the  gutter  on  which should face down-
wards, would keep the lips of the  wound open, and form an excel-
lent  conductor, without in any manner  moreover incommoding either
the artificial opening or the inner surface ofthe bladder.  Alter this,
nothing more remains than to withdraw the calculus.
   IV. The use of the director.—When we  make use of a director, it
is better to adjust it before opening  into the hypogastrium than after-
wards ;  in the first place, because its point may in  some cases serve
as a guide above  the  pubes;  and in the second place, because its in- 
LITHOTOMY.
959
 troduction afterwards would give greater uneasiness to the patient.
 We will suppose that the  sonde-d-dard is the one to be employed.
 The surgeon introduces it in the manner of an ordinary sound, glides
 its  concavity behind the symphysis, and in this manner conducts its
 point to above the upper strait, and opposite to the linea alba.  An
 assistant is  directed to keep it in this  position, while the operator
 proceeds to divide the integuments and the aponeurosis.   The blad-
 der being now laid bare, the surgeon again takes the sonde-d-dard,
 withdraws it slightly in order to bring back its point again from be-
 low upwards, while  grazing  gently against the pubes and  in such
 manner that the peritoneum may not form a duplicature in front of
 that part of the wall of the  bladder which the point of the instru-
 ment is intended to  make  protrude  through the wound.  The  left
 forefinger introduced into  the  bottom of the wound  enables us to
 appreciate these movements,  and points out  the  height  to which it
 has arrived, and the degree of  protrusion it makes.   After having
 adjusted it in a proper manner it is again consigned  to the assistant.
 The surgeon, who immediately pinches the salient point by the sides,
 then  directs the assistant to push upon the dart, which  he  causes
 to  emerge to the distance of one or more inches, and the point of
 which he unscrews if he  apprehends any embarrassment from it.
 Without changing the  position of his left  hand, he takes  in his right
 hand a bistoury which, according to Scarpa, should  be convex, and
 on  the contrary concave, according to  M. Belmas,  but  which may
 be  straight or the ordinary bistoury, and nevertheless have the same
 advantages ; places  its point, while  holding it as a pen, upon  the
 groove of the sound; penetrates into the  bladder and divides it on
 the median line from above downwards and from before backwards,
 nearly as far as to  its neck or to the prostate; then withdraws the
 dart into its  sheath  and immediately introduces  the left forefinger
 into the  bladder.  The  assistant now  removes the  sound, and if
 the surgeon considers it to  be necessary to make use of an artificial
 suspensory,  he  attends for the moment to the  adjusting of the one
 that he  selects ; takes the hook or the beak gorget in his right hand,
 supposing that this is the one he prefers; presents it  at the wound
 into the bladder in the direction which is most  suitable;  raises it  up
 after it  has  entered into this organ ;  glides it in the place of the
 forefinger, which he replaces in the lower angle of  the wound, and
 immediately leaves the instrument in the charge of an assistant. His
 two hands being now free, he explores without any difficulty the in-
 terior of the bladder, and ascertains the volume as well as the posi-
 tion of the calculus, the extraction of which  is the  only thing that
 remains to be  done to  complete the  operation.  This  extraction,
 which may frequently be effected by means ofthe forefinger curved
 in the manner of a hook, or by the forefinger and the  thumb, or by
 the  forefinger aided  by a scoop, requires in other cases the assistance
 of tenacula, which are generally managed with more facility in this
 operation  than in infra-pubic  lithotomy.   The  precautions  to  be
 attended to in using them, moreover, are precisely the same.  Only
 that we  should  observe still more  caution than ever to avoid  sepa-
rating the bladder  from the pubes and abdominal  wall, and that
we  may not in any  manner cause a laceration of the  loose cellular 
960          NEW ELEMENTS OF  OPERATIVE SURGERY.

tissue placed between these different organs.  Dzondi, (Bull, de Fer.,
X.  XXII., p.  424,) with a view to  avoid  making any devious track,
drew through the wound  by means of the sound in the bladder, a
concave plate, which enabled him  to extract the stone.  M. Krimer,
(Journ. de Graefe et Walther, vol. X., p.  578,) being unable to ex-
tract a  calculus through  the incision at the perineum, had  recourse
to the hypogastric operation to extract a stone  twenty-three ounces
in weight,  and thus cured his patient.  Calculi  respectively of nine
and a half ounces, twenty-five and a half ounces, and three pounds
three ounces, are said to  have been extracted  in the same manner,
(Pechlin and Verduc, Theses de Haller, X. II., Fr. transl.)  Noel thus
extracted one of more than four inches in diameter, which was shown
to me by M. Loze.  M.  Mandt, (Kleinert's Repert., Janvier, 1836, p.
51,)  after having extracted three calculi  through the perineum, was
obliged to lay open the hypogastrium  to  remove a fourth.  In the
case of  M. Leonardon, the  stone, which  completely filled up the
bladder,  left behind an  incrustation which had to be scraped down
and  removed with a scoop.   M. Voisin, (Gaz.  Med., 1836, p.  373,)
who had incised the tissues nearly transversely, was not enabled to
remove any more than the body of the stone, the head of which re-
mained strangulated  in  the prostatic portion of the urethra.  In an-
other case, M.  Voisin, (Gaz. Med., 1839, p. 90,) after  having cut
through all the tissues of the  hypogastric region, and also the walls
of the  bladder, by means  of  a simple bistoury,  found that the stone
was expelled in some measure of its own accord, so that  his patient
was promptly restored.   As  the largest sized  calculi may be ex-
tracted at  the  hypogastrium, and as in this region  a small wound
could scarcely be  attended with less danger than a  large one, we
cannot  comprehend  why  M.  Dudon  should  have  recommended
that  we  ought  to  make use  of puncture, by  means of an enor-
mous sized canula, in order  to  dissolve  the stone in its place, nor
how puncture with dilatation and lithotrity through  the  wound of
the hypogastrium, and  which is so much  eulogized by M. Franc,
(Nouv. Meth., &c, 1836,) could offer the slightest advantage over
pure and simple lithotomy.
  V. Dressing.—Supra-pubic cystotomy, different from other kinds
of lithotomy, has occupied  much of the attention of operators in re-
lation to the dressing which is best adapted to it.
  a. The suture of the  wound was  recommended  at the  time of
Rousset, and has frequently been made use of  since.  It was hoped
by this means to prevent the  urine from passing through  the  hypo-
gastrium, and of becoming infiltrated outside of the  bladder.  This
suture, which has been more  frequently advised than  used, is far
from having been  understood in the same manner by the  different
authors who have ventured to recommend  it.   Solingen, one of its
warmest partisans, does not express himself  with  sufficient clear-
ness to enable  us to understand positively whether he confined him-
self to sewing up  the skin, or  included at the same time the en-
tire thickness  of the lips  of the wound.  Others have expressed
themselves more  categorically on  this  subject.   Douglas, for exam-
ple, considers that the suture of  the integuments would be sufficient.
Rossi, on the contrary,  alleges that we should especially endeavor 
LITHOTOMY.
961
to suture the vesical wall itself, while Gehler maintains  that the
whole should be  embraced in  the  same ligature.   Monro,  (J. Bell,
Traite des Plaies, translation of Estor, p. 388,) who recommends that
we should operate upon  the  patient under water, in order  to avoid
the action of the  air on  the  bladder, also prescribes the suture with
the same intention.   The  cases  related  up to the .present time,
whether in favor or against the  suture, scarcely prove any  thing.
Heister, it is true, says  that Praebisch, who had used it on  a pa-
tient,  soon saw such alarming symptoms supervene,  that he was
obliged to cut the points and  to withdraw  the threads.  But how
had the suture  been applied ?  what tissues had been perforated by
it 1 and  to  what degree had  the coaptation been effected ?   We
are left wholly in darkness on  the  subject.   M. Pinel Grandchamp
(Arch. Gen.  de  Med., t. IX., p.  612,) had recourse, in 1825, to some
investigations on  this subject.  After having opened the bladder in
a certain number of .dogs, he closed it up with the suture, and the
operation in these animals,  it  is  said,   succeeded sufficiently well.
Since that  period M.  Cazenave  (Bull. Med.  de Bordeaux,  1833,
p. 82,) and M. Amussat have pronounced in its favor, and related-
several cases of successful results.   Nevertheless,  it is a  resource
against which both  numerous and. powerful  objections  maybe ad-
duced.  In the  first  place, it is not probable that any body here-
after will have recourse to the suture of the integuments exclusively,
nor to that of the aponeurosis or muscles.  It would have the effect
in fact, to close  up the  passage  to  the  urine, without preventing its
escape from  the bladder ;'the result would be to force  this  fluid  to
effuse itself into the  cellular  tissue  of  the pelvis.  As to the  suture
of the wound into the bladder, it is  far  from  being  always  an easy
matter.   Could  the  urinary bladder have remained distended up  to
the end of the  operation, if the division of its  anterior wall did not
extend below the upper  border of the symphysis, and were the hy-
pogastrium always found thin, we might, as I consider, hope to derive
an actual advantage  from it.  But should the  incision have been pro-
longed to ever  so litte extent towards  the prostate, how can we be
sure that we shall not leave any void between  its lips, at its lowest
portion?   Afterwards, is it  not to  be  apprehended  that the"points
of the suture themselves may, by becoming enlarged,  constitute so
many passages  for the  urine ?  Ought we  not also  to consider  as
something the pain which their presence will occasion,  and  the pro-
tracted length which they give to the operation 1  The suture then
could  only possess some  advantage  in those cases in which  it  would
be actually possible to  unite the entire  extent of the wound  of the
bladder in the most  perfectly accurate manner ; also,  it would be
necessary that the glover's suture, which is the only one which could
be proposed with any apparent degree of reason, could be applied with-
out producing too much laceration,  and too much traction upon the
surrounding cellular tissue.   I conclude in fine, that the suture, under
whatever form  it may be offered, ought to be rejected in hypogas-
tric lithotomy.
  b. The indication, however, which it was  proposed  to carry out
by means of the suture, is one  of the highest importance;  hence it
has never ceased  to be an object of enquiry.   After having devised
                              61 
962          NEW  ELEMENTS  OF OPERATIVE SURGERY.
a great number of modes,  it has been supposed  that a canula left
to remain in the wound would  be certain to conduct the urine ex-
ternally.   Solingen is  one of the first to whom this idea  suggested
itself.  It is not, however, very certain that the leather sound which
he mentions  was not  introduced through the urethra, rather than
through the hypogastrium ; but Heuermann, a German surgeon, leaves
no doubt upon the subject, for Sprengel says  in express language, that
he warmly  eulogized the utility of a canula inserted into the incision
after the operation.   An operation performed in the month of Decem-
ber,  1818, at  Dublin, by M. Kirby, and published in 1819, shows that
this  surgeon  had  some confidence in the practice of Heuermann.
We perceive in fact, that after having terminated the high operation,
he left a tube in the wound, in the same  manner  as M.  Cazenave
(Bull. Med. de Bordeaux, 1833,  p. 82,) states that he did also, on
the 17th of August, 1827.
  In France M. Amussat, who supposed  himself  to have been the
first  that made this  suggestion, came out  with  great zeal in favor
of it.  The hopes that some persons  had  indulged in, in respect to
this  process,  have  unfortunately  not been  realized.  M. Kirby  per-
ceived, at the expiration of four days, that the urine passed between
his canula and the lips of the wound.  Some operations performed
by M. Amussat himself, have shown that  the same thing also  had
happened  to  him.   The fact is related of a patient at the Hospital
St.  Louis,  and in whom  the conducting tube  did  not prevent the
formation of urinous abscesses, if in fact  it was  not the cause of
them.  It is a law  of the organism, that when a foreign body is  shut
up  and closely embraced  within  the lips of a   wound, it  soon
enlarges  its position and enables  the fluid to glide over its external
surface.  Consequently, a canula could not  prevent urinary infiltra-
tion ; and  as its presence could not be unattended with inconve-
nience, it in reality deserves the oblivion into which it has fallen.
  c  Surgeons have  been  so reluctant to dismiss this suggestion, that
they have  looked  for  some  other mode by which they might be
enabled to  draw off the urine externally, in  proportion as  it entered
by the ureters.  It is in this manner that M. Segalas has proposed
to insert a meche of cotton in  a gum-elastic catheter, and leave one
extremity of this meche in the  interior of the bladder and the other
hanging outside, in order to serve in the manner of a filter, forgetting
without doubt that if  the efficacy of this  means were  admitted, it
must necessarily  produce  precisely  the  same effect  when it  is
placed in the  wound  of the hypogastrium.  M.  Souberbielle has
recommended the use of an aspirating syphon, composed of a large
flexible catheter placed in the  urethra, and a long gum-elastic  tube
which plunges in  a  vessel placed below the  plane upon which the
patient reposes.  It was for the  purpose of carrying out the same
indication that M. Heurteloup contrived his uretro-cystic tube, which
combined in some respects the apparatus of M. Souberbielle and that
of M. Amussat, inasmuch  as it consists of a hollow tube which issues
through the wound,  and of another similar tube which occupies the
urethra, so that the urine would pass into  the lateral openings which
it meets with near  the neck  of the  bladder, and  must  necessarily
escape by  one extremity or the other.   But  experience has  not yet 
LITHOTOMY.
963
pronounced in  favor of any of these contrivances;  and when we
reflect upon the annoyance they occasion to the urethra, bladder and
wound; and when we  consider  that  in the  horizontal  position in
which the  patient is  placed after the operation, the line  of the arti-
ficial  opening is  sometimes less elevated than that of the urethra
opposite to  the suspensory ligament of the penis, it is exceedingly
difficult  to  understand what advantages their inventors  could  hope
to derive from them.
   d. A  circumstance which  does not  appear to  have  sufficiently
attracted attention, is the cause of that almost invincible tendency
which the urine has to pass above the pubes.   At  first sight it would
seem that in this movement it ascends against its  own law of gravi-
tation.  In  examining it attentively we soon  find that this is by no
means the case.   It rarely happens, in fact, in the hypogastric  ope-
ration that the incision into the bladder does not descend as far down
nearly as to the prostate, or at least to the middle of the height of the
symphysis  pubis.   This being admitted, it  is easy  to convince our-
selves that  the urethra, when  it comes out  from  under the  pubic
arcade,  is  elevated at  least  to as  great a height, even when the
patient is almost in a vertical position, and that in  the horizontal  posi-
tion the urine has certainly a longer route to make to arrive at this
point than to reach the lower angle ofthe wound.   It  would be time
lost therefore to attempt the use of such means.
   e. The majority of practitioners have confined themselves to the
use of meches, either of linen or cotton, and one extremity of which
is introduced into the bladder,  that it may perform the office of a
filter.  Tents of lint  and the dried roots of plants would be more
injurious than useful.  It is not even certain that the simple ravelled
meche of F. Come in reality possesses any advantages ; it should not
at least, if  we should have recourse to  it, be besmeared  with oil or
any kind of unctuous matter.  As the  blood  and purulent matters
with which it soon becomes impregnated almost immediately destroy
its permeability, there is scarcely, in fact, any benefit to be expected
from  it.   The  only  real want the  operator  feels is,  that of pre-
venting  the parts, by their too rapid  agglutination in the direction
of the wound, from  interposing an obstacle to the passage of the
fluids wThich come from the  direction of the  bladder.   Should we,
during the first twenty-four hours, leave nothing between the lips of
the wound, we might perhaps in this respect have some serious con-
sequences  to  apprehend ;  but at  a  subsequent  period, when the
reuniting process  has  developed itself, the permeability of the tissues
is so  much diminished  that we may leave to the care of the system
everything  that  relates to the cicatrization and  the  escape of the
urine.
  /. It is not necessary for the patient, after  the high operation, to
remain  so  long  a time  in  the same position  as  after  perineal
lithotomy.   He may turn upon one side or the other, or sit up, and
no one at the present day would recommend that  he should rest con-
stantly on his belly, as somebody advised in the last century.   I will
add that after the first symptoms have passed over, and  that at the
expiration of from five  to six  or eight days, should no accidents
or fever have supervened, the patient  may get  up and soon  after 
964           NEW  ELEMENTS OF OPERATIVE SURGERY.
walk without any danger, but on the contrary with advantage, inas-
much  as  the vertical  or seated position unquestionably  favors the
passage of the urine through its natural route.
  C. Accidents.—I. Hemorrhage, to prevent which so many pre-
cautions  were adopted in perineal lithotomy, and against which the
high operation  was apparently  calculated to protect us,  has never-
theless been noticed after this last  in a number of instances.  Pye
makes known a remarkable case, and another is found in the obser-
vations of Thornill, quoted  by Middleton, then again a third in the
work of  M. Belmas; while I  myself know that one of the patients
operated upon  by M. Souberbielle came near being a victim to it.
M.  Cazenave (Bull. Med. de Bordeaux, 1833, p. 82,) was  even com-
pelled  to perform hypogastric lithotomy, in order to withdraw from
the bladder clots  of  blood which had been collected there in conse-
quence of a simple puncture.  M. 'Tonnelle  informed me (March,
1839,)  that in one of his patients, who died in this manner, it was im-
possible to discover the lesion of any vessel, and that the blood evi-
dently issued by exhalation from the interior of the bladder.   Up to
the present time surgeons have not been enabled to specify the vessel
which gives rise to this sanguineous exudation.  Some have supposed
that it depended upon sub-cutaneous  veins or arteries that were more
largely developed than usual; while others  have imputed it to arte-
rial anomalies in the substance ofthe linea alba, or in the fascia pro-
pria.  Some also have conjectured sanguineous exhalations from the
internal surface of the bladder.   But in all  these opinions there is
scarcely  anything at bottom but bare supposition, having a greater
or less degree  of probability.   Anatomy, moreover, would perhaps
furnish an explanation  to this accident, if more attention  had been
manifested in practice to discover its seat.  It might, for example,
turn out  that the arteries, which naturally mount  up upon the sides
of the bladder and  cross each other  above its neck, might constitute
a noose of sufficient size  to  account for this hemorrhage;  it  might
also be possible that the dorsal arteries of the penis, coming directly
from the hypogastric and passing upon  the sides or above the pros-
tate, as in the  cases mentioned by Burns, M. Senn, Shaw, &c,
might have  been  divided if the incision had been prolonged very  far
down.   However this may be, this accident is rare,  and surgery
possesses a number of means of triumphing over it.   Should it hap-
pen during  the operation itself, it might be possible, as all the parts
that are divided are exposed to view, to discover the wounded artery,
to seize it with a sufficiently long pair of forceps, and  to twist or tie
it.   In the contrary case, that is to  say when the hemorrhage does
not take  place until after the dressing, we may begin by keeping  the
pieces wet with cold water during the space of several hours should
not the loss of blood threaten to exhaust the patient; otherwise  we
should have to lay bare the wound  and look for the vessel.  Upon
the supposition that we could not reach it or discover its seat, tam-
pons saturated with Eau de Rabel,  or  with  some hemostatic lotion
of any other description, should  be  inserted  into the bladder.   We
might  also introduce into this organ a large sized roll of lint, having
fastened to it a long double thread destined to receive between its two
heads  a  second tampon, upon which they are to be tied in front of 
LITHOTOMY.
965
the wound, in such manner as to make sufficient compression upon
the tissues from behind forwards.  We ought also to have previously
removed all the clots contained  in the bladder, and even washed out
this cavity with copious injections of water.
   II.   Middleton alleges that the prostate may be wounded when we
incise too deeply, which assertion is true; and  moreover, that this
wound may frequently give  rise to a dangerous ulcer, which, in my
opinion, appears  to be entirely  destitute of  foundation.  He  also
speaks of injuries done to the symphysis pubis, and of the accidents
which might result from them;  but  at the present day nobody pays
any attention to these lesions, which, in fact, scarcely deserve to be
mentioned.
   III. Abscesses.—One of  the accidents most  to be dreaded is the
formation of abscesses around the periphery of  the bladder.  Douglas,
Cheselden, and almost  all  those authors  who have since occupied
themselves with  the subject of hypogastric lithotomy,  have made
mention of them.   There  are two descriptions of these  and which
we must endeavor not to confound.   One order arises from the infil-
tration of  a greater or less quantity of urine  between the bladder
and the surrounding  tissues ;  while the others are the pure  and
simple result of inflammation of the cellular tissue of the pelvis.   It
is readily conceived  that  if the operation has been attended with
numerous lacerations and extensive separations, the urine will  readily
effuse itself into the cellular tissue instead of escaping to the exterior,
and everybody knows how dangerous are those inflammations  that
are caused by the urine.   Should there  have  been no  decollement
we rarely meet with these infiltrations.  In fact, after a  few hours,
the lips of the wound have lost a considerable deal of their porosity,
and the fluid passes over them without insinuating itself, as it might
have  been apprehended it would do, into their tissues by the force
of gravitation or  capillary attraction.  The passage  and infiltration
of the urine external to the wound,  does or does not take place ac-
cording as the bladder in retracting does or does not bring  the lips
of the division into contact.  This  condition  appears to me to em-
brace the whole secret of the dangers and successes of hypogastric
lithotom)'.   Unless the reaction  should be very intense, and that the
parts have  become very r*d, and  that there is an  acute  degree of
lever  present with a full and  strong pulse, sanguineous evacuations
either by leeches or the lancet, will be rarely found of any great ad-
vantage in such cases.  The urine that  has penetrated by transuda-
tion into the lamellar tissue constitutes  a putrescent fluid. If there
be anything which can arrest  its ravages, it would be scarcely any
other than deep incisions, multiplied to a great extent and as speedily
as possible, upon all the parts that have become infiltrated, and even
upon those in the neighborhood.   Unfortunately the seat of the  mis-
chief cannot always be reached by this remedy.  Nevertheless, we
should  make these incisions penetrate in every direction where we
can do so without  its  being attended with too much danger.   The
wounds are afterwards  to  be dressed, at least until the eliminatory
inflammation is developed,  by means of tincture of camphor, decoc-
tion of bark, or some solution of chlorine.   Ordinary abscesses with-
out urinous infiltration, are  of more rare occurrence, and are almost 
966
NEW ELEMEN1S OF OPERATIVE  SURGERY.
always  to  be imputed  to  the  manner  in which the operation has
been performed.  When the bladder has been opened by the sonde-a-
dard or by the bistoury, the forefinger introduced into the bottom of
the wound, so readily pushes it backwards in place of entering into its
cavity, that it frequently happens that it completely detaches it from
behind the pubes, and forms there a large  pouch which necessarily
becomes the source of a violent inflammation and abundant suppura-
tion.  There can be no doubt that this result has taken place in most
of those cases in which  the 'operators have alleged  that the bladder
was found to have been partitioned into two cavities, one anterior in
which nothing was discoverable, and the other posterior, which con-
tained the calculus.   In  these  cases antiphlogistics are not suitable
unless  the  patient is  sufficiently strong to  support them, or  unless
extravasation  of urine  be  not  complicated  with  an   accident,
which is in itself of  so serious a character.   Moreover we must give
as free  egress to the fluids as  possible, and not have any fear of
multiplying the  incisions or of increasing their extent in different
directions.
  IV. Lesion of the peritoneum.—The lesion unquestionably  which
has been most spoken of in hypogastric lithotomy, is that ofthe peri-
toneum.  Almost all authors have looked upon it as one of the most
dangerous character, and some even consider it to  be always fatal.
Without pretending to deny its gravity,  I nevertheless consider that
its dangers  have been singularly exaggerated.   It is  certainly not
calculated in itself to  create much apprehension ; buX much  rather
from its enabling the urine  to  extravasate into the cavity of the ab-
domen.   Now the operation is no sooner terminated than the blad-
der falls down,  retracts, and agglomerates  behind the symphysis.
The wound in its walls, from that time, is  no longer placed  in re-
lation with  that  of the  serous envelope.   Consequently  the urine
cannot in reality escape through that wound, and thus reach the ab-
dominal cavity.   What  proves this however better than arguments,
is the fact, that the peritoneum has been frequently wounded without
the slightest accident of a serious character resulting from it, and that
in patients  who have died with this wound, causes sufficient to  pro-
duce death have been found, which were entirely independent of it.
One of the patients operated  upon by Douglas, had the peritoneum
laid open, but recovered notwithstanding.   One of  those of Thornill
was equally fortunate.   It is even said that in another who also got
well, the intestines had escaped through the  wound in such manner
that fhey had to be reduced.   The same accident happened to F.
Come and M. Souberbielle, without those surgeons appearing to have
entertained much apprehension from it.  A woman who was  opera-
ted upon at Tours, in  1828, by M. Crozat, and who also had the peri-
toneum laid  open to  a  very considerable  extent, was nevertheless
perfectly restored.  M. Leonardon (Observ. a I'Acad., 22d March,
1837) has since published another example, which is one of the most
remarkable.   It  is said that Dupuytren was  not so fortunate ; but il
the account  given  of his  operation is  correct, a  meche  must have
been  introduced into the interior of the  serous cavity, in place of
having gone into the bladder itself; from whence it follows that this
fact does not in  reality demonstrate the dangers of a wound of the 
LITHOTOMY.
967
 peritoneum.   When it has taken place, we should, in my opinion,
 aggravate the danger  by sewing its lips together, as  recommended
 by MacGill, or by applying a suture to the entire  extent of the solu-
 tion  of continuity, or at least to its upper half, as is recommended by
 Douglas.  A meche of lint or linen, placed at the lowest part of the
 division, and penetrating into the  interior  of the  bladder, is all that
 would in reality be proper in a case of this kind.   To this we might
 add  a strip of adhesive plaster above, and the injunction to the patient
 not to make any  movement which  would  be calculated to push the
 viscera towards the peritoneal wound.
   D. Resume upon the relative  value  of the operations for storte in
 man.—A last question which remains to  be examined, is that of as-
 certaining which method in these cases should have  the  preference
 over the others,  as a general method.  To solve this problem it is
 first necessary to take into consideration those accidents which ter-
 minate  fatally to the patient after the operation of lithotomy, when
 the case in question is  that of extracting a vesical calculus in  man.
 Hemorrhage has, in many instances,  been the  cause of death; in
 others this result  has occurred in consequence of inflammations, ab-
 scesses, and gangrene in the cellular tissue of the lower pelvis, or from
 peritonitis.   There are some in  whom a fatal issue appears to have
 taken place only in consequence of affections of organs more or less re-
 mote, such as cerebral or intestinal diseases with ataxic and adynamic
 symptoms, serous or purulent effusions into the cavities of the pleura,
 and  especially from  numerous suppurative  collections in the paren-
 chymatous organs. Besides these lesions there are others which con-
 stitute only infirmities, as for example, incontinence of urine, a wound
 of the rectum and urinary fistulas of every description; but perito-
 nitis, inflammation of the cellular tissue of  the pelvis,  (Arch. Gen. de
 Med., X. II., p. 387, 2d  ser.,) phlebitis or  purulent  infection, purulent
 inflammation of the ureters and kidneys, together with cystitis, are
 nevertheless the usual  causes of death.  It is true that recto-vesical
 lithotomy exposes less than any other to the danger of pelvic suppu-
 rations and metastatic abscesses ; but in this we have more risk of
 inflammations of the  bladder and intestines.   It  much  more  fre-
 quently gives place to  urinary fistulas,  and without  allowing, as  is
 generally  believed, the  extraction  of large-sized  calculi,  with  less
 danger  than  the  others.  Hypogastric  lithotomy, while it is rarely
 accompanied with hemorrhage, is exempt from the danger of fistulas,
 and  almost always also from that of inflammation ofthe  bladder, in-
 continence of urine, intestinal inflammation, or multiplied collections of
 pus in the remote organs.   It admits of the extraction of stones of
 the largest size, and is not of difficult execution, but the wound of the
 peritoneum is in itself exceedingly dangerous, should there supervene
 from it  an inflammation of this membrane.  It  is proper to  add
 that  infiltrations   and   purulent  and  gangrenous destructions  of
 the pelvic cellular tissue,  are  nowhere to  be  more  apprehended,
 and  that nowhere are  we possessed  of fewer means of avoiding
 them.
  Perineal lithotomy, when  it goes beyond the limits  of the prostate
exposes, though in a less degree, to the risk of the same infiltrations,
to  the wounding ofthe vessels of the rectum in some  cases, to recto- 
968           NEW ELEMENTS OF OPERATIVE SURGERY.

vesical  fistulas, or to recto-urethral  or urethral only, to incontinence
of urine, and also to metastatic suppurations, more than the two pre-
ceding processes  ; which appears  to me to be owing to the fact,
that on one hand  it more frequently involves large veins  which be-
come inflamed, and on the other gives rise to small suppurating col-
lections, which develope themselves in  the neighborhood  of  the
wound, and the pus of which is  absorbed  by some means or other
into the general  circulation.  This  operation, when confined within
the periphery of  the gland, must, from its enabling us to avoid the
arteries as well as the  intestine, be but rarely followed by idiopathic
or symptomatic abscesses, and has scarcely any other inconvenience
than that of not making an  opening sufficiently  extensive for very
large sized calculi;  but in such cases the bilateral operation or re-
peated debridements after the manner of M. Vidal, present  an ade-
quate resource ;  while  the incontinence of urine or the urethal fis-
tulas, which might  be  apprehended under such  circumstances, are
of not sufficiently frequent occurrence, nor  so difficult of cure, as to
be calculated to give rise to any uneasiness; so that perineal cysto-
tomy is still the one which possesses in reality the  greatest  number
of advantages, and which, in  the  last  analysis,  deserves  to have
the preference as a general method.  According  to  this  opinion,
recto-vesical  lithotomy would be allowable  only  as  an exceptional
method; for example, when tumors, ulcerations, and alterations, in a
word, of the perineum to a greater or less depth, do  not admit of
our passing through this region ;  or again, when the calculus is
found lodged by one of its extremities in the prostate, or when this gland
is diseased and ulcerated, or the seat of an excavation, which would
cause an incision  upon  its sides to be attended  with too much  diffi-
culty or danger ;  and finally, when  the stone appears to have atten-
uated or ulcerated the  recto-vesical septum itself.   The high opera-
tion would be reserved  for very large calculi and  for children, and
where the bladder could be distended with facility, or where the em-
bonpoint of the patient did  not render it  too difficult of execution.
It is, however, to  be remarked that  if obesity is an obstacle in the
hypogastric operation,  it possesses on the other hand  the  advantage
of placing the peritoneum at a distance  from the  instrument by the
interposition of the adipose matter which ordinarily accumulates be-
tween this membrane  and the walls of the belly.   Finally, t-hose
cases in which there  is a horny degeneration, or thickened condi-
tion of the walls of the bladder, wrould also come under the  class  of
those which belong to  recto-vesical lithotomy, should it not be possi-
ble to have recourse in them to the perineal operation.

                    §  X.—Lithotomy in Women.

  Women, who are much less  exposed to calculous affections than
men, are also much more easily cured of them  by an operation.  In
them the urethra is  straight, short  and  large, so  that  small calculi
pass through it with the greatest facility, and rarely enlarge in  size
in the interior of the bladder.   Nevertheless, they are met with  in
this sex, and we have recourse to the same means to get rid of them
as in the other.   Lithotomy in women is also performed by the high 
LITHOTOMY.
969
and the low operation.   If the first of these methods should require
no remark, because it is subjected in every respect to the  same rules
as in man, it is not so with the second, where we  find the recto-ves-
ical replaced by the vagino-vesical operation, and the lateralized ope-
ration by the incision into the urethra.
  A. Examination of  the  methods.—Some surgeons  have alleged
that all the lithotomic processes applied to  man might be also em-
ployed in women  ; this assertion is certainly incorrect.  The  great
operation, for example, never could  be  put in  practice in women.
The same nearly may  be said of the  bilateral taille, at  least when
applied to the lower  side of the  urethra.  There remain  then  the
lateralized, the little, and the vaginal processes.   Calculi, moreover,
of every description, have been noticed  in  this  sex as in man.   A
woman who was  operated  upon  by M.  Seutin, (Encyclogr.,  1839,
p. 157,) and who died, exhibited debris of a foetus in  the ovary,
which extended into  the bladder, where was found a tooth.  In  the
girl mentioned by M. Gendron, (Bull, de la Fac.  de Med., 6th year,
p. 132,) the calculus had a needle case for  its nucleus; in the case
related by M.  Poupinel, (lb., 6th year, p. 65, and 148,)  an exostosis,
twenty lines long  at the upper strait led to  the supposition  of a cal-
culus.  The needle which served as a stem to the stone, in  the case
related by M. Macario, traversed the uretro-vaginal septum, in such
manner as to  render coition  excedingly painful  by the punctures
which it inflicted upon the husband.   The siliceous calculi noted by
M. Hill, (Gaz. Med.,  1834,  p.  135.) and M. Segalas, evidently came
from without.   M. Janson and M. Castara have  found  some that
were of very friable  texture.
   I. Ancient processes.—Lateralized method, or rather lateral litho-
tomy.  The Greeks,  Arabs, and surgeons of the  middle ages, per-
formed lateral, or  lateralized lithotomy in woman in the  same manner
as in man.  Before the knowledge of the sound, they confined them-
selves to  making the  calculus descend  into the neck of the bladder,
where they fixed it by means  of two fingers bent into a hook, and
introduced  into the  vagina, or if it was a  virgin, into the rectum.
They then cut from the skin'towards the bladder,  all thetissues over
the stone, in an oblique direction, from  above downwards, and from
within outwards.   F. Jacques modified  this process only  by making
use of a sound  to  stretch the  parts, which  enabled him to dispense
with looking for the stone with his fingers in the  vagina  or rectum.
The trials made by this monk in the presence of Marechal and Mery
having demonstrated, as  an accurate knowledge of  the  anatomical
arrangement of  the  parts would have anticipated, that  the vagina
was almost constantly wounded, and that the rectum itself might be
implicated, it was speedily abandoned ;  so that at the present day no
person either recommends or practices  it.
  II. Method of Celsus.—Celsus expresses  himself in  so obscure a
manner, or with so few details in regard to lithotomy in women, that
it is quite difficult to ascertain precisely what he  means  by these
Words : Mulieri vero inter urina iter et os pubis incidendum est, sic
ut utroque loco plaga transversa sit.  Some persons, and  M. Des-
ruelles amono- others, have  supposed that at the time of this author
they made a transverse or semilunar incision between the meatus 
 970          NEW ELEMENTS OF  OPERATIVE SURGERY.

 urinarius and the roots ofthe  clitoris, and that they cut down upon
 the stone through this, in the same way as we lay it bare in man, be-
 tween the  anus and the root of the scrotum.  But, as has been re-
 marked by M.  Coster, it is not impossible that Celsus had in view the
 incision into  the urethra itself, instead of that which I have just indi-
 cated.  The method which consists in penetrating by the vestibulum
 is moreover so defective in every point of view, that it was not worth
 the  trouble  of disputing  M. Lisfranc's title to it.  This method,
 which was defended by M. Meresse at  Montpelier, in \^2'A, and  de-
 scribed in great detail in the Archives for the year 1824, is performed
 in the following manner :  a sound  is first introduced into the bladder
 in such a manner that its groove or convexity may be turned upwards
 and forwards, in place of resting  downwards and backwards as in
 man.  The surgeon placed in front of the perineum,  makes a semi-
 lunar incision between the clitoris and  the external orifice of the
 urethra; divides  in succession and  layer by layer,  all the  tissues
 which separate the vestibulum from the  interior of the pelvis ;  ar-
 rives at the anterior surface of the bladder at the point where  the
 urethra unites with the neck of this organ ; encounters the sound and
 cuts down  upon its groove ; prolongs the  incision upwards, by turn-
 ing the cutting  edge of the bistoury in this direction, and then down-
 wards in such manner as to make  a  longitudinal division in the pos-
 terior portion of the urethra; or he incises the bladder transversely
 to the extent of an inch or 15 lines.  In  whatever manner we pro-
 ceed, the calculus will always be compelled  by this operation, to pass
 through the narrowest part of the pelvic cavity.  The bladder, when
 it is opened longitudinally, will scarcely admit of extracting  from it
 stones which are  somewhat  voluminous.  If we  should divide it
 transversely, the unavoidable separation of the lips of the wound in a
 region surrounded with so great a quantity of cellular tissue, would
 not probably fail to give  rise to  those infiltrations, and  abscesses  so
 dangerous, which have been described  in speaking of hypogastric
 lithotomy.
  III.  Vesico-vaginal lithotomy.—The  idea  of extracting   vesical
calculi through the vagina  goes back at least  as far  as  to  the
time of Rousset, since this author states that he removed 11 of them
through this passage, in a woman in whom  the bladder  protruded at
the vulva.   F. de Hilden   (Bonet, Corps  de Med., p. 139,) followed
the example of Rousset, in a case in which the vesico-vaginal  septum
had been partially perforated by the  stone, and again in  another case
in which the  urinary bladder had been  ruptured at  the time of ac-
couchment.  Ruysch also  performed this operation, and  extracted 42
 calculi from the same woman, but it was a case in which there was
 an eversion of the vagina.  Tolet  acted in  the  same manner under
 circumstances nearly similar.  In  1740  Gooch met with a female in
 whom the inflammation had ulcerated the vesico-vaginal septum, and
 wdiich he cut into  in order to extract  the calculus, weighing 3 or 4
 ounces.  M.  Faure exhibited in 1810, to the faculty of Paris,  a frag-
 ment of wood which he had taken from the bladder of a young girl,
 by means of an incision into the vagina.   M. Gemot performed vagi-
nal lithotomy for the first time in 1814, in a patient 21 years  of age,
 and  soon  after repeated it  in another female.   Since that period 
LITHOTOMY.
971
 he has had recourse to it a third time.  A short  time  subsequently,
 M. Flaubert  made use of the same process in order to extract a pin
 and needle, which had become the  nucleus of a calculus, in a child 11
 years of age.   In 1816 he operated upon a woman 33  years of age,
 who had a stone of the size of a nut;  and afterwards upon a woman
 of 40 years of age, in whom the stone was nearly the  size of a bil-
 liard-ball.  On the 10th of December, 1818. he operated upon a fourth
 woman, who was 21  years  of age, and  extracted a calculus of the
 size of a  large nut.   M.  Philippe, of Reims, extracted through this
 passage, in a pregnant woman, a calculus weighing 9 ounces, which
 he has transmitted to me.   A fistula remained behind.  A large stone,
 having a fragment of wood 3 inches and 3 lines long, for  a nucleus,
 was extracted in  the  same manner, by M. Castara, (communicated
 by the author, November 26, 1838,) from  the  bladder  of a maiden,
 who was 45 years of  age, and who recovered.  The female that M.
 Macario (Bull, de Fer., X. II., p. 262,) operated upon, and who had
 a calculus which had bec6me developed upon a needle, which was in
 the substance-of the vesico-vaginal septum, also recovered.  M. Rigal
 (Coze, Journ.  Univers. des Sc. Med., September, 1819,)  also operated
 through the vagina, in 1814, on a woman 40  years of age, and in
 whom the calculus weighed two and a half ounces.   The same practi-
 tioner had already performed  this operation several years before, in a
 woman aged 38, and who had had  a calculus of considerable size for
 the space of 8 years.  Another instance has been  published by M.
 Lavielle, (Bull, de Fer., X. VIIL, ,p. 72,) and  M. Rigal, the son, has
 furnished another instance.  So that science now  possesses about 25
 instances of the vagino-vesical  operation, without speajung of those
 which Gooch ascribes to various practitioners in his  country, but of
 which he has furnished no detail.
   B.  Operative process.—Many surgeons who  have performed this
 operation, have omitted to mention the process which they adopted.
 F. de Hilden, who was the first to  recommend it formally, advises
 that a scoop of small calibre should be introduced into  the bladder,
 through the urethra, and that it should embrace the calculus with its
 concavity, and then depress it by bringing it down near the neck of
 the bladder ;  finally, that the surgeon should incise upon the projec-
 tion which is thus made in the vagina, and then complete the extrac-
 tion of the stone through this passage.  The process of Mery, which
 consists in substituting the ordinary sound  for the scoop (curette) of
 Fabricius, in such  manner as to divide the vesico-vaginal septum upon
 the groove  of that instrument, was calculated to cause the method of
 the Swiss  practitioner to be  forever rejected.   This,  in fact, is the
 process which with certain  modifications modern  surgeons have
 deemed it advisable to follow, some by associating with it a gorget to
 depress the posterior wall of the vagina with its outer extremity, while
 the other end butts against the sound, in front of the neck of the ute-
 rus ; and others, like M. Flaubert, for example, in confining themselves
 to the introduction of  the bistoury flatwise on the  right forefinger, in
 order, afterwards  to turn its cutting edge upwards, to cut the septum
 from before backwards, or from behind forwards, to within a greater
or less distance from the meatus urinarius.
  I. Position of the patient.—In placing the woman as for ordinary 
972           NEW ELEMENTS OF  OPERATIVE SURGERY.

lithotomy, we may, without any  doubt, attain our object.  Never-
theless it appears to me evident that if she were upon her belly, with
her thighs and  legs flexed, it would  be still more easy to make the
incisions that are necessary.   The instruments required consist only
of a sound, the gorget  of Marchettis, a straight bistoury  and the
tenacula.   The sound is  first adjusted, with  the plate  raised  up
towards the  pubes in order to depress the bas fond of the bladder
upon the median  line.  An assistant  is charged  with keepino- it in
this position.   The gorget having been introduced to the bottom of
the vagina, is  then  given in charge  of  a second  assistant, who
depresses its  handle, while taking care  that  its other extremity
serves as a point d'appui  to the  sound, and that its groove looks
upwards and  forwards if  the woman is placed on  her back;  and
downwards and backwards on the contrary, if she is on her belly.
The surgeon separates the labia  majora with the thumb and first
fingers of his left hand ; seizes the  bistoury in the manner of a writing
pen and directs its point behind the urethra, that is to say, to an inch
at least in depth  into the vagina; inserts it into  the groove  of the
sound, then makes  it glide along  this instrument to  the distance of
eight  or ten  lines, or more if  it is  necessary,  and terminates  by
depressing it a little in order to make it  fall into the groove  of the
gorget.   We might also hold the bistoury in the second position, that
is  to say. with the handle in the hollow of  the hand  and the cutting
edge turned towards the  bladder, in such manner as  to introduce its
point  to the depth  that may be required, and to divide the septum
from behind  forwards, and always upon the  groove of the sound.
These two methods differ so little as to their ultimate result, and even
in respect to the facility of the manipulation, that we must leave the
preference to  be given to one  over the other, to the choice  of the
operator.   There  is no doubt also that  the surgeon might himself
hold the sound with his left hand, while with his  right he incises in
the manner that  M.  Flaubert  operated; or as M.  Gemot recom-
mends,  he may on the contrary seize  the gorget  in order not  to he
interrupted by the assistant at the  time of making the division of the
septum.  We might also, if necessary, dispense with the  gorget  by
adopting the course of the  surgeon of Rouen ; that is, introduce the
bistoury protected by the palmar  surface of the forefinger, into the
interior of the vagina, in order to make the opening into the bladder
without having need of any other assistance than such as would keep
the patient steady; but it  cannot  be denied that  the operator, with
his two hands free, is more at his ease to make the principal  incision,
and that  the  gorget  possesses  the  advantage of  stretching  and
exposing the  parts which  are to be divided;  only that it would be
advisable that this instrument  should have a handle which is bent
into an  angle, and that its  groove should terminate  without any cul
de sac.
  II. The incision, if commenced at some lines behind the meatus
urinarius, in such  manner  as to include a  greater or less extent oi
the lower wall ofthe urethra, as in the process followed by  M. Flau-
bert, would, in the first place, have the inconvenience of not favoring
in any respect the extraction ofthe calculus, and in the second place,
of rendering the  cicatrization of the wound more tedious  and diffi- 
LITHOTOMY.
973
 cult.  It is better therefore to imitate MM. Gemot, Rigal, &c, and to
 commence only at the point of the trigonus vesicalis, if we incise from
 before backwards, or to terminate there in case we should prefer to
 make the incision from behind forwards.   As the vagina has a length
 of from three to four inches, there will  still remain, when we adopt
 this process, an extent of over an inch, which may be divided without
 danger.  Moreover as the tissues possess so great a degree of distensi-
 bility, it is  unnecessary  to give a greater extent to the opening than
 appears to  be required by the supposed volume of the calculus.   M.
 Faure, the  oculist, (Observ. sur I'Iris, &c, p. 60, 1820,) who recom-
 mends that we should traverse the vesico-vaginal septum by a very
 oblique incision from before backwards, states that he cured in this
 manner, in  1808, a young girl without any fistula ensuing.
   III. Extraction of the Stone.—The incision  having been  made,
 the sound is to be withdrawn.  If the calculus does not present itself
 of its own  accord  in the wound ; or if it does not fall spontaneously
 into the vagina as has sometimes happened, the operator  proceeds
 immediately to search for its  situation and relative position by means
 ofthe left forefinger ; he then extracts the calculus by means of suit-
 able  tenacula, regulating his course by the  rules above laid down.
 When the stone is of large size or when we operate on a young girl,
 this extraction may, in consequence of the narrowness of the vagina,
 be attended with some difficulty.  M. Flaubert, in a case of this kind,
 was obliged to break up the foreign body and remove it in fragments.
 Nevertheless, as the canal which is to be passed through is exceed-
 ingly dilatable, it is scarcely to be conceived that it would present an
 insurmountable obstacle to the termination of the cystotomy.
  IV. The stone  being  once removed, the woman is to  be replaced
 in bed and submitted to the same attentions that are required by the
 usual sequelae  of  lithotomy.   These  sequelae  in the vagino-vesi-
 cal method are generally  of a very simple character; up to the
 present time there  is no case related in which they have resulted in
 death. In  most cases  scarcely any fever supervenes.  No  large-
 sized  artery can be wounded.  The  peritoneum is too far off to run
 the slightest risk, and the cellular tissue of the septum is too dense to
 admit of the possibility of a urinous infiltration.   But the wound does
 not always  cicatrize agreeably to the expectations of the patient and
 operator.   Its position alone, must have already led to the presumption
 that in many cases it would be transformed  into a fistula, and expe-
 rience has unfortunately confirmed this anticipation ; without count-
 ing that it might well have occurred in  some of the patients who
 were first operated upon, though no mention may have been  made
 of it by the surgeons:   It is at least certain that out of three cases of
 M. Gemot, he has  found one  followed by a fistula; that three of the
 patients treated by M. Flaubert were affected in this manner ; and that
 those related by M. Rigal the son (Rev. Med., 1831,1.1., p. 489,) and
 M. Philippe, were  not more  fortunate ; from whence it follows that
this accident is met with in at least one case out of four.  M. Coste
supposes that it might be prevented  by reuniting the  wound by su-
ture immediately after  the extraction  of the calculus ; but vaginal
cystotomy  would  then  become an  exceedingly tedious operation.
There is also reason to doubt, after the trials of  this kind in cases of 
974           NEW  ELEMENTS OF OPERATIVE STRGLRV.

ordinary vesico-vaginal  fistulas, notwithstanding the  fortunate  re-
sult of M. Coley, (L'Exper., X. III., 1839,) if we should by this means
be enabled to obtain the success which M. Coste appears to anticipate.
  C.  Urethral Methods.—For a long time perineal  lithotomv in
women has been almost exclusively performed by making an incision
into  the urethra; this canal, however, is so dilatable that a lon^
while ago  the idea was suggested that  we should extract  the cal-
culi  without  making  any kind  of incision.  Bartholin  speaks of a
woman who expelled  one which had a diameter of over two inches;
Borelli cites another in whom was as large as the finger; and Middle-
ton relates that a woman, during a paroxysm of  coughing expelled
one which  weighed  four ounces.  Heister has collected examples of
the same kind, in which it may be seen that calculi as large as a nut
or even a  pullet's egg have  been ejected through this passage ; F.
Collot mentions one of the size of a goose egg, and which had caused
ischuria for the space of eight days before it  was expelled ; Moly-
neux (Transact. Phil.-Chir., vol. IV., p. 227) states  that he has seen
another which weighed two and a half ounces ; while the one men-
tioned by M. Yellowly weighed more than three ounces.   We  find
in Planque, (Bibl. de Med., X.  IX., p. 467, in 4to,) instances of calculi
of still larger size that were expelled in the same manner.  Kerkrin-
gius, Morand and Grunewald, and scientific collections both ancient
and modern, relate cases which are no less extraordinary.   The one
which M. Segalas has exhibited, (Rev. Med., 1836, t. IL, p. 279,)  had
no less than an inch in its smallest diameter, and M. Simon, (Ibid.,
1826, 1.1., p. 133—Journ. de Graefe und Walther, X. VI.,p. 163.) has
mentioned  one which was two and a quarter inches in length  and
one  inch in breadth.   A woman that fell under the notice of M.
Harris, (Gaz. Med.,  1838. p. 744,) expelled a calculus which was two
and  a half inches long, by one in breadth, and weighed 651 grains.
Though  some of these  calculi may have been  expelled from the
uterus and vagina instead of having been formed in the bladder,  it is
nevertheless indisputable that many of them  have in  reality come
through the urethra, and that in certain cases this enormous dilata-
tion has not been followed by incontinence of urine.
  I.  The method by  dilatation, which grew out of these facts, is per-
formed in two principal modes: in one we proceed rapidly by means
of metallic instruments ;  in the other, on the contrary, we act with
extreme caution, and-by means of permeable substances temporarily
retained in the passage.   Tolet is the author of the first method and
Douglas  of the second.
  a.  Sudden dilatation.—The process of Tolet consists in introdu-
cing into the bladder the  dilating instruments of the  great  operation,
and in moderately separating their branches until we are enabled to
pass  the fingers and tenacula  between them, in order to reach the cal-
culus.   Since that period the ancient dilating instruments have been
replaced by the following process.  A grooved  sound serves as a
conductor  to a gorget which is narrow in its anterior  portion, and
which widens rapidly  towards the handle.  By means of this gorget
the fore or little finger of one of the  hands afterwards dilates the
urethra from before backwards, in order to make a passage for the
tenacula ; but in whatever way we effect this dilatation, it is a painful 
LITHOTOMY.
975
 operation, and  so much so that many women are utterly unable to
 support it;  it is moreover frequently followed by incontinence of
 urine, laceration of the urethra, &c.
   b. Gentle  dilatation.—Douglas supposed that he could remedy the
 inconveniences of  sudden dilatation, as proposed by Tolet, in opera-
 ting by means of a  tent which was made of sponge or of dried gentian
 root.  This  is the way in  which those practitioners still proceed, who
 suppose  that they can  dispense with an incision into  the  urethra.
 The little cylinder ofthe coecal appendix introduced empty into the
 bladder, and then filled with water,  and brought out from behind for-
 wards, as proposed by Bromfield, the dilator of the same description
 contrived by Arnault, and the little speculum of Weiss, (Bull, de Fer.
 X. L, p. 82,)  are no  better, while the sponge in  fact has this advan-
 tage, that it  enables us to introduce through its centre a catheter
 which  allows the urine to escape, should we propose to leave the
 dilator in its place for a long time.   We  should be wrong, however,
 after all in supposing that  this kind of dilatation is much less painful
 than the other, and that it protects us better from the dangers of in-
 continence of urine and the different accidents which that is considered
 chargeable with.   It is certain that a pure and simple incision, as it is
 performed at the present day, does  not involve  any greater danger,
 that it causes less suffering, and that it enables us to afford more prompt
 relief to the patient; so that dilatation, whether gentle or sudden, is not
 in reality adapted but to those calculi whose greatest diameter does
 not exceed five  or six lines.
   II. Uretrotomy.—The uretral incision may, if necessary, be  per-
 formed on any part of the two upper thirds of the  circumference of
 the canal.
   a. Fleurant has  proposed to divide the urethra on both sides at the
 same time, by means of a double  lithotome, introduced shut up, and
 drawn out open, and to commence  the  incision at the neck of the
 bladder and  terminate it at the meatus urinarius.  Louis, who adopts
 the same principle, recommends that we  should incise  from before
 backwards.   For that purpose he had contrived a flattened sheath
 which was open on its sides, and  in  which he plunged from without
 inwards a blade with a double cutting edge.  Le Blanc, to whom he
 communicated his  invention, remarked to him  that an  instrument
 which had a cutting edge on one side only, and  a sheath which was
 open in that  direction only, would answer the purpose.   But the pro-
 cesses which have  been based upon such instruments have at the pre-
 sent day completely fallen into disuse, and uretral taille no longer re-
 quires for its execution any other than a straight bistoury and grooved
 sound, or the lithotome of F. Come ;  unless we should desire to revive
 the process of Fleurant, in which case the double lithotome of Du-
 puytren would obtain a new application.
  b. The most ancient process and the one which has been the longest
 followed, is  that which consists  in  introducing into the bladder a
grooved sound,  to  serve as  a guide  to a  long straight  bistoury, by
means of which we divide obliquely from  above downwards, and
from the right to the left, through the whole extent of  the urethra.
But this method, which M. Klein, (Rust's Handb. der Chir., vol. IL,
p. 177,) calls cystenchenotomy, one which F.  Come and Dupuytren 
976
NEW ELEMENTS OF OPERATIVE  SURGERY.
have rendered still more simple by making use of the concealed litho-
tome in place of the bistoury and sound, and which Kern (Ibid., vol.
IL, p. 183.) performed with a male catheter, the groove  upon which
he turned to the left and downwards, was frequently  followed by a
wound of the vagina, and moreover, if the incision  was carried a
little too far, exposed  to the risk of dividing the superficial vessels of
the perineum, and even the pudic artery itself.  MM.  Scheuring and
Schroeger, (Ibid., vol. IL, p. 181,) who, in operating also with the
grooved sound  and  bistoury, made their incision transversely, have
in this matter added nothing useful to this  proeess.
   c. Process of Collot.—This operative process, therefore, has been
generally abandoned,  since it has become the practice to incise the
urethra  directly upwards.   The origin of  this  last  process, which  is
ascribed to A. Dubois, goes back as far at least  as to the  sixteenth
century.  It is  to Collot to whom Pare, after having given the figure
of a grooved sound, ascribes the honor of this process : " Other prac-
titioners," says  he, " operate in another manner, as  I have frequently
seen done by Master Laurent Collot; it is this, that they in nowise
place their fingers within the seat, nor within  the neck of the uterus,
but content themselves with inserting the conductors into the urinary
passage, and  then afterwards make a small incision altogether above,
and in a straight line from the orifice of the neck of the bladder, and
not upon one side, as is done in males."   At the present day this ope-
ration,, after  the  modification under which it has  been  revived  by
Dubois, is performed in the same way as the preceding, by means of
the sound and bistoury, or with the concealed lithotome. In the
first case, we introduce a large sound terminated in a cul de sac, and
with its groove turned upwards.   The surgeon holds the instrument
at its plate with his left  hand, and  by means  of this  depresses the
front part of  the vagina with a certain degree of  force.  With the
right hand he conducts upon it a  narrow and very sharp bistoury,
by means of which  he incises the upper wall of the urethra through-
out its whole extent,  together with the surrounding tissues, as high
up  as to the infra-pubic ligament.   By  this  means  we  obtain an
opening  of from 6 to  8 lines, which is sometimes  increased from 8
to 10 at the moment of making tractions upon the  stone. Neverthe-
less it would be dangerous to attempt to extract  through a passage
of this kind a calculus of over an inch or 15  lines in diameter.  1
have seen M. Bougon remove one  of this size in  a young woman
who recovered perfectly, and M. Thomas of Tours was no less for-
tunate in a similar  case.  The one mentioned by M. Castara, (let-
ter of the 19th March, 1839,) was as  large  as  an egg, but it was
crushed  by the simple pressure  made  upon the tenacula.  It is im-
portant  when we withdraw the  tenacula  to rest them with a certain
degree of force against the lower plane of the urethra, and raise  up
their handles in such manner that they may act in the direction  of the
axis of the lower strait.  Otherwise the calculus and the instrument
would butt against the symphysis, and  the  surgeon  would in this
manner surround himself with serious difficulties, and at the same time
would expose the woman to dangerous contusions.   A good operator
in one of the hospitals of Paris in 1824, was for a long  time embar-
rassed by this obstacle, though the calculus, which was extracted with 
LITHOTOMY.                        977
extreme facility by  changing the direction of the tenacula, was no
larger than a partridge egg !   In certain cases also the calculus may
be extracted with so much facility that a simple dressing forceps will
answer  the purpose.   M. Gaspard, (Bull. Med. de Bordeaux, 1833,
p.  171,)  while in a remote part of the country,  and without any
assistant or special instruments at command, succeeded by this means
after having incised  the urethra with a bistoury guided  upon  a
grooved sound.
  B. Appreciation.—It is perceived from the above facts that no kind
of perineal lithotomy will allow  of the extraction of large stones in
women.  The lateral  or even  the  lateralized incision itself, would
not, under such circumstances, be of  any great advantage.  As the
superior incision is located  at the top of the arcade, it  can necessa-
rily furnish us with but a very limited  opening.   The bilateral in-
cision would present more  advantages ; but experience has not  yet
shown that  it could be  performed  with any positive prospect of
success, and reasoning induces us to  apprehend that the urethra di-
vided in this manner into two halves, might allow of dangerous urin-
ous infiltrations, or give  rise  to  an incurable  incontinence of urine.
Nevertheless, I am of opinion with Dupuytren, that it would be  ad-
visable to re-examine this question and to decide upon it by the evi-
dence of facts.   If now we should take into consideration that in the
feminine sex,  lithotomy  is in  the  majority  of cases requisite for
calculi of a large size, we shall find  ourselves immediately reduced
to the necessity of making  choice between the vaginal and the hy-
pogastric operation.   The fistulas which too  frequently follow after
the first, constitute an infirmity which is  sp disgusting, and so  often
incurable, that we would rarely decide upon  performing  it, without
being very certain  that it was not possible to  succeed  in  any other
manner.   Now the second, all other things being  considered, being
more easy, in  consequence of  the less  considerable  height of the
pubes, and the more marked projection of the bladder above the pel-
vic cavity, and having at every epoch been considered less danger-
ous than in man, ought in my opinion to  be  preferred in all  those
cases where  the  urinary organ retains a  certain  degree  of dilata-
bility ; so  much the more so, inasmuch as those calculi which it
would be found impossible to extract by the incisions into the urethra,
would require in the vesico-vaginal septum too great  an opening to
exempt  us from the danger of producing a fistula in that region.  In
conclusion, dilatation in my view appears to be adapted to small cal-
culi ; the upper incision to those which  do not exceed the size  of  a
small egg;  while the oblique  incision  should be made  trial of in those
cases only where the stone is a little larger, or where the vagina is
not sufficiently dilated to make it almost impossible to  avoid  its le-
sion.  While vaginal lithotomy would be adapted  only to those cal-
culi which  were as large as a  pullet's,  or at most,  a turkey's egg,
upon the supposition that we were not disposed upon  any account to
resort to the hypogastric  operation, which  nevertheless  is the only
one that in reality could be adopted where the stone is still more vo-
luminous.
                               62 
 978          NEW ELEMENTS  OF OPERATIVE SURGERY.

                    Article IV.—Lithotrity.

   Lithotomy, notwithstanding the improvements which it has under-
 gone, is still of so dangerous a character that efforts are constantly
 being  made,  to  get  rid  of the necessity of it,  and to substitute
 for it  a less painful -operation.  Many  persons conceive that this
 result, which is so desirable, has been achieved by  modern sur-
 gery ;  and that by means of lithotrity, we shall  henceforward have
 it in our power to dispense with the operation of lithotomy, at least
 in an  immense majority  of cases.  We shall see  farther on what
 foundation there  may be for anticipations of this kind.   Lithotrity,
 or the crushing of the  stone, consists  in  the breaking up of the cal-
 culi into fragments, (le morcellement)  and their  extraction  after-
 wards through the natural passages by means of special instruments.
 It  comprehends in its largest acceptation the pure and simple extrac-
 tion, crushing, pulverization, breaking up, perforation, and tritura-
 tion of calculi in the interior of the urinary bladder itself, or  of the
 urethra.   The designations  of lithopriny, lithodialysis, lithotripsy,
 and lithocenosis, which it has been proposed  to substitute  for the
 term lithotrity, being no more  free from objections than this last, do
not deserve the preference which has  been contended for by  those
who have proposed them.   The idea of extracting calculi entire, or
after having broken them  up, and without incising into the organs, is
far from being new.   It has  attracted attention at every epoch, at
least for those calculi which are lodged in the urethra.  It also some-
times  happens that the stone crumbles  to pieces  of itself in the inte-
rior of the bladder.  A patient mentioned by M. J. Harding, (Gaz.
Med.,  1838, p. 777,) and who died at  the age of 81 years, without
having undergone an operation, had 50 calculous  fragments resulting
from the spontaneous disintegration of a stone in  the bladder.   A fact
almost in every respect similar was  seen by M. Segalas, and pub-
lished  by  him.  I saw a  case  some^vhat analogous  in 1836, at the
hospital of La Charite.  Albucasis had already made mention of an
instrument which would enable us to seize calculi at the remote por-
tion of the urethra; the sheath forceps, with three  or four branch-
es, as  described  and figured in the Bibliotheque of Manget,  under
the name of Asta,  appeared  to  F. de Hilden, to  be calculated to
effect  the same result.  A  tube  with three elastic branches was made
use of for the same purpose by Sanctorius.  Franco had  contrived
for this object a vesical  quadruple, and  Pare  a kind of augur or
turrell, which  he conducted  upon the  calculus  through a  can-
ula.   F. de Hilden used a forceps with three branches, which was so
constructed as to crush the stone  after having embraced it.   How-
ever, though it may have appeared to almost all authors to be prac-
ticable to  seize small calculi, and  to perforate and break them up, in
the urethra, it is by no means as  clearly demonstrated  that their in-
struments were ever introduced farther  than this point, to carry out
the same  indication.   Nevertheless, an  Arabic author, who is evi-
dently no other than Albucasis, says, in a work in which he is spoken
of under the name of Alsaharavius, or Acaravius, (Liber Theor. nee
non Pract., 1519,) that we must " cautiously introduce into the blad-
der a fine (subtil) instrument, called Maschabarebilia, in order to seize 
LITHOTRITY.
979
the stone and to crush it if it is soft, and then to extract it."  Alex-
ander Benoit also remarks, that we may crush the calculus by means
of metallic  instruments, and  without making  any wound in the  or-
gans ; it appears finally that Sanctorius, (Haller, Bibl. Chir., X. I., p.
213,) Franco, ahd F. de Hilden, also went so far as to look for small
calculi in the urinary bladder itself; but  the few  facts furnished by
these authors are too vague to have any great weight in this ques-
tion.  I might say the same of Aretmo, (Strangalament. Uter. Post.,
&c.,) who, in his posthumous surgery, speaks of a forceps with three
branches, designed for extracting gravel from the  urethra  and blad-
der.  In the last century, Hoin  related the history of a monk of Ci-
teaux, who, by means of a flexible  sound, and  a  steel stem termina-
ting in a bevelled edge, had succeeded in breaking up a stone in him-
self, by striking upon it small strokes with a mallet, in the same man-
ner as upon the  chisel of  a statuary.  The journals of Calcutta, and
afterwards Marcet, (on Calculous Disorders, &c, p.,20,) have made
known an experiment which is more conclusive,  viz., that of Major
Martin, who succeeded upon himself in reducing a  stone into powder,
by means of a file which  he introduced into the  bladder through a
curved sound;  which did not prevent him, it  is said, from dying of
stone in  1800.   As with M. Civiale, so with me, it has been impossi-
ble  to find the work  of D. Marco, published at Venice in 1799, and
entitled A New  Manner of Dividing  the Stone in the Bladder, &c.
Though  the forceps of Hales,  called Hunter's,  enabled Desault to
bring to the outside very small vesical  calculi,  and  though M. A.
Cooper,  who has modified it,  has extracted with it in this manner in
a chimney sweeper near 80 calculi from the bladder; all this  never-
theless did not  by  any means constitute  a method; nor  did the
breaking up of the calculi, by making percussion  upon them with a
sound, as recommended by Thomassin, or with a catheter, according
to the manner of Rodriguez, furnish  anything very conclusive, not-
withstanding the much better systematized experiments made by M.
Gruthuisen  and  M. Eldgerton,  which last also with  the intention of
breaking up the  stone in the interior of the bladder, likewise made use
of a curved catheter, (sonde,) in whichhe introduced  a grater (rape)
in order  to break down the calculus by a  movement backwards  and
forwards, (va et vient.)   Nevertheless, the project of M. Gruthuisen
though not used in practice, and perhaps not practicable, went farther
than any other.   This surgeon has delineated numerous instruments,
and made  repeated  experiments, and demonstrated that we may in-
troduce into the urethra straight canulas of from four to five and six
lines in diameter.  Though his principal object was to dissolve the
vesical concretions  by means of  the  galvanic pile, he nevertheless
contrived an apparatus to break them up; which apparatus is com-
posed of a straight canula, a noose of brass wire  which opens at its
extremity in the  bladder, and of a perforator which may protrude from
it and re-enter at pleasure.  The trials of M. Gruthuisen, however, had
like the others passed into oblivion, when several of our countrymen,
feeling the same want of an operation of this kind, exerted themselves
to give a permanent foundation to lithotrity.   M. Civiale, who, in the
year 1818,  endeavored to discover a means of dissolving  stones in
he bladder,  and had already conceived  the  idea of certain  instru- 
980           NEW  ELEMENTS  OF OPERATIVE SURGERY.

ments by which they could be grasped and broken up, maintains that
those which he now employs were invented  by him.  M. Leroy, on
the contrary, alleges that M. Civiale had not at that time devised any
but unsuitable instruments,  and that the forceps with three elastic
branches, and which is nothing  more than a modification of the for-
ceps of Sanctorius or the ball  extractor of Alphonse Feri, were un-
known to him.   I remember, in  fact, that M. Leroy showed me this
forceps, the same as that which he still uses, before presenting it to the
Academy, in April, 1823 ; and  that that which is found in  the first
work of M. Civiale, published in the course ofthe same year, is very
different from it, and is much more analogous to the vesical quadru-
ple of  Franco.  It  is however a difficult matter to come to a deci-
sion on  this point;  Percy, in his report to the Academy of Sciences in
1824, declared himself wholly in favor of M. Civiale ; while in 1825,
1828 and 1831, the same learned  body recompensed M. Leroy, for
having invented  the principal instruments, and among others the for-
ceps with three branches.  A review, however, of the  different pro-
cesses now in use, and of the  various instruments which have been
employed up to the present time, will  oblige us to return  to these
questions, and will  place us in  a condition to form a  more correct
judgment in  respect to them.

              § I.—Examination of the Methods.

   Lithotrity  comprises two methods, which  are sufficiently distinct
in respect to  the instrumental apparatus used ; in one straight instru-
ments are  employed;  while in the other, on the  contrary, the in-
struments are curved.
   A. Rectilinear method.—One of the  difficulties which for a long
time embarrassed practitioners, was that of penetrating into the blad-
der with straight instruments, so much so that lithotrity actually dates
its existence  from  the time at which practitioners ascertained  the
practicability of rectilinear  catheterism.  As the  straight  catheter
(sonde)  has  thus become a principal instrument, we cannot be sur-
prised  at the importance which has been attached by  some persons
to its invention.  But upon this point, as in almost all those questions
which relate  to the great operations in surgery, we have only gradu-
ally arrived at the  realization of the fact, while the actual discovery
is found to be separated by a very considerable distance from the de-
monstration of its utility.  Though it may not be proved  that Albu-
casis or Sanctorius, or  any other ancient author had  conceived the
idea of straight instruments  for penetrating into the bladder; though
it might be allowable to call in question  the fact, that the straight in-
struments found  in the  diggings of Herculaneum, by E. Clark, or in
the Officinium of a surgeon of Portici, were ever  made  use  of for
catheterism ; or though it should be incorrect to say the Rameau had
proposed sounds that should be altogether straight, it is at least indis-
putable that Lieutaud did formally make this suggestion,  and that
his proposition was far from having been forgotten.   We find it in
fact  reproduced  in the Elements of Surgery published by Portal, in
1768, and afterwards in  the Dictionary of Surgery edited by Louis.
In 1795, Santarelli, a surgeon of Rome,  returning to this question, en- 
LITHOTRITY.
981
deavored to prove that the urethra has no curvature  in its  prostatic
portion, and  that we may, by depressing the penis, easily overcome
that which is noticed under the symphysis.   Lassus  held the same
language in his course, at the  school of medicine, and M. Montagut
positively maintained, in 1810, that rectilinear  catheterism, in a con-
siderable number of cases, is an operation as  easy as it is  advanta-
geous.   Another French physician, M. Fournier of  Lempdes, who
was investigating the subject of lithontriptic processes, in the year 1812,
made use of the straight sound.  Authentic certificates collected by
him, leave scarcely any doubt upon this  subject.  The work which
was published in 1813 by M. Gruthuisen, finally appeared and re-
vealed the most important  proof;  so  that  though we attach no im-
portance to  the assertion of several  military surgeons, and  MM.
Larrey and Ribes among others, who state that they  have frequently
used the straight catheter in  the army campaigns, it would still be
impossible to ascribe wholly to our epoch  the invention of catheterism
by instruments devoid  of curvature, an invention which  M. Moulin
also in his turn  presented a claim to in 1829.  Habit, however, and
prejudices succeeded in predominating, and for so much the greater
reason, because the straight catheter, as an instrument for penetrating
into the bladder, and for giving egress to the  urine,  is incontestably
less convenient than the curved.  It became necessary that this kind
of catheterism should present itself under another point  of view, to
enable it to take rank in surgical practice.  From 1815 to 1823 seve-
ral  surgeons, feeling more  sensibly than ever the necessity of dis-
covering some means by which calculi could be destroyed without  a
bloody operation, exerted themselves to obtain this result by investi-
gations, which were undertaken about the same time, in  similar di-
rections, or by different processes.   While these events were transpir-
ing, the practicability of traversing the urethra by means of canulas
without any curvature, was again announced.  Though M. Amussat,
in order  to prove this, supported himself principally upon an  anato-
mical error, he, nevertheless, ultimately succeeded in awakening the
attention of surgeons upon this subject.   While  he was  in vain en-
deavoring to demonstrate how much deception had existed in relation
to the direction of  the excretory duct of the urine, MM. Leroy and
Civiale availed themselves of this practical fact, which immediately
became for them a  matter of high  importance.  Up to that time
it would appear in  fact, that  they had  had no  idea of the straight
sound for the purpose of breaking up  calculi; while the instruments
that M. Leroy  in  particular made use  of, were still curved.  The
observations  of Lieutaud, Santarelli and M. Montagut, and  also the
work of M. Gruthuisen, which might have been  of such great assist-
ance to them, had evidently escaped their attention.   We  may, there-
fore, assert with every degree of confidence, that it was from this
epoch only that lithotrity dates its existence.  From that time the
breaking up  of the  stone has been performed by so many different
processes, that it becomes necessary that we should enter into a suc-
cinct review of them.  In one, and which  was the first  that  was
made trial of on living man at Paris, nothing more was done than
to pierce the calculus in various directions, and afterwards to reduce
it into fragments, in order to perforate them  and break them up in sue- 
982           NEW ELEMENTS OF  OPERATIVE SURGERY.

cession, and then  to  extract them by  piecemeal,  should the  blad-
der itself not succeed in expelling them with the urine.  In another
process simple perforations were not the only means made use of.
The surgeon endeavored by means of particular kinds of instruments,
to hollow out the calculus from its centre to its circumference, in order
to transform it into a sort of shell, which was afterwards broken up and
reduced into fragments, as in the preceding process.  In a third pro-
cess the instrument acted upon  the stone,  from the circumference to
the centre, and its effect is to pulverize it by means of an actual con-
centric crushing.   A  fourth process consisted of an effort to crunch
(gruger) and crush the stones without  previously perforating  them,
and this either from the centre to the circumference or from before
backwards.  Another process had for its object  to  crush and  break
up (casser) the stone.  It was also proposed to  split it up from the
centre, (faire eclater par le centre.)
   I.  Perforation, which was the  method  adopted  in  the  beginning
by M. Civiale, is  the same which this lithotritist  still eulogized in
1838.  The instruments which it  requires are:  1st. A large canula
of from two to four lines in diameter and from nine to twelve inches
in length, and which serves in some respects as a sheath to the other
instruments;  2nd. A forceps or  litholabe destined to seize and to
hold  the calculus; 3d. A drill, either cylindrical and  with  a  triple
or quadruple  point,  or  with a  head  and in shape of a trephine;
4th.  Auxiliary instruments,  such as a winch, rings, racks, a  mandril
lathe, and the vice, &c, which serve to support the principal instru-
ments  outside, and to make them manipulate in the interior of the
bladder.
   a. The chemise or  outer canula, after being once introduced into
the urethra, is to remain there and to serve to  protect it.  As it must
be adapted to this canal, its dimensions  are to  be increased or dimin-
ished, according to the age  of the patient and the peculiar  anatom-
ical  relations of the parts.   It is  necessary  that its walls,  with
as little degree of thickness as possible, should  also possess a great
degree of resistance, at  least at its vesical extremity.   Its outer ex-
tremity is generally provided with a box (boite) of leather or cork,
and cut  into four facettes (pans) to  the extent of an inch or two, in
order that it may be embraced by the mandril lathe or vice.
   b.  The litholabe is one of the  articles which has undergone the
greatest  modification ;  it is unnecessary to speak  in this respect of
M. Civiale's first  instrument, which  resembled the  vesical quadruple
of Franco, or of that which M.  Leroy  proposed in  1822, and which
is composed  of four  watch-springs, which form when they open a
double crossed noose in the bladder, since these instruments have not
been adopted by any body, not  even by their  inventors, and that the
one  made  by M. Luckens, a cutler of Philadelphia, upon the same
principle, is  no  better.  M.  Colombe  proposes a  litholabe  com-
posed of two concentric canulas, each of which is terminated by two
elastic branches united at their extremity,  and which may be crossed
at a right angle around  the stone when this latter has been grasped.
This instrument, which is evidently  constructed upon the same idea
as the litholabe of M. Leroy or that of M. Luckens, will have the
same fate as the preceding ones. 
LITHOTRITY.
983
  c. It is the forceps, properly so called, which, up  to the present
time, has been generally relied upon.  This forceps, which is a simple
modification of the trifide canula of Sanctorius or F. de Hilden, and
of the ball extractor of A. Ferri or Andre de la Croix, is also the one
the authorship of which  has given rise  to  the greatest contention.
Three elastic branches, curved in the form  of a hook, and  lapping
over in such manner that they may be closed up and reduced to the
size of the principal stem in bringing them  into  their sheath, termi-
nate  its vesical extremity,  while the other  has  a leather cap,  but
without  any pressure screw, like that of the first canula.
  d.  The litholabe, such as  I have just described it, has not met with
the sanction of all lithotritists.  Many of them have specially endeav-
ored to  increase the number of its branches.  Some have given it
four, M. Amussat proposed five, and Meirieu  (Bull, de Fer.,  X. VIL,
p. 360—t.  XII., p.  240)  had divided it  into twelve.  M. Tanchou
(Ibid., X. XIX., p. 72)  recommends  ten.   That of M.  Recamier is
composed of two canulas  which each contain five branches, and
which, by turning upon each other, soon form a forceps with from
five to ten  branches.   These various modifications have been con-
trived, for the common object of retaining the calculus with  greater
facility as soon as it has been  grasped, and also of not allowing its
principal fragments  to. make their escape  from the instrument.
  e.  The  lithomyleur  of Meirieu, successively improved by MM.
Recamier and  Tanchou, is  also distinguished from the others  in this
particular, that the free extremity of all its branches  is  pierced with
an eye  for the  passage  of a  very  strong  silk cord, intended to
approximate them and to prevent their separation, in the same way
as the cord of a purse, and which, in order to come to the outside,
is made to  pass between the  two canulas in a  special groove for
that purpose.  That of M. Recamier moreover may, by the rotation
of the two canulas, present  on one of its sides a large opening to the
calculus, and then close  itself up around the foreign body.   In  the
apparatus of Meirieu and M. Tanchou, we again find the same pre-
caution, but under  another form,  that is to  say, that one  of  the
branches of the forceps which has remained in the canula, leaves a
lateral opening for the entrance of the stone, and may be afterwards
brought to a line with the other branches  by  means of tractions made
upon the silk cord.
  /. M. Ashmead, of the United States, has presented  one to the
Academy which has four divisions, three  of which are quite approxi-
mated together, while the fourth is considerably separated from them.
By means of this arrangement, the forceps leaves on  one side all the
interval  required for  grasping  the largest sized stones, and  on  the
other  represents a sufficiently close grillage, which is to be  turned
downwards at  the time of breaking up the stone, in order not to allow
ofthe escape of those fragments which are of considerable size.   It
would be better without doubt,  if we could  be enabled to  keep the
calculus shut up until it was completely  destroyed ;  but the  instru-
ments proposed do not procure this advantage but at  the expense of
several  others.   In  multiplying  the  branches they are necessarily
weakened.   As the  calculi  are far from always having a regular form,
or being constantly so situated that they  may be seized by the for- 
984          NEW ELEMENTS OF  OPERATIVE SURGERY.

ceps centre to centre, there would be reason to apprehend  that one
of its numerous branches might be placed under the necessity of sus-
taining the whole  effort, and consequently that it  might slip or be
broken.  If, as in the apparatus of Meirieu, its  extremities are united
by a silk cord, the accident doubtless is less to be apprehended, while
the little cage (cage) presents a much greater  degree of regularity :
but might not the silken thread break, and might it not become en-
tangled in the  branches of the instrument itself?  Are we always
very  sure of being enabled to make it work freely ?  Moreover,
when the litholabe is once  shut, how could we disengage the stone
from it, if the bladder should be emptied and had contracted violent-
ly 1   If the forceps with three branches could not fulfil our intentions,
that of M. Ashmead, which while  it  possesses sufficient force, enables
us to  have a grillage closer than the common forceps, might of iteelf,
as I conceive, be substituted for it, at least in  the  process of simple
perforation.  The eel-skin  bladder connected by M. Deleau  with one
of these lithotritors, would not improve them any, even though we
should attach this  pouch to the extremity of a straight catheter, in
order to inject into it diluted hydrochloric acid, for the purpose of
dissolving the calculus, as recommended by M. Zaviziano, (Mem. de
I'Acad.  Med. Chir. de  Naples,  1831.)
  g. Lithotritors.—A steel rod, the  vesical extremity of which only
can be  susceptible of important modifications, is charged  with the
office of acting on the stone.  In the first instruments used by M.
Leroy, this stem was cylindrical,  and terminated in  points.  In the
instruments of M. Gruthuisen, there is one which is armed with a
head similar to the crown  of a trephine.  This last is  the  one that
M.  Civiale has  preferred.   It results  from this, that his lithotritor
must  be introduced at the  internal extremity of the forceps, and that
it can only be withdrawn with the whole of the instrument, while the
cylindrical drill  penetrates and comes out by the outer extremity.
On the other hand, these drills  with  a head evidently make a more
considerable perforation  than the others.  M. Civiale, in order to ob-
tain a still greater  opening, has had  some constructed which are ex-
centric, that is to say, having their axis outside the axis of the stem.
The advantages of the drill are, that it  presents a great degree of
solidity, acts with  force  and certainty, and  does not expose to any
serious accident.   The actual objection which  is made to it,  is that of
giving us an opening only of three to  four lines, that  of requiring us
frequently to change the position of  the calculus, and of repeating the
operations, should  the stone be  somewhat large.
  h. Opening drills,  (Forels  a developpement.)—Struck  with the
above mentioned imperfection,  several surgeons immediately under-
took to find a remedy for it.  M. Leroy, who was one of the first, had
constructed countersink drills (forets  a fraise) and opening lances (lan-
ces a  developpement.)  A drill cleft at its extremity first enabled him
to make a perforation, and afterwards to enlarge it, because in pushing
the fraise out of its canula its two branches opened from it forcibly in
consequence of their natural elasticity.  Another instrument of the
same  character, appeared to him to be calculated to attain the object
still better.   Its two branches separate  apart, from  the  head of
the drill, by retracting  upon themselves.  Finally, M.  Leroy  con- 
LITHOTRITY.
985
 stantly following out the same  idea, has employed with  success a
 cylindrical stem enclosing a fraise with a double blade, which may
 escape from it when we  push upon it, through two  apertures placed
 near the extremity of the drill.   The  double fraises  of M. Civiale,
 which are parted by a transverse bar, or simple head, as they retract
 upon  themselves under the influence of a quick screw acting upon a
 central stem, do not appear to me to be calculated to remain in prac-
 tice.  M. Heurteloup, in order to obtain an  excavation of from 8 to
 12 lines in diameter, made use of a drill  with a cylindrical head,
 and pierced on one  side, and which at  first  served him as a stone
 perforator, (perce-pierre)  When he afterwards wishes to hollow out,
 (evider,) excavate, and reduce the calculus into a shell, he pushes by
 means of a central stem, the base  of a toothed virgule,  contained in
 the head of his drill, and  which immediately  goes  beyond its circum-
 ference  to the  extent of one, two or three lines, while making its
 escape through the lateral aperture.
  II.  Evidement.—For calculi that  are  still larger, M. Heurteloup
 has invented what he calls his forceps-evideur, that is to say,  a cyl-
 indrical  drill with a jointed fraise, arid which may  be parted laterally
 in such  manner as to make an excavation of more than an inch  in
 diameter; but a slight inspection of this instrument will show that
 we cannot place any great confidence in it and that it cannot have any
 great degree of power.   M. Amussat has also occupied himself with
 the subject of evidement.  His drill, which is based on the  principle
 of one of those of M. Leroy, is composed of a central head and two
 lateral portions.   When we have perforated  the calculus with the in-
 strument closed, its stem  is withdrawn by means of a screw which is
 between the two fraises,  and which separates them so as to  allow of
 our making a considerable enlargement to the excavation.   This is
 the drill which  two cutlers, MM. Greling and Charriere, have suc-
 cessively modified.   The cylindrical drills, having a virgule which is
 separated at the distance of three to four lines from the axis of the
 principal stem, like those which  have been  proposed  by MM. Tan-
 chou and Pecchioli, appear in  my judgment to be less commodious.
 I would  say the same of the fraises  with triangular points  and with
 wings like a windmill, like those of M. Pravaz, and also of that
 which M. Rigal  recommends with a sheathed drill.  This last men-
 tioned surgeon also proposes to obtain  another result, different from
 any proposed  by those who  have preceded him.  When  the per-
 foration  is effected,  a  quick  screw  withdraws the  fraise  between
 the  two blades  which constitute its sheath, separates  them and fixes
 them  firmly in the centre of the calculus, which  is thus found as it
 were impaled upon the drill in such  manner as to be susceptible of
 being  broken up against the inner side of the branches of the  litholabe.
 M. Rigal considers, on the other hand, that  in separating the forceps
 from its instrument,  we would  be enabled to break up the stone
 into splinters by an excentric effort.   In  this respect  he follows out
 the views of M. Civiale,  who proposes a similar means after lithoto-
 my, when the stone is too large to be extracted without danger;  or
 those of M. Leroy, who  says the same of calculi of the  urethra; an
idea which Fischer (Theses de Haller, X. IL, Fr. transl.) and some
authors of the seventeenth century had  also entertained.   It is doubt- 
  986          NEW ELEMENTS  OF OPERATIVE SURGERY.

  ful if lithotrity  by  excentric  rupture will ever become a general
  method, whether  we effect it  by the  action of sheathed dril'.s, or
  divergent  blades, or  by means of percussion upon the free extremity
  of the  lithotritic instrument.  As  to evidement in itself, the fraise
  with a  double elastic branch, as proposed by M. Leroy, and as it
  has been  improved  by MM.  Amussat and Charriere,  is  the one
  which  has most solidity and is most certain of effecting this object,
,  though the mandrin with a virgule, as contrived by M. Heurteloup,
  and the developing  drill  of M. Pecchioli, might  replace  them in
  certain cases.
    III.  Concentric Crushing, (Broiement)—In place of opening the
  stone at its centre, and of hollowing it out from  the interior to the
  exterior, Meirieu conceived the  idea of reducing it into powder, by
  acting  from its surface to its central portion, by means of a cylindri-
  cal drill provided with two  virgules with a lateral development, and
  which  could be separated at pleasure so as to  form with the stem
  a sort of clover leaf.   MM. Recamier and Tanchou have followed
  out the same principle,  and all the efforts that have been  made have
  had no other object than that of  rendering its application  more easy
  by improving either the litholabe  or  the lithotritor.   It  cannot
  be denied  that this  way  of breaking  up the stone is  more  rapid
  than the  preceding; that we may by this means possibly pulverize
  a large sized calculus  at  a single sitting; that  it protects us from
  the inconveniences  of  breaking the stone into fragments, and en-
  ables us to hold it grasped to the end of the operation, without be-
  ing under  the necessity of letting go our hold to resume it at another
  time.   But the  drills and  the  fraises which we  are obliged  to make
  use of  are  necessarily  weak, and may bend or break.  The separa-
  tion of  the virgules may lead us  to apprehend that they may become
  entangled  between the  branches of the forceps, if we are compelled
  to approximate  them a little too near the sheath.  We have, more-
  over, all the inconveniences which I  have pointed out in speaking of
  the litholabe with multiplied branches supported by a silk cord.  The
  essays  of Meirieu and those of M. Recamier, were only made upon
  the dead  body.  M. Tanchou, (Lancette Franc., X. V., p. 232,) like
  M. Pamard, (Transact. Med.,X. VIL, p. 306,) went farther.   His ap-
  paratus enabled him  in a patient to break up at a single sitting, a cal-
  culus of a certain size.   On the other hand he  permitted me to wit-
  ness essays which he  had the goodness to make in an adult man whom
  I had sent to him for this purpose.   The stone could not be grasped,
  and I supposed  that lithotomy would be necessary.  We then ascer-
  tained  that the  foreign body was of too large a size to allow of any
  method of breaking it up to succeed.  It  would not, therefore, be
  just to deny to  the apparatus of M. Tanchou the capability of being
  applied with advantage.  The  breaking down  the stone from the
  circumference to the centre by means of the inner surface of the
  branches  of the litholabe, against which  the. calculus which is im-
  paled  by  the sheathed drill is  made to turn, as had been  proposed
  by M.  Rigal, (Bull de  Fer.,X. IX., p. 67—t. XXL, p. 104,) has some-
  thing very ingenious in it, and at first sight even specious, but the
  slightest  reflection also shows  immediately that  such a suggestion
  must be inapplicable. 
LITHOTRITY.
987
   IV.  Crushing  the  stone,  (Ecrasement) is one  of the means
 which the ancients especially directed their attention  to.  Thus it
 was the  ecrasement, and  not the  breaking up (broiement) of the
 stone which was recommended by Acaravius, and which  F. de Hil-
 den and many others made use of.  Ecrasement was  also the me-
 thod which Amussat used in 1822.   This mode of breaking up cal-
 culi, for a  time forgotten, appears to be upon the point of  contesting
 the palm with broiement, properly so called.  Among those who pro-
 pose this mode, there are  some who adopt it  only  as  an  accessory
 method, for the small  calculi, or for the fragments which result from
 perforation and evidement; while  others endeavor to bring it into
 repute as a general method.  In the first case  it has almost always
 been combined with the other processes.  When M. Civaile, for ex-
 ample, finds that he has seized a calculus of only 3  or 4 lines dimen-
 sions, he  compresses  it forcibly between the branches  of his litho-
 labe, and afterwards crushes it by pushing the head of the lithotri-
 tor  by means of the  palm of his right hand.  He proceeds in  the
 same manner with fragments that  are  somew7hat  large,  and with
 all those particles wThich are of too considerable size to be  extract-
 ed entire through the  urethra.  M. Civiale  had also contrived a for-
 ceps with  two branches,  which could glide upon  each other, and
 crush the  small stones by a  movement backwards and  forwards,
 nearly in the same way as with the  instrument  of M. Amussat.  M.
 Rigal has modified this instrument in making it act by means of a
 quick screw, while  dispensing  with  the  movement backwards and
 forwards.  M. Colombat endeavored to make it more easy  to man-
 age by adding volants to it, to give it motion, and by fixing a small
 chain to the extremity of its  branches, in  order that these, should
 they be broken, might be brought out without danger.  The forceps,
 which in this respect  has attracted  most attention, is the one that
 M.  Heurteloup  has delineated under the title of  brisecoque.  Its
 branches rub against  each other,  and by means of an encliquetage
 we are enabled to make  these  branches  re-enter into the external
 canula, with such degree of force, that they scatter  into splinters the
 hardest and most unyielding calculi.  A forceps constructed upon
 nearly the same principles, and which has three instead of two
 branches,  was  contrived  in  1829 by M. Rigaud, (These, No.  276,
 Paris, 1831.)   This species of grugeoire can seize calculi of an inch
 in diameter in the same manner as the ordinary litholabe.   The ad-
 dition of  an encliquetage, enables us also to give motion to its three
 branches, and to execute  on the  three  corresponding points of the
 stone such  frictions  as will reduce it into a fine powder, and allow
 us to grind it  up and destroy it completely before letting go our
 hold of it.   It is  a species of brisecoque or stone-breaker, which does
 not possess as much force as that of M. Heurteloup, but  which has
 the advantage of breaking down  the calculus by friction  instead of
 splitting it into fragments.  A skilful  cutler, M.' Sirhenry, has con-
 structed another  forceps,  which is  equally well calculated for  the
 ecrasement of calculi.  Its three  branches,  which are destitute of
 hooks, present on their inner side a dentated crest, which is to be ap-
plied upon the foreign body.   It is to be introduced  into the bladder
in  the  same  way as  an  ordinary litholabe.  After the calculus is 
988          NEW ELEMENTS OF OPERATIVE SURGERY.

once  seized, we make the branches re-enter into the external can-
ula by means  of a quick screw, and this  screw acts with so great a
degree of power, that even siliceous and  flinty stones are incapable
of making resistance to it.  An essay which  was made with it at
the Hotel Dieu, was followed by the breaking of one of its branches,
and this,  in fact,  is the danger that we  would  appear  to have to
apprehend from it  at first view ; but  M.  Sirhenry replies to this,
that the instrument which  was made use of, was not designed for
such  large calculi, and that he had  foreseen the accident  in question.
It is  at least  true  that the instrument which he has  shown  to  me,
and which the hardest calculi are incapable of resisting, possesses so
great a degree of  strength, that it would seem  absolutely impossible
to break  it.   An  objection  which some  persons  have also  made
against it, is that of exposing to the risk of wounding the bladder by
means of the splinters of stone which the instrument  has a tendency
to throw off to a considerable distance.  This danger  is evidently
imaginary.  A  stone which  was thus  broken  up between my two
hands did  not occasion me any sensation  of pain, and inasmuch as
we act in the  bladder full of  fluid, there can in this respect  be no-
thing  in reality to apprehend.
  V.  Of these four modes of breaking up calculi, there is no one of
them  which deserves to be adopted  to the  exclusion of the others, or
which should be absolutely proscribed.   The perforation  of a stone
of from 5  to  6 lines in  diameter, may be advantageously combined
with ecrasement.   If the fraise has  made an opening of four lines,
for example, we may, after having drawn  it back to near its sheath,
bring  the litholabe forcibly backwards, and make use  of  it then as a
brisecoque.  Instead of this process we may, if the exploring means
we have  made use  of have enabled us to  ascertain  with certainty
that the  calculus is of but little  size,  employ  the  grugeoire of M.
Heurteloup, or one of the forceps, either that with  the encliquetage
or with the volant, or the quick screw, which have  been described
above.  When the  stone exceeds ten lines or an inch, the most suit-
able process will then be  successively, perforation, then evidement,
and finally ecrasement.  By means of the forceps  of  M. Rigaud,
we might succeed  without any very  great degree of difficulty, in
breaking up calculi of from 8 to 12 lines  in diameter ;  which could
be effected, as I  conceive, with still  greater facility, by means of M.
Sirhenry's  instrument.   A remark which  should not escape the at-
tention of the  practitioner is  this, that  by means  of the new ecrase-
ment  forceps,  which will be  mentioned farther on, the  operation  is
found at  the present day to be surprisingly simplified, since it is no
longer necessary, with these,  to have recourse  to drills,  fraises, sup-
porting apparatus,  &c.;  so rnuch  so that  they have succeeded in
giving general reputation to lithotrity.
  VI. Accessory apparatus.—Whatever may be the lithotritic appa-
ratus  selected, the means  by which it is put in operation deserves also
the attention  of the  surgeon.  The mechanism of  stone-breakers,
brisecoques, saxifrages and grugeoires having been everywhere based
upon  the system of quick screws, double levers, encliquetages, or en-
grenage, constitutes a part of the principal instrument, and does not
require to be separately described.   This remark does not apply 
LITHOTRITY.
989
to broiement, properly so called, whether by perforation, evidement
or concentric pulverization.  Two kinds of springs, then, become in-
dispensable :  1st, to steady the litholabe firmly ; 2d, to give action to
the lithotritor.
   a. In regard to the first, the chevalet, which is  a sort of mandril
lathe, as proposed by M. Leroy, after Ducamp, and as modified by
MM. Civiale,  Rigal, &c, has been  generally adopted.   Some per-
sons, however, have proposed  to  substitute for it an  ebony vice
(etau en ebene) with one or two grips; others  have directed much
attention to the manner of steadying at the same time both the in-
struments and the  patient.  From  hence comes those beds, which
are or  are not furnished with supports, as proposed by MM. Leroy,
Heurteloup, Tanchou and Rigal, and  which are evidently useless.
The bare idea of metallic supports intended to be kept immovable
on the  foot  of  the  operating table,  like the one  proposed by  M.
Charriere, or  the suggestion of mechanical beds (tits mecaniques),
like that of M.  Heurteloup, is in itself revolting.   Let us imagine,
for example,  a forceps, or any  kind  of lithotritor  manceuvering in
the bladder of a living man, while a solid bar  of iron implanted in
the table fixes them securely outside, and we shall see  whether the
slightest irregular or unexpected movement  on  the part  of the pa-
tient, is not  calculated  to make us tremble for the consequences.
However ingeniously constructed these dead forces may be,  they
should  be  rejected,  and  we  must  depend for  accessory means
upon the hands of intelligent assistants, or upon the surgeon  him-
self.  M. Amussat, by pressing with his chest against the lithotritor,
by means of a point d'appui interposed, in such manner as to be en-
abled to hold  the litholabe with the left hand at the same time, that
with the right hand he  is enabled to turn the drill with a wooden
handle,  in the  manner  of a centre-bit wimble (vilebrequin), has
none of these dangers to dread; but it acts with less force  than
when we make use of the  mandril lathe, and  fatigues much more,
so  that all things being properly considered, the  chevalet is  still
the instrument which is best adapted to the object in view.
   b. In the action of the drill there  are  two forces to  be directed,
that which presses upon its outer extremity to keep it applied against
the stone, and  that which compels  it to turn upon its axis.  Those
who have supposed that they  could  substitute for the first, either
the thumb, forepart of the  chest or the knee,  are evidently under
an  error, unless, in fact, they can discover a better arranged sys-
tem of  mechanism  than  that of the wheels, villebrequins and mani-
velles hitherto employed.  The cork-screw spring, enclosed in the
movable poupee of the  mandril, certainly leaves much room  for
improvement.   Nevertheless, I  see  nothing which  can be advanta-
geously substituted  for it, so long  as the bow (archet)  shall  con-
tinue to be preferred as  the rotating power.   The rings, volants
and manivelles, which at first view would appear to be  sufficient
to supply the rotating power, are not sufficiently extended in  their
action, nor  do not sufficiently favor the forces put into play, nor the
movements made use of, to enable us to derive any great  advantage
from them.  The engrenage wheels placed underneath, as was pro-
posed by M.  Leroy, or  upon the side, as in the  apparatus of  M 
990           NEW ELEMENTS OF OPERATIVE  SURGERY.

Pravaz, whether they act upon a pignon, parallel to the axis of the
litholabe, or catch into a dentated conical and circular pignon, impart
to the drill as rapid a movement as can be desired ;  but there still re-
mains to be discovered a means of making pressure upon its extremity
at the same time with a sufficient degree of force.  As to the mechan-
ism of the bow, it is the same in lithotrity as in the mechanic arts from
which it has been  thought proper to borrow  it.   Until the wheels
can be substituted  for it, prudence  requires  that we should  con-
tinue  to make use  of it, and the  useful results  which it has already
procured, enable us after all to employ it with  more confidence than
any other  means designed  for the same object.  All these contri-
vances, however, become unnecessary in the apparatus of new for-
ceps and nooses.
  VII.  The general operative manual.—Before proceeding  to litho-
trity, there are some special precautions to be  observed.   Upon the
supposition that the urethra has been  diseased,  we should in the first
place restore it to its natural dimensions, and impart to it its original
dilatability.   Even  though this canal  should  be sufficiently large  to
give free passage to the instruments, it may be advantageousto ha-
bituate it  during several days to the action  of flexible  bougies,  or
sounds, in order to blunt its sensibility, and to accustom it to the pre-
sence of foreign bodies.   It is advisable also for the same reason,  to
throw up some injections into the bladder, in order to diminish its  ir-
ritability, and that  it may be distended with more facility  at the time
ofthe operation.  Although these preparatives  are not indispensable,
they cannot however be absolutely omitted, but in a very small num-
ber of cases.
  a. Position of the patient.—In private practice we may lay the
patient on his back on the edge ofthe bed, with the pelvis supported
upon a cushion which is somewhat hard, the feet resting upon stools,
and the head moderately flexed upon  the chest.  At one's own office,
or in a public establishment, we may place him upon a narrow bed,
of convenient  height, in such manner that his legs may go beyond
the foot ofthe bed, and be supported in the manner just described.  In
this position there is no  need of his being tied  or bound down  ; the
posterior Wall of the bladder having  become its lower wall, enables
the calculus to  become removed to a greater  distance from the ure-
thra, and to present  itself, so to speak, of its own accord,  to the  litho-
labe.   It is moreover easy to modify this according to necessity, either
by a greater elevation of the pelvis, if the  stone has- a tendency to
remain in the bas fond, or by diminishing the thickness of the cush-
ion, when we apprehend the contrary ; which resource is not afford-
ed us to the same  extent by the employment  of lithotritic beds  or
tables.
  b. Injections.—A first stage of the operation consists in filling the
bladder with tepid water, or some emollient  decoction.  Unless this
injection were made, we could not give free play to the litholabe or
lithotritor.   The stone could not always be  seized, and  the bladder
might be frequently pinched up by the instrument.  This injection is
effected by means  of an ordinary catheter  and hydrocele syringe,
with more certainty and with  less embarrassment than with  blad-
ders, or bottles of caoutchouc, or by the canula or sheath of the  litho- 
LITHOTRITY.
991
 labe.  After the silver  catheter is once introduced, it serves at the
 same time to ascertain again the presence of the calculus.   An assis-
 tant then immediately takes charge  of it in order that the surgeon
 may adapt the syringe of the syphon to it,  and throw up the liquid.
 When from 8 to 12 ounces of the injection have been thrown up, or
 what is better still, as soon as the patient has a  somewhat urgent de-
 sire to urinate, the catheter is to be withdrawn in order that the litho-
 tritic apparatus may immediately  be substituted in its  place, and be-
 fore the injection has time  to be discharged.
   c Introduction of the forceps.—The  drill, provided with its drill
 box to receive the bow, being glided  into the canula of the forceps,
 and the litholabe, furnished with a box at its outer extremity, being
 introduced in its turn into the common sheath in such manner that, its
 brancjies accurately closed upon the grooves of the head of the litho-
 tritor, represent an olive head which is to be lubricated with ointment,
 are then introduced united together into a single piece, in the same
 manner as a sound into the urethra.  For this purpose, the operator
 placed on the right of the patient, grasps the penis with his left hand,
 in the same  manner as in ordinary catheterism,  and raises it slightly
 upwards ; presents to it perpendicularly with his right hand, the in-
 strument well  oiled  or greased ;  gently  inserts it  by slight move-
 ments of rotation into the meatus urinarius ; soon arrives at the bulb ;
 stops for a moment;  gently but firmly  depresses his hand in order
 to pass under the  symphysis and through the membranous and pros-
 tatic portions of the  urethra, and in this manner arrives beyond the
 neck of the  bladder.
   d. To find the stone.—Before  opening the litholabe, we look for
 the calculus by passing around, by means of gentle vibratory move-
 ments, the olive of the  metallic tube, which is still shut up:  1st, from
 before backwards, upon the middle portion of the bas fond and  pos-
 terior wall  of the bladder; 2nd, from  behind forwards, in order in
 returning to complete the circle, either on  the right or the left side;
 3d, from before backwards a second time,  returning by the opposite
 side in order to come  back on  the middle portion, where the stone
 may have again fallen,  and then transversely in such manner as to
 leave no  point on the  vesical wall, which has not in reality been
 touched.  If, notwithstanding this minute research, we encounter
 nothing, it would be better to defer the operation than to  persist in
 continuing the exploration.  We ought not, however, to give up
 until after having  sufficiently varied  the posture of the patient, and
 after having thoroughly satisfied ourselves that  no  cavity or natural
 depression has been overlooked.
  e.  To  open the  forceps.—When the seat of the stone  has been
 proximately determined, the operator takes in his right hand the ex-
 tremity of the litholabe, which he  holds immovable, and with his left
 hand draws  towards him the external canula, as if with the intention
 of extracting it from the urethra, and in this manner enables the forceps
 to open  itself by leaving it to the natural elasticity of its  branches.
In this manner the bladder incurs much less risk, than if he made the
litholabe glide forwards without deranging its sheath for the purpose
of protecting the  urethra,  the entrance into which  latter, moreover, 
992          NEW  ELEMENTS  OF OPERATIVE SURGERY.

remains perfectly filled up by the gorge of the triploide which opens
itself in the bladder.
  f. The finding of the calculus and the grasping of it is frequently
a more difficult matter than is supposed, so much the more so as it is
not sufficient alone that we should feel it in  order to  know exactly
where it is.   To discover it,  therefore, exacts the greatest degree of
attention.  The difficulty is  to know whether we  touch  it:  1st. by
the convexity of one or both  the lower hooks ofthe instrument; 2nd,
by  the middle portion of one  of its branches, either on their inside or
outside, and in this case whether it is to the right or the left; and 3d,
by the l&wer surface of these same branches near the prostate, &c.  In
this respect the following rules should not  be neglected.  If by ma-
king the forceps vibrate, we  perceive that it strikes upon a foreign
body and gives the sensation  of a double shock, the calculus is below
its two branches and behind the prostate.  If one of the branches
descends lower than the other while  turning on its axis, and a simple
shock only is produced, the calculus  will  then be found on the  most
elevated part.  If it is in front, and the two hooks pushed in succes-
sion, and not simultaneously, alike feel it, we may consider  that the
calculus lies in the interval between them.  If one of  them only re-
cognizes it, it should be on one  side.  We ascertain whether it  is on
the right or left by keeping one hook immovable, while we make the
other gently  advance.  Admitting in  place  of this, that  it  may  be
outside of the left branch itself; if, in taking the other for a point
d'appui, we raise up and depress it by movements, of rotation de-
scribing  the arc of a  circle, it will  not  fail to  be soon recognized,
while the same movements repeated on the opposite  side will dis-
cover nothing.   A transverse movement of slight extent to the right
and then to the left, will in the same manner inform us  if, the stone is
in the interior of the litholabe, or nearer to one of its branches than
the other, or in  the centre.   Finally, these various movements com-
bined with  some  degree of skill, will not permit us to hesitate for
any length of time upon its actual situation, provided the surgeon has
taken the precaution to place two of its hooks  below and upon the
same line.  Having arrived to this point there can be no longer any
great difficulty in  embracing the calculus in the open space of the
instrument, and consequently none  in grasping it.   In order not to
derange the relations of the objects, we again take the free extremity
of the  forceps and raise it  slightly upwards with the right hand, in
order that its branches may continue to rest against the bas fond of
the bladder, after which we push over it again the sheath or external
canula by seizing the leather  box  of this last with the  left hand.
It  is advisable, moreover,  before doing  this, to impart to the drill
certain movements backwards and forwards in the tube, and between
the divisions of the litholabe, until the fraise has actually touched the
stone.  By an effort made in  the contrary direction upon  the sheath
and upon the stone,  we finally secure this last, after which we  have
nothing more to do than to attack it  with the lithotritor.
  g. To apply the mandril lathe and the bow.—This is the moment
for  placing the supports and the moving powers.  A pressure screw,
in the first place, prevents the two instruments when closed from re-
opening.  A mortice on the  head of the mandril then  embraces in 
LITHOTRITY.
993
  seizing it below, the quadrilateral extremity, having lateral arrests,
  ofthe sheath in front of its box, while a pressure screw immediately
  secures them in this position.  The small cap (cuvette) of the spiral
  spring, supported by the poupee of the mandril, is then applied upon
  the queue of the drill.   We push forward this poupee with a force
  proportionate  to the action which we intend to exercise upon  the
  stone and drill.  This in its turn is  to  be  arrested  by a turn of the
  screw.  If the pressure of the spring appears  to  be" too strong,  a
  fourth screw enables us to suspend it or to resume it at pleasure. The
  apparatus is then  prepared.  An  assistant with  his face turned  to-
  wards the pelvis, and placed between the legs or on the right of the
  patient, takes charge of it and seizes  its handle with his  right hand
  and its angular part with his left hand.  The operator takes the cord
  detached from  the hook of  the bow, passes it around  the drill box,
  which has previously been adjusted  upon the drill, and reapplies its
  buckle upon the extremity  of the elastic bow, from which  he had
  momentarily separated it; it being well understood that this  cord,
  while it should  be sufficiently slender, should possess a great de°ree
  of force, and work with  the  least degree of friction possible.
   b. Broiement.—This being arranged, the surgeon, who is to be  al-
  ways placed on the right, holds  the instrument firmly in  his left  hand
  between the penis and the head of the chevalet, while with his  right
  hand he puts the bow into action, taking care to  incline its  motion
  forward, and to unite pressure against the stone with rotation, should
  the spring not appear to be sufficient.   The  drill  box moreover has
  been fixed in-such manner as to strike against the  drawing  box  of
  the litholabe, before the head of the drill can reach the vesical extrem-
 ity of the litholabe, and go beyond the circle of the forceps.   This
 first perforation having  been terminated, we withdraw the  poupee
 of the mandril backwards,  in order to bring the drill towards us.
 If the stone is  small  and friable, we endeavor to  crush it by acting
 forcibly in an  opposite  direction  on the two cork boxes,  before
 loosing our hold upon it.  In the  contrary case  we open the for-
 ceps gently, and then by small  taps on its free extremity, endeavor
 to move the calculus and  change its  position; a  change which we
 may  assure ourselves of, and may favor or even  accomplish, by
 means of the drill directed with  the  right hand.  If we  cannot  in
 any way effect this, we let go the  stone altogether, in order  to re-
 grasp it in the same manner as if it had escaped in  spite of the in-
 tention of the operator.  Under the apprehension that  it may  pre-
 sent itself exactly at the same diameters, which rarely happens, we
 push the head of the drill against it,  and displace this  drill  again,
 should it again fall into the same hole, nor set it in  movement  a  sec-
 ond time by means of the bow, except it shall meet  a solid portion
 of the  body which is to be destroyed.   The employment of develop-
 ing drills, and fraises with  a virgule  or  with files,  or with  simple
 or double  wings, is subjected to the  same rules, whether we have
 recourse to them at first,  or only after the first perforation.  In the
 first case they are to be separated apart  in such  manner that they
 may turn freely behind the calculus, without touching the inner  sur-
 face of the  branches of the litholabe, and that the central head may
serve as an axis to the lateral wings while they are acting on the
                              63 
994           NEW  ELEMENTS OF OPERATIVE  SURGERY.

stone.   In the second case, they are to be opened only by degrees
and in the interior  itself of the  first perforation.  It is  under such
circumstances that the name of cchoppeur  and ivideur may be lit-
erally applied to them, inasmuch as their effect  is to transform the
stone into a shell, and to dig  out a conical cavity in it, the apex of
which is placed posteriorly.   The spherical stones,  which are some-
what large, and which are [accurately] grasped  centre to centre, are
the best adapted to these drills ; those stones which are elongated, and
which are seized only by  one of their projections or at their side,
and  which leave a void on  one side  between  the  branches of the
forceps, render the  action of the drills difficult and sometimes  dan-
gerous,  in  consequence of the  unequal  resistance which  they
encounter while  turning.  The apparatus of M. Tanchou, though
more ingenious, is not altogether exempt from this  inconvenience,
and in my opinion it would  be advisable in such cases to confine our-
selves to the simple percussion (taraudage,) combined with the ecrase-
ment.   When the  stone is actually  broken up, or  the  patient too
much fatigued, that is to say, after the expiration of 5,  8, 10, or at
most 12 minutes,  it  is  advisable to terminate  the sitting.   The bow
is to be then removed.  We  loosen all the pressure screws in order
to  remove the chevalet and  to withdraw the drill in proportion as
we shut up the forceps.  When a fragment has become arrested be-
tween its branches, we  should, if it  is not too large, withdraw it
with the rest of the instrument; but should  there be ever  so  little
reason to apprehend that it may injure the urethra, it is better to let
go our hold upon it or make it fall again into  the bladder by pushing
it back by means  ofthe lithotritor.   The remains ofthe injection and
urine which the patient generally feels a desire to discharge immedi-
ately after, almost always bring away portions of the calculi, and a
greater or less quantity of powder resulting from the  broiement, and
wihch are a proof  in  regard to the  patient,  that the operation has
been  attended with as much success as it  was possible.  A  bath
is to be  prescribed immediately, or during  the course  of the eve-
ning.  In ordinary  cases, the attentions required, consist of nothing
more than those  which are demanded  during any state of convales-
cence, or for valetudinarians in general.  We recommence at the
expiration of 2, 3, 4,  or  5 days, according as the system has  been
more or  less disturbed by the first essay, and always  with the same
precautions, and so on  consecutively until there  is no  longer any
vestige  of calculus in the  bladder.  One or two explorations by
means of a simple sound  at intervals of a  few days, are also re-
quisite in order  that  we may obtain  satisfactory evidence  on this
point, and should  not on any  account be neglected.
  B.  Curvilinear  method.—It is  a remarkable circumstance, that
the breaking  up  of  a  stone  could not  be  accomplished  until at
the epoch when it was demonstrated that it was practicable to intro-
duce straight  instruments into the bladder.   To place the practica-
bility of this process  beyond dispute, even grave  anatomical errors
were adduced in support of it; and now, when there is no longer
any  doubt with any body in  respect to both these circumstances, it
is  found that curved instruments enable us full as well as those that 
LITHOTRITY.
995
are  straight,  to attain  the  object which had been  so long  de-
sired !
  I.  The mandrin file,  employed by Major Martin, was introduced
through a curved catheter.   The  instrument  of M. Eldgerton also
had the usual curvature  of sounds, as  likewise had the first lithopri-
onne forceps  of M. Leroy.   The most difficult point in the ancient
system was to make the  lithotritic instrument turn on its axis.   Now
M.  Pravaz, in  1828, succeeded in giving the same facility to  the
movements of the drill or fraise, in a curved as  in a straight catheter ;
for that purpose he  transformed the inner fourth of his perforator
into an articulated stem or small chain, which was full as strong, how-
ever, as the stems which were  of  a purely cylindrical form and of
one single piece.  Nevertheless, his instrument, which was curved
into a very elongated arc,  did not yet possess  all  the  advantages
which it was desirable to obtain from it, and the author ultimately
gave to it a curvature similar to that  of  ordinary sounds, that is to
say, a curvature which comprised only the vesical fourth.  M. Pra-
vaz did not succeed with this instrument, though he applied it once
on the living subject in one of the  hospitals of Paris.   But the fail-
ure in this  case may be attributed to the want of practice, to  the
indocility ofthe patient,  who was a child, and especially to the pecu-
liar character of the calculus.   It is difficult in fact to conceive why
his apparatus, which differs from the others only in the direction of
its principal portions, should not be capable of  effecting the same re-
sults.   I would even  remark  that  it  ought to be introduced with
greater facility  and should produce less annoyance upon  the urethra.
M.  Leroy has shown  me one in every respect similar in regard to
the arrangement ofthe chain and drill, and the curvature of which is
analogous to that of ordinary sounds, but which he intended to modify
still farther ; this instrument however has this remarkable feature in it,
that the third branch of the litholabe  is fixed  and constitutes a part
of the  conducting  canula.  The instrument of M. Pravaz,  as well
as that of M. Leroy, enables us to make use of perforation, evidement
and  concentric broiement,  in the  same way as the straight  instru-
ments, but their form is much more applicable  still to ecrasement.
  II. MM.  Weiss and  Rigal have also  given a slight curvature to
their encliquetage or friction  forceps,  and  the species of noose used
by  M. Jacobson is also curved.   This last  instrument is  compo-
sed of an external canula like the others, then of a steel cylindrical
stem which perfectly fills it up, and  prolongs it to the distance of
three inches in the  direction of the bladder, which stem is formed of
two halves jointed at their extremity, one placed above and the other
below, in such manner that the lower one being pushed forwards,
separates itself from the upper one which is fixed, and forms, by
means of two or three hinge-joints, a  noose which is capable of em-
bracing a calculus of from 12 to 15 or 18 lines in diameter.   A quick
screw is placed on its free  extremity and enables us to replace  it in
its original position.   The one which was proposed by the Danish
surgeon had  only two joints  in its  lower branch.   Dupuytren con-
sidered that  it would be better to give it three, m order that the
noose mio-ht be more uniform and  more rounded.  It is to be intro-
duced shut up,  into the bladder.  In pushing it afterwards upon its 
 996           NEW ELEMENTS OF OPERATIVE SURGERY.

 outer extremity, its  lower half separates itself little by little.  A
 void is made between it and the other half,  which void  is increased
 at pleasure, and the extent of which is ascertained by  figures placed
 outside of the  nut.   The  calculus becomes lodged in this void or
 noose.   When it is accurately embraced, we act on the quick screw,
 as if for the  purpose  of isolating it and shutting up the  instrument by
 the approximation of its two branches.   Nothing is more simple than
 an apparatus of this kind, nor should anything be more easy than the
 operation itself, which in this  manner is  relieved of the necessity of
 supports, containing means, &c.  Nor have we even to fear here the
 breaking of the instrument, for its joints would  enable us to extract
 its broken portions without any danger.  All that may  be said is that
 from having  only two branches, it  may not  be enabled  to seize the
 calculi with  as  much facility as the others do, and that  from  being
 confined to the crushing merely of the stone, we are obliged to  seize
 hold of all its fragments separately.  I will add that the detritus of
 the stone, which sometimes  remains attached to the inner surface of its
 branches, is also calculated to render their  approximation difficult.
 Dupuytren, who put it to the test on living man, was very well satis-
 fied with it, and was  enabled  in four or five sittings to destroy com-
 pletely a calculus of very large size ; I have also made  use of it with,
 the same advantage in many patients ; so that whether it be consid-
 ered in the condition in which it now is, after the  improvements made
 upon  it by MM. Leroy, Segalas, Thomas, Pasquier and Charriere, or
 after it shall have undergone certain modifications of which it appears
 to me to be still susceptible, this instrument will make excentric broie-
 ment by perforation  or evidement a matter  hereafter  of much  less
 importance, in addition to  the fact that  it has already  disproved the
 necessity of straight instruments.
   III.  M. Segalas, in  adopting the curved lithotritor, also deemed it
 advisable to modify it, in using it upon a patient  who could not sup-
 port the  straight sounds.   The improvements of this surgeon relate
 chiefly to the stem of the perforator, which in his apparatus, instead
 of having an articulated chain, is formed of metallic wires united in a
 bundle;  and also have reference to the means of bringing to the out-
 side and without danger, the fragments of the litholabe,  should  it be
 broken in the bladder; but I cannot see in these improvements any
 other than a very slight alteration, together  with unnecessary com-
 plications.
   IV.  New processes.—M. Heurteloup, going back to the ideas of
 the monk of Citeaux,  has proposed a curved instrument which opens
 in the manner of a shoemaker's  podometer, and  which, after having
 firmly embraced or secured the  stone between its  two branches, en-
 ables  us to break it  and to reduce it into fragments, by means of
 strokes  with  a  hammer made upon the  extremity of its  movable or
 upper branch.  This  apparatus  has effected an absolute revolution
 in lithotrity, and to such extent, that at the present time no other instru-
 ment scarcely is any  longer recommended.  In  place of the original
percussor of M. Heurteloup, surgical practice at the present day has at
 its disposition the percussion and compression forceps of  M. Touzet,
 the same instrument modified by MM. Leroy and Charriere, the dy-
 namometric percussor of M. Benique, the screw stone-breaker of M. 
LITHOTRITY.
997
 Sirhenry, the pressure and percussion stone-breaker of M. Amussat,
 a similar instrument of M. Clot-Bey, the percussion stone-breaker of
 M. Costello, that of M. Lestrange, the excentric screw stone-breaker
 of M. Charriere, the stone-breaker with a central screw or volant of
 M. Segalas, that of M. Civiale with rings, that of M. Leroy of funnel
 shape, the transverse stone-breakers of M. Amussat, those of M. Ban-
 cal and M. Bevenuti with handles, and better than  all  these the pig-
 non stone-breaker, such as it has been improved  by M. Charriere.
 These instruments, which may be manipulated with as much facility
 as a shoemaker's podometer, and which appear to have all derived their
 origin from that of Stodard, that of M. Hodgson, or that of M. Retore,
 (Leroy, Journ. Esculap., X. L, p.  3;  Hist, de la Lithot., Paris, 1839,
 in 8vo. fig.,) or the forceps of Weiss, or the catheter proposed by me
 in 1827, or the double  catheter of Cleland, (Bibl. de Planque, X. X.,
 p. 398, in 4to.,) render  the broiement much more secure, simple, and
 prompt, than by the ancient method.   Their free  extremity  being
 armed with transverse pieces,  handles, (poignees,) plates, buttons,
 screws, volants, nuts, heads, or pignons, enable us  to act upon  the
 calculus either by percussion or by pressure, with as little or as much
 force as we may desire.   Moreover, as they possess  a large  open-
 ing at the other extremity upon the inferior or fixed branch, an open-
 ing which in the forceps of M. Saas the upper or movable branch may
 go  beyond posteriorly, they  cannot become choked  up  with frag-
 ments or gravel.   Constituting in their ensemble instruments that  are
 sufficiently slender, though very  solid, they give much less  annoy-
 ance to the organs than the other  litholabes.
  a. Operative process.—The patient should  be placed and arranged
 in the same way as has been described above.   The forceps is to be
 introduced, shut up, and according to the usual rules of catheterism.
 The surgeon having introduced it to the bottom of the bladder, and
 made use of it to ascertain again the presence of the  stone, opens it
 by drawing upon its movable branch with his right hand, while with
 his  left hand near the  penis he holds the  other branch fixed.   He
 then makes  it describe the movement  of the. quarter of a  circle,
 which quickly  brings its convexity upon the  middle portion  or side
 of the bas fond of the bladder.  By pushing  the branches  of the for-
 ceps towards each  other, it is soon ascertained if the stone is grasped.
 In the contrary case, the same movement is to be repeated, or  we
 incline the branches or point ofthe instrument to the right or left, or
 downwards or backwards, in such manner as to seize the calculus
 firmly.  As soon as it is well  embraced, we  commence with break-
 ing it up.  The remainder ofthe manipulation then varies according
 as we adopt percussion, ecrasement, or simple pressure.
  b. Percussion.—If we propose to break  up the  calculus by per-
 cussion, we fix the  instrument by means of one of the  supports men-
 tioned, or with the left  hand ;  with a small hammer  made  expressly
for this purpose, and held in the other hand, we make rapid  strokes
 upon the button, head,  or plate of the litholabe, with a force propor-
tioned to the resistance of the calculus, without however being ever
increased to  such degree as to break the forceps.   Under  this point
of view the dynamometric apparatus contrived by M. Benique, as well
as all the other means hitherto proposed, in order to proportion the de- 
998           NEW ELEMENTS OF  OPERATIVE SURGERY.

gree of percussion to the force of the instrument, appear in my judg-
ment to be still less convenient and  less  secure than  the hand ham-
mer.
  c  If pressure with the hand should appear to be sufficient, the sur-
geon, who is always to be placed on the right, and with his back turned
towards the head of the patient, or to the outside, holding the litho-
labe  in the same way as in the preceding case, glides his right hand
under the instrument, in order to embrace its root from below upwards
and from behind forwards between the middle and ring finger, while
the palm of this hand makes full pressure upon its button or plate, by
the action of the wrist.
  d.  On the supposition that the instrument was provided with han-
dles or traverses, as in that of M. Bancal, for example, it would be
necessary that an assistant should  fix its  root firmly in the direction
towards the urethra; the operator being  situated in front or upon the
side, then embraces the double traverses of the fixed branch, and of
the movable branch on each side, in  order  to press upon them with
all the  force of his two hands,  and to make them glide on each other
while crushing  the calculus.
  e.  To effect ecrasement by  means of  the screw, the right hand
causes  the nut or the head-volant, or the virole-volant to turn, by a
mechanism which is too simple to make  it necessary  to describe it.
The  instrument, moreover, is fixed and secured as in the preceding
case.
  /.  The employment of the pignon is attended with no less facility.
The  stone being grasped, the surgeon holding  the  litholabe with his
left'hand in front of the urethra, adjusts and makes  its key, which  is
applied on the left side if he is on the right, and on  the right side if
he is in front, act in the pignon of the instrument until its two branch-
es are approximated and closed.
  g.  As the same instrument, among  those which are constructed
by M.  Charriere, enables us at pleasure  to make use  of the percus-
sion hammer, the dynamometric lever, pressure with  the hand, and
the nut or volant, or pignon, the surgeon may  substitute one of these
manipulations for the other, and employ them in succession or alter-
natively, without changing anything in the rest of the  operation, and
without being obliged to let go his grasp upon the stone, or to with-
draw the forceps.
  h.  Should the calculus have once become broken, or escaped from
the forceps, its fragments are to be taken up and crushed in the same
manner ; we may in this manner crush up 4, 6, 10 and  12, or even 15
fragments at a single sitting, if everything goes on well, and the pa-
tient suffers but little, and  should the  whole sitting not  extend beyond
ten to fifteen minutes.   Should the calculus appear to be very hard,
or make resistance, it would  be imprudent  to persist in crushing it.
We let go our hold upon it in order to grasp it in a different manner;
we strike upon  it again with direct and sudden strokes.  It is in these
cases that percussion possesses a  positive advantage over  pressure.
In cases however, where the hardness of the calculus would seem  to
make too  great a degree  of resistance,  as  I saw it do in the case
of M.  Desaugiers, and on  which  occasion  nearly  two  thousand
strokes with the hammer did not enable  M. Leroy to make any ap- 
LITHOTRITY.
999
  preciable impression,  lithotomy  could  still be substituted for litho-
  trity.
    i*. Before withdrawing the instrument, we shut it up completely,
  while cautiously avoiding to pinch up the bladder or inner extremity of
  the urethra between its branches.  Should portions of gravel, or frag-
  ments continue to remain attached between the branches ofthe litho-
  labe, they are to  be separated from it,  not by means of M. Leroy's
  rake, (rateau,) nor the blade grater  (lame-rape) of M.  Charriere,
  which can scarcely be combined  with any  other instrument than the
  stone-breaker of M. Jacobson, but by  repeated  drawer-like move-
  ments, and slight  movements of percussion, or  by friction with the
  movable extremity, which  is to be pushed one or more times through
  the aperture of the fixed branch, in such manner as to pass a line or
  two beyond its posterior plane.   It  is so much the more  important
  not to omit these  precautions, inasmuch  as the forceps, when angular
  bodies have become entangled in it, may, as it  comes  out,  irritate or
  lacerate  the  urethra;  and  because when the  instrument is  thus
  rendered  too  large, it  may  moreover become  wholly  arrested,
  either at the membranous portion, or in the fossa navicularis of the
  passage.
   j.  All the other attentions moreover, required by the operation,  are
  in these processes, both in respect to their manual and subsequent
  treatment, the same as  in the processes with straight instruments.

                  § II.—Difficulties of Lithotrity.

   Notwithstanding the leather boxes, and the accuracy with  which
  the three principal pieces of the apparatus set into each other, it some-
  times happens  that the  injection escapes between them, or between
  the external  canula  and the walls of the urethra.  A small gutter
  which is made upon the dorsum of the sheath, and which communicates
 with the bladder by means of a groove  which runs along the outer
 surface of the litholabe, is added to some of the new apparatus, with
 the view of remedying  this inconvenience.   We  might in fact apply
 to  this  the syphon of the syringe, and make use  of it as a catheter
 to renew the injection ;  but the irritability ofthe bladder soon places
 things in the  same condition ;  fortunately the  organ rarely empties
 itself completely.
   A.  Before  puberty lithotrity is attended  with less facility than in
 the adult, because of the slight degree of development of the sexual
 organs, the small calibre of the urethra, the indocility of such patients
 and the exquisite  sensibility of the parts.   The instruments cannot
 have  more than  two to two lines and  a   half in diameter, which
 sensibly diminishes their power, while at a  more  advanced age we
 may give them as much as four lines, although those of three to three
 and a half lines generally suffice. _  It is still Jess adapted to the first
 years of infancy, for  the reasons just given, and  moreover because
 the bladder, which  is raised up too much in the, pelvis, increases to
 the same extent the curvature of the posterior third of the urethra,
and also because at this period of life lithotomy presents  numerous
chances of success.   It  does not however follow  from this that  the
broiement of the stone is  an impossible operation  in infants.  MM. 
1000         NEW  ELEMENTS  OF OPERATIVE SURGERY.
Leroy, Segalas and others  have demonstrated the advantages that
may be obtained  from it at that period of life.   I have said only, and
I still maintain,  after having  frequently verified the fact, that  in
general it then involves more inconveniences than lithotomy.
  B.  The prostate, in certain  patients,  renders the  application  of
lithotrity a matter of considerable difficulty, in consequence of the
urethra being pushed back behind the symphysis.   It is under such
circumstances that curved instruments would, to some,extent, become
a matter of necessity.   M. Leroy, struck with this circumstance and
with the view of lessening its  gravity, and from  having frequently
witnessed the danger or the  impossibility of using straight instru-
ments, proposes a means which is very simple in appearance, which
he calls the adjuster (redresseur)of the urethra, and which consists
of a  gum-elastic  catheter which  is  introduced curved, and  is
afterwards to  be straightened when in its  place by  means  of a
straight stilette, which a screw pushes gently into its interior  from
before backwards.  This instrument, analogous to that  proposed  by
M. Rigal for  the same purpose, and which, as  has been remarked  by
M.  Pravaz, the  lithotritor cylinder  conducted by means of  spiral
movements of the hand  through a  large flexible catheter opened at
its two extremities, might if necessary replace, exposes to the risk of
serious  inconveniences, and to  the contusion of the verumontanum
and laceration of the  urethra, in consequence of the screw or nut,
the force of which cannot be calculated,  and because  the head of its
stilette cannot progress except by butting against each point of the
lower wall  of the canal.   The instrument of M. Tanchou  being
formed in its vesical third  of  a series of small articulated pieces,
which allow of its being  introduced curved, and of its being straight-
ened when in its place without making  the slightest friction, would
be evidently preferable  if the  straightening of the urethra were a
precaution of actual importance in  such cases.  An extreme degree
of development in the prostate involves another  inconvenience: it
sometimes, as I have said farther back, transforms the bas fond and
trigonus vesicalis into  a deep  cavity, where the  stone  cannot  be
always seized with facility, unless after the  manner of M. Begin,
(Elem.  de Chir., 2e edit., Paris, 1838.  p. 667.)  we should  prefer
placing the patient on his  knees and elbows.  The fingers of the
assistant or of the surgeon  introduced into the rectum, in order to
raise  it up and to  present  it  to the  claws (serres) of the litholabe,
would answer full as well, I conceive, as the  little sac suggested  by
M. Tanchou,  or  the tampons, of whatever  description they may be,
which might be introduced above the anus.
  C.  In women,  in whom M.  Buret (Bibl. Med., 1828, t. IL, p.  16)
has succeeded by means of a simple stone-breaker, lithotrity is more
easy  than in  man, and  almost unattended with danger.  As their
urethra is large, distensible, short, destitute of curvature, prostate, or
seminal orifices, it accommodates itself admirably to the introduction
of the necessary instruments,  and  does not  require  as complete a
pulverization of the calculus.   Only they have more trouble in sup-
porting and retaining the injections, which however are  less  neces-
sary in a bladder which is naturally large, pliant, and, so to  speak,
exposed to view; so much so  that M. Segalas  succeeded  in  re- 
LITHOTRITY.
1001
 moving, in a little  girl three years of age, and  after a verv few
 sittings, a calculus of large size, though no liquid could  be kept" up in
 the bladder.  It must nevertheless be confessed, after what occurred in
 the patients operated upon by MM. Bancal, Civiale, Leroy, Breschet,
 &c, that as  lithotomy in women rarely causes death in more than
 one case out of twenty or twenty-five, it would appear to be still less
 dangerous in them up to the present time than broiement.
   D. The curved instrument, of M. Pravaz, (Bull, de Fer., X. XVIL,
 p.  264; Gaz.  Med.,  1833,  p.  143,) M.  Pamard,  (Ibid:,  X. XIX.,
 p. 71,)  or of M. Leroy, being intended for the same system of broie-
 ment as the apparatus whose application I have  just  described, do
 not require  any  other  details for the operative  manual.  Their
 principal  advantage consists in occasioning less annoyance to the
 urethra, and  causing consequently less pain, and of penetrating with
 more facility into the bladder.   As  on the other hand they are less
 commodious than the others, for exploring  the  organ and for find-
 ing and seizing the  stone, it  is unnecessary if we adopt the process
 of  perforations,  to employ them in women.   All  other things  being
 equal, the straight instruments are to be preferred for lithotrity by
 perforation, evidement or concentric broiement; while the curved
 instruments are better adapted to ecrasement.
   E. The instrument of M. Jacobson is one of the easiest to mani-
 pulate ; there is not  one which exposes less  to the risk  of wounding
 the bladder.  As it consists of nothing more than a single  articula-
 ted noose, and has neither hooks nor free points, it w7ould be almost
 impossible for it to pinch up  or perforate the walls of  the bladder;
 so that we might if necessary use it without  any previous injection.
 Its curvature renders its introduction as easy as that  of an ordinary
 sound.  The manner of opening it is very simple.  The nut having
 been brought up to the end of the screw, the palm of the right hand
 is made to  rest  upon this extremity.  We push  upon  it,, and the
 jointed branch of the forceps immediately opens itself in the  blad-
 der, as if for the purpose of forming a racket circle, which  is some-
 what irregular, in consequence of the dorsal concavity on the other
 branch.  We proceed in search of the  calculus  after the rules laid
 down above.  When it has finally entered into the metallic circle,
 we act upon the screw first with  the  hand, in the same  way as for
 shutting up a litholabe,  and then upon  the nut which is transformed
 into a quick  screw,  and which, by  making  the  two halves of the
 stone-breaker act in the manner of two large files moving in a con-
 trary direction upon the calculus, concentrates all its  action  on this
 last, and cannot fail  of effecting the ecrasement.   The various frag-
 ments which  are thrown off, are subjected to the same researches and
 the same manoeuvres.  The  surgeon has  no need  of any assistant,
 the patient experiences  but little fatigue, and nothing prevents our
 repeating  the sittings  at short  intervals.  Finally, the  position re-
 quires  no other  precautions than those of catheterism in  general.
 Only that it  is  unfortunate that these advantages are countei'bal-
 anced by the greater difficulty of finding and seizing those stones that
 are small, and of  satisfying ourselves whether they  have or have not
entered into the noose of the  forceps, also by the impossibility of ex-
tractino- any fragment of them, and by the pinching up  of the pros- 
1002
NEW ELEMENTS OF OPERATIVE SURGERY.
 tatic portion of the urethra, which is sometimes  caused by the  slip-
 ping of the branches.
   F. Forceps with two branches.—The modern forceps, either those
 for percussion, those that have a volant  or screw, or those that are
 intended  only  for simple ecrasement, may  be employed with still
 greater facility than the instrument of M. Jacobson.   As their ex-
 tremity may be turned to the right or left or backwards, they enable
 us to seize the  calculus in any of the recesses of the  bladder.   As
 they admit of being opened  and  shut  without any effort, and with
 all the rapidity desirable,  they do not require any support, and  thus
 render the operation evidently more  prompt.   Their  principal in-
 convenience is that  of allowing the stone to escape from them with
 facility, and  that  of reducing the calculus into  angular fragments,
 which disturb and irritate the bladder.
   G. M.  Heurteloup, for the purpose of extracting these fragments,
 makes use of a large  and straight, or  curved catheter, the species
 of die which forms  the vesical extremity of which may be unscrew-
 ed at pleasure, and is designated by the  name of magasin.   Later
 ally, and at nearly an inch from its inner extremity, it has two large
 apertures, which are placed in front of each  other.  The other ex-
 tremity is provided with a stopper box, (boite a bouchon,) afasset, to
 make  injections, and a ring, to serve  as  a support to the fingers.
 The liquids, which by means of this instrument  are thrown up  into
 the bladder, bring with them as they return through  the apertures,
 all such  fragments  whose size will admit of their passing through
 the instrument.  Those which are of larger dimensions are  arrested
 in its apertures.  The author then makes use of a jointed  stilette,
 and  which is flexible  like  the lithotritor of M.  Pravaz, in order to
 break or crush  the projecting portion of the  stone, and to crowd it
 to the bottom of the  magazine of the catheter, while the other por-
 tion  of the calculus falls back again  into the bladder.   When after
 the repetition of  this  manipulation  a greater or less  number of
 times, the magazine  is found  to be filled, the instrument is withdrawn,
 in order to unscrew and to empty  and reintroduce it, in order to
 repeat the manipulation if it is deemed advisable.   M. Leroy alleges
 that  this object  can be still better accomplished by means of an in-
 strument of the same kind, but in which the central stem can act at
 the same time both by pressure and rotation.   Without rejecting in
 an absolute manner the aid of such instruments, we nevertheless feel
 compelled to avow that their probable advantages are not so evident
 as to induce practitioners  to  be anxious to adopt them,  or  to sub-
 stitute them  for, or  even to  associate them  with, the  other instru-
 ments already known.

   § III.—Comparative examination of lithotomy and lithotrity.

  The broiement of the stone was scarcely invented, when its parti-
 sans gave it out as an operation altogether innocent and devoid of
 danger.  Some, moreover, have  considered  that it was of such a
nature, that it would one day enable us to dispense with lithotomy in
surgical practice.  The public has been deceived in  both these re-
spects.  Lithotrity, such as it is now practised,  is in the aggregate 
LITHOTRITY.
1003
 still an operation in many instances more  painful and more tedious
 than cystotomy; I  have seen patients, and among others one who
 was operated upon by M. Souberbielle, after having been treated by
 M. Civiale, affirm that one single essay at broiement gave them more
 suffering than all the manipulations of  lithotomy.   A fourth, if not a
 third even, of the individuals upon whom lithotrity is performed, ex-
 perience accidents, and it is not true that it never results  in death.
 Out of 82 calculous patients mentioned by M. Civiale, 31 succumbed
 at the expiration of a year, and 19 others were not restored until after
 having experienced a certain number of accidents.  Out of forty M.
 Leroy was not enabled to effect  the radical  cure of more than 25.
 Out  of 10 M. Bancal  accomplished it  in only 2 instances, &c.; so
 that among a selected .number of patients, there dies at least  one
 out of every 10 or  12, and if we  take an aggregate of calculous pa-
 tients, some of whom are subjected to lithotrity, others  to lithotomy,
 or left to  the  resources  of the  system, there will perish at least, a
 sixth or eighth part of them.  Lithotomy, if examined in this point of
 view alone,  will, nevertheless, always be still the most alarming,
 and the enthusiasts of broiement have no need of blackening the ca-
 talogue which relates to this operation, to  disgust the public with it,
 and deter patients from submitting to it.  Although authentic details
 show, that out of 812 persons operated upon  at the Hotel  Dieu and
 La Charite, in Paris, 255 perished, between the 31st  of December,
 1719, and the 1st of January, 1728, other facts demonstrate, that out
 of 213 Cheselden lost but 24.  Though M.  Sanson says  that he has
 seen 6 perish out of 20, Dupuytren, nearly at  the same epoch, had
 operated upon 26 patients before he lost a single one, and M. Dudley
 of the Transylvania University, met with the same success  out of 72
 patients.   Without  admitting the astonishing cures imputed by some
 persons to Raw, and without conceding that this surgeon was enabled
 to succeed in 1500 operations in succession, instead of affirming only,
 that out of the totality of patients operated upon by him, he had ef-
 fected 1500 cures, it appears certain at least, that Martineau lost  but
 2 out of 84 ;  M. Pansa, of Naples, 5 out of 66, Pouteau 2 out of 80,
 Lecat 3 out of 63, M. Pajola, of Venice, about  the same  proportion,
 M. Viricel, of Lyons, 3 out of 83, M. Ouvrard, of Dijon, 3 out of 60,
 Saucerotte 1 out of 60, and that  Deschamps, at one period, suc-
 ceeded in effecting  19 cures in succession.  It is true that these facts
 are but imperfect.  The same practitioners have not always been so
 fortunate ; but why should it not be the same with lithotrity 1  Senac
 had reason for saying that the greater portion  of patients  operated
 upon for lithotomy in the hospitals of Paris perished, since out of 29 in
 1725, at La Charite, 16 succumbed.  Another person, however, would
 not have  been wrong in asserting that there died but one only out
 of 8 or 9 cases, for in the same establishment 22 were  cured out of
 25, in 1727, and 23 out of 26, in  1720; which, however, did not pre-
 vent  Morand from ascertaining that in  this hospital 71  perished  out
 of 208 operated upon during the space of 8 years, while at the Hotel
 Dieu, in the  same  space of time 18  only succumbed out of 594.
 Though M. Souberbielle lost 18 out of 52,  in 1824  and  1825, his
average proportion  was not less than one out of every  6  or 8 opera-
tions.  Though M. Richerand has considered that the failures and cures 
1004         NEW ELEMENTS OF  OPERATIVE SURGERY.
balance each other equally at the beginning of this  century, MM.
Roux and Dupuytren have set them down in the proportion of 1 out
of 5 to 6.
  The following is what is exhibited by the best  accredited statisti-
cal tables which have been published since the year 1810:  At Nor-
wich, out of 506 there were 70  deaths ;  at Leeds, 28  deaths out of
197  persons  operated upon;  at  Bristol,  1 out of 4 and a  quarter;
at Luneville, 1 out of 14 ;  and  in the table of Dupuytren, which coin-
prises Taris and its environs, there were since the year 1820, 61 deaths
out of 356 operated upon, that is, one out of every six.  Thus lithot-
omy causes death in one case out of every 6  or 7 operations and no
more.   Lithotrity I am convinced is less fatal; it would be necessary
however, to know to what extent, but experience has not yet enabled
us to decide  on  this matter.   In order  to determine this  question
there is one condition which  conscientious persons should  not lose
sight of, which is this, that individuals who can be operated  upon by
lithotrity are precisely those in whom lithotomy would succeed the
best; while almost all those patients in whom  broiement would be
inapplicable, have also fewer chances of being cured by lithotomy.
The solution of the problem therefore wouid  not be final, unless we
should select several hundreds of calculous patients for lithotrity, with
the view- of afterwards dividing them into two equal parts, one of
which should be  submitted to lithotomy and the other  to lithotrity.
  Even though lithotrity should  be attended with still  less danger, it
could not be applied to all cases.  Those calculi which have for their
centre a metallic body, pin,  needle, ball, &c, or for their nucleus a
fragment of wood, horn or ivory, would  in general be unsuitable for
lithotrity.  An Italian surgeon completely failed  in endeavoring to
break up a calculus the nucleus of which was formed by a fragment
of the pith of wood, (Petrequin, Gaz. Med., 1837, No. 42,) and M.
Leroy,  (Rev. Med., 1836,  t. I., p. 50,) in a  case where the stone had
formed upon a  stem of wood, did not succeed until  after  a num-
ber of trials.  I  should however add, that M. Cazenave found five
sittings sufficient  (Gaz. Med.,  1838, p. 186) to break up  and extract
a calculus which had become encrusted upon an ear of wheat.  The
same difficulty occurs with encysted or adherent calculi, or those which
have become in  any manner whatever immovable, those which are
exceedingly hard and which exceed the dimensions of a pullet's egg,
and upon which the bladder is constantly applied, also in individuals
who have the urethra deformed, either from  birth, (as in epispadias
and  hypospadias,) or in consequence of  disease, and to  such extent
as to render the  employment of  suitable instruments a mattei of too
great difficulty.   M. Franc,  (Ext. des Calcules, p. 6,)  who  proposes
when the urethra is diseased or  contracted, that we should  have re-
course to lithotrity at the hypogastrium, and who, like  M. Dudon,
advises that we should for this purpose make use of a  trochar armed
with a large canula, in order to be enabled to introduce by that means
the suitable instruments required of as large size as possible, calls to
his aid in this manner an operation which is  more dangerous than
lithotomy.  A great number of calculi, a considerable degree of conges-
tion in the prostate, or an ancient diseased condition and racornissement
of the bladder, would in the majority of cases make the operation of 
LITHOTRITY.                      1005
lithotrity at least  as dangerous  as lithotomy.  Its  advantages  in
the other cases appear to me to be indisputable, except in infants, and
especially useful in those cases in which the patient is possessed of a
certain degree of fortitude and docility, and an irritability sufficiently
obtuse to support the various manipulations without fear, and also in
those  cases where the patient  has a sufficient, repugnance to cut-
ting instruments to induce him to resign himself without difficulty to
the prospect of being relieved at the expiration of a greater or less
length of time, and where he can endure the introduction ofthe lithotri-
tic apparatus as often as it shall  become necessary for the purpose
of destroying  the  stone.  Though the return of the disease is much
more  probable than  after  cystotomy, because  of the fragments of
calculus which must frequently escape the  most minute researches,
we should not however hesitate in having recourse to  it, when there
is reason to believe that two, three, four, five or six sittings will prove
sufficient.  Lithotomy therefore is incomparably the most alarming of
the two.   By  it, it is true, the stone is more rapidly and more per-
fectly removed, and the sufferings, so to speak, are momentary ; but
the patient nevertheless is obliged to keep his bed or chamber during
the space of twenty  or  thirty days, while lithotrity, with the excep-
tion of the sittings, scarcely  interferes with  his customary occupa-
tions.
  A. Statistics of Lithotomy and Lithotrity.—I. Lithotrity.—At the
present day, which is eight years  since  the publication of the pre-
ceding remarks, it is still  almost  impossible to come to any other
judgment on  the appreciation  of lithotrity.   Its  results have been
given with so much partiality that science, in this matter, will have
to be almost completely reconstructed.
  a.  When, for example, we  analyze carefully the facts taken from
the  practice of M. Civiale, who considers that he has  lost but six
patients out of more  than two hundred, we find the following result:

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

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

  1st observation.    The size of the stone not mentioned ; cured.
  2nd     "        Stone friable and small; cured.
  3d      "         Size of a nut; cured.
  4th      "        Size of  a  nut and friable; operation  difficult;
                     cured.
  5th      "        Size of an almond; operation difficult; orchitis;
                     cured. 
1006         NEW ELEMENTS OF OPERATIVE SURGERY.
6th observation.		Size of a small egg ; dead.
7th	a	Size of a nut; fever and accidents ; cured.
8th	a	Stone friable; difficult; disease returned.
9th	u	Size of an almond ; dead.
10th	a	Two calculi; cured.
11th	a	Size of a small nut; cured.
12th	a	Small and friable ; woman ; cured.
13th	u	16 calculi; three months of treatment; cured.
14th	.(	Size of small egg ; cured.
15th	u	Size of nut; returned, and died one year after.
16th	a	Stone flattened; cured.
17th	\.	Several stones; cured ; difficult
18th	a	Size of almond ; cured.
19th	a	Friable ; returned ; died one year after.
20th	a	Size of an egg ; cured.
21st	a	Several stones; cured.
22nd	a	Large, friable ; died in a month.
23d	a	Several small calculi; cured.
24th	a	Several stones ; died two months after; re-tention of urine.
25th	M	Nut; friable ; cured.
26th	u	Large stone; operation difficult; cured.
27th	a	Large and friable ; eured.
28th	a	Nut; cured.
29th	M	Many ; treatment of several months; cured.
30th	a	Small, friable; cured.
31st	«	Small; cured.
32nd	«(	Nut; difficult; cured.
33d	a	Small, friable; died three months after.
34th	u	Small.
35th	u	Nut; two months of treatment; cured.
36th	M	Many; size of a nut; 2 mos. treatment; cured.
37th	«	Medium size; treatment tedious; cured
38th	((	12 lines; cured.
39th	a	Friable; cured.
40th	a	Medium size; returned.
41st	u	Voluminous; cured.
42nd	a	Small; cured.
43d	u	a .1
  Other facts which M. Civiale does not take into consideration, have
nevertheless a certain degree of value ;  I extract them  from his
book:
             Gervais. Essays ?  Lithotomy performed.      Dead.
             ---------------   Stone 5 ounces.
             Baticle; preparatives and lithotomy performed.   "
             Count de  Bournon ;  stone broken  up ;  lithoto-
               my performed.                               "
             Admiral Leroy ; lithotomy performed.           "
             Bonleu; explored;   "         "               "
             Demausse;          "         "               "
             Bellefond;   "       "         "               "
Page xxxiv.
  "   XXXV.
 xli.
xlii.
xliii.
xliv. 
LITHOTRITY.
1007
              Pallu.                                      Dead.
              De Tascher ; broken up.                      "
              Diernot;                                     "
              Montessu;  explored.                          "
              Combes.                                      "
              Desrenaudes.                                 "
              Vincent; broken up.                          "
              Chevals ; died during the preparatory treatment.
              Fayau; broken up.                           "
              Regnauld.                                    "
              Faure;  broken up.                     .      "
              N.; explored.                                "
              Labat; attempt to break up.                   "
              Chetelal;  explored.                           "
              Farder.                                      "
              Aumont; broken up.                          "
              Quartara;  essays.                            "
              Balet; broken up.                             "
              Viollance;  "                                 "
              Huet;     "                                 "
              Lebaigue;  "                                 "
              Azille ;
              Provostv, a physician ; explored.
              Dallery:
              Leblanc Lavalliere; essays.                   **
              Carpenter; broken up.                        "
              Jule Perin.                                   "

As for  the rest I have made use of subsequent  publications of M.
Civiale, M.  Larey, M. Double and M. Ledain, and valuable informa-
tion which  has been furnished  me by ocular witnesses, or which  I
have myself taken on the spot.
  b.  Without measuring by the same  rule the successes announced
by M. Heurteloup,  who states that he  has  succeeded 37 times in 38
patients ;  by M. Leroy who  lost only 11 out of 116 operations ; and
by M. Bancal who, in 1838, lost but one out of 23, it is nevertheless
allowable not to take literally  the statements of those gentlemen.
The English journals of medicine, in  fact, together with the letters
of M. Key  and of M. B. Cooper and M. Tarral, as also the lectures
of MM. Brodie, Liston and Chas.  Bell,  show  that several  of the
patients of  M. Heurteloup had deceived the  operator, and that they
were not cured when their cases were published.   In the twelve cases
of lithotrity taken  by M. Doubowitzki, (Reprod. Fid. des Discuss.,
fyc, 1835,)  from  the practice of M. Amussat, we find five positive
cases of cure, four of doubtful success, and three instances of death.
Though M. Amussat has formally denied  this,  it is  certain that
the Count D'Auxi, among others, died  after the expiration of a few
months without ever having ceased to suffer, and that there were
still remaining three or four small  calculi with facettes in his bladder.
The patient operated upon  by M. Civiale at Florence in 1835, was not
cured.  At the Neckar Hospital, at the same period, there died at
'east two out of  six or eight.  A merchant of Lyon, a patient from
ge xii.	
i<	xiii.
i<	«
K	xiv.
a	xvi.
u	xvii.
a	xviii.
u	xix.
n	XX.
n	xxi.
a	xxii.
u	«
u	lviii.
a	Ixv.
«	cxlviii.
u	clvii.
a	clix.
i«	clxxiii.
u	clxxix.
u	clxxxi.
a	clxxxiii.
«	clxxxviii.
<<	xxviii.
il	XX.
a	xxxi.
a	ccxv.
n	cciv.
 
1008          NEW  ELEMENTS  OF OPERATIVE SURGERY.

Anjou, another from the country, two from the department of Seine and
Oise, the husband of a midwife at Paris, a printer, a  patient of M.
Roux, two of mine, one of M. Lenoir, the English  Colonel Rankin,
another personage of the same country, a case operated upon by M.
Attenbury, a patient of M. Olknow, one of M. Colliex, and one of
M. Norris, and others also have alike succumbed under the operation
of lithotrity.   It would be therefore, I repeat, to abuse the public, to
give out this  operation as destitute of every kind of danger.   M.
Bancal  having 53  calculous  patients  to  treat, (Clin.  Civil.,  fyc,
Bordeaux, 1839, in 8vo.,) attempted broiement in 30 ; 22 were cured,
7 gave  it up, and  1  died.  Thev were of the following ages:  72,
60, 78, 74, 45, 06, 59, 40, 70, 35, 68, 34, 70, 72, 70, 37, 52, 64, 77, 74,
63, 52, 76, 75,55,52, 32,60, 56, and 78.   Twenty-three patients were
subjected by this practitioner to lithotomy:  6 died and 17 were cured.
Those who survived were ofthe following ages: 77 (with 55 calculi),
70 (3 calculi), 50 (1 calculus),  69 (1 calc), 70 (3 calc), 68 (8 calc),
50 (1 calc), 72 (1 calc),  66 (1 calc), 60 (1 calc), 70  (25 fragments
by the  lithotritor), 32 (1  calc), 70 (7 calc), 60 (7 calc), 6  (1 calc),
10 (1 calc), and 68 (15 calc).   The ages of those who died were:
80 (3 large calculi), 22 (I large calc), 56 (2 large calc. and  the blad-
der bilobate), 84 (10 calc), 66  (1 large  calc), and 58 (1 large calc);
from whence it appears that  in 22  it was practicable to perform
lithotrity to the end ofthe treatment, while 31 had to be subjected to
another course of remedies.   But this  table scarcely  accords with
the first publication  of M. Bancal, since, out of 13 patients whom he
then mentioned, 4 of them died, one or two were cured, and  7 gave
up the process.  M. Randolph, (American Journ. of Med.  Sciences,
Nov. 1834, '36,)  who  asserts  that  he has  performed lithotrity 13
times successfully, does not declare that he has never failed in it.  In a
patient  in whom lithotrity was  attempted  with a percussor, which
made a false track,  it resulted  in death and  became in this way the
subject  of an inquest in England, on the part of the College of Sur-
geons, (Gaz. Med., 1837, p. 676.)  With M. Tonelle however, (Precis
Med. d'Indre  et Loire, 1838, p. 83,) who has already performed this
operation a  great number of times with success,  three sittings were
found sufficient  to  relieve a patient of a stone as large as an  egg.
M. Breschet also (Gaz. Med., 1838, p. 184) rnade use of lithotrity
successfully in a woman who had  suffered for the space of eight
months.  It has also  been performed with success by M. Bonfils,
(Trans.  Med., X. XL,  p. 264,) M. Liston, (Bull, de Fer., X.  XVIL,
p. 400,)  M. Wattemann, (Ibid., X. XVL, p. 440;  t. XVIIL, p. 73,)
M. Randolph, (Account of six  cases, fyc, 1834; American Journ. of
Med. Sc,) M. Depeyre, (New York Med. Journ.,  February, 1831.)
M. Cazenave, (Oper. de Lithotrit., fyc, 1837,) and MM. P. Guersant,
Blandin, Sanson and Payan;  but a patient, who was operated upon
by M. Castara, (Journ. des Conn. Med.-Chir., X. III., p. 368,) died
from cystitis, and that of M. Lallemand (Lafosse, Clin, de Montpelier,
6fC, p.  19) from purulent infection.
  c.  In what  relates to myself, I count up to the present time (May,
1839) but twelve cases in lithotrity:
  1. Man; 55 years; calculus size of a large nut;  two sittings; 
LITHOTRITY.
1009
 calculus badly  seized;  pains  quite acute, which vexed the  patient,
 and he went to a specialty practitioner ;  straight instruments ;  1827.
   2.  Man; 32 years; calculus like a small nut; seized and broken
 up in one sitting; litholabe with three branches;  1829.
   3.  Man; 61 years; calculus size of a large nut; perineum  pain-
 ful ; cystitis distinctly pronounced;  an essay with M. Sirhenry's for-
 ceps ; urinous collections ; nephritis; death; ulcerated urethra; kid-
 neys in state of suppuration ;  1831.
   4.  Man ; 58 years; calculus flat;  fruitless attempt with M.  Tan-
 chou's instrument; patient cut and cured ;  two inches and  a  half in
 the great diameter of the calculus ;  1831.
   5.  Man ;  same age ; ineffectual attempt with the apparatus of M
 Pravaz; no accident; cut; cured;  1832.
   6.  Man ;  57  years  of age ; calculus like a  small egg; thirteen
 sittings ; success ; instrument of Jacobson ; 1834.
   7.  Man ;  65 years ; calculus of moderate size; six sittings ; suc-
 cess; instrument of Jacobson ;  1834.
   8.  Man;  68 years; size of large  nut; three easy sittings;  cys-
 titis ; acute nephritis ; death ;  13 fragments in  the bladder ;  instru-
 ment of Jacobson ;  1834.
   9.  Man;  58 years; size of pullet's egg; seventeen sittings; suc-
 cess ; Heurteloup's pressure forceps, with  screw and volant;  1835.
   10. Man; 54 years ;  numerous stones ;  prostate diseased ; will
 undergo lithotrity at any hazard ; four easy sittings ; 60 fragments
 expelled ; cystitis;  nephritis;  death;  73 calculi intact;  95  frag-
 ments ; fungus of the prostate, and kidney in suppuration; Heurte-
 loup's instrument as modified, tried once; Jacobson's brise-pierre
 three times: 1836.
   11. Man; 69  years;  calculus  like a  small  nut;  three  sittings
 rapid success ; pignon forceps ; 1837.
   12. Young man ;  20 years ;  calculus size of an egg; does not  wish
 to be cut on  any account; first  attempt  easy;  stone broke twice
 with the pignon  litholabe.  Second attempt—patient extremely in-
 tractable ; violent and  incessant  contractions of  the bladder;  sud-
 den erections of the penis on the slightest movements ofthe forceps.
 Third and fourth attempt fully as ineffectual; lithotomy performed :
 success prompt;  1837.
  In  examining the results furnished by lithotomy in different coun-
 tries, M. Civiale, it is seen, has singularly imbrunated the  table, so
 that on this point, as well as  in what  relates  to  broiement, the
 works of this practitioner, from the first to the  last, are only calcu-
 lated to mislead  the  reader into the strangest delusions.
  II.  Lithotomy.—The following  now is what the tables furnish in
 respect to lithotomy.
  M.  Dudley, (The  Lancet,  1838,  vol. IL, p.  307—London Med.
 Gaz., June,  1837, p. 448—Transylvania Journal, &c, vol. X., p. 91.)
 Out of 148  patients, 10 refused to be operated upon.   Out of 138
 operated upon, 131 were cured ; 4 died, 1 of pleurisy, 2 of nephritis,
 1 of disease  of the liver, though the  wound had  cicatrized;  and 3
had a fistula succeed to the operation.
  Brett, (Kleinert's Repertoire, March, 1835, p. 163.)  In India out
of 22 cases  of operation, 4 patients died from exhaustion.
                               64 
1010         NEW ELEMENTS OF OPERATIVE SURGERY.
  Clot, (Compte  Rendu  d'Abouzabel, 1832, p. 49.)   Out of an ag-
gregate of 58 patients, 6 died.
  Paxsa,  (Naples, 1827, Bull, de Fer., X. XV., p. 66.)   32  cases, 5
deaths.
  Kern, (Bull, de Fer., t. XV., p. 64.)  Lateral method ; 334 cases
and 31 deaths.
  Burnard, (Arch.  Gen. de Med., 2e  ser., t.  I., p. 427.)   At the
Hospital of Benares at Bengal; out of 22 operated upon, 5 deaths.
Cheselden,	213	operated upon,	24 deaths.
Pouteau,	80	a	2 "
Martineau,	84	a	2 . "
Saucerotte,	60	a	1
Deschamps,	20	a	1 "
Viricel,	83	a	3 "
Ouvrard,	60	(<	3 "
Pajola,	50	a	5 "
Dupuytren,	27	«	1 "
a	70	(<	6 "
Mejean,	105	a	1 "
Delmas,	11	n	1 "
  Hotel Dieu, and Charite, from 1719 to 1728, 812 operated  upon,
251 dead.
  At Luneville, for the same period, 1629 operated on, 147 dead.
  Cross, at Norfolk and Norwich, mentions 704 calculous patients, of
whom there were:
      Men.       669 cases,       478 cures,      91 deaths.
 35
197
33
33
 2
28
    Women,
At Leeds,

At Naples, (De Renzi, Gaz. Med., 1835, p. 217,) in fourteen years:
                      440 cases,   375 cures,    65 deaths.
                       25
Petrunti,
Santoro,
Smith,
Souberbielle,
F. Jacques,
24
 56
 17
133
 60
 38
 50
 23
100
 22
 50
at Brassels,
" Versailles,
" Angers,         2
" Hotel de Lorges,  1
     81 cures,     19
                   1
                   1
17   "
no deaths
  b
Ste
    F. Come,
    Chelius,
    Mott,
     Out of  1411  calculous patients, received into  the Hospital of
    Marie at Moscow, from the year 1808 to 1836, there were  411
operated upon from  1829 to  1837.  Out of these last 369 were
cured; 41 were not cured  at the time  of their leaving; 42 suc-
cumbed ;  17 died without being operated upon ;  46  were from 15 to
62 years of  age, and  323  between  1  and 16 years; 11 of the  first
succumbed,  and 31 of the second.   M. Roos, (Gaz. Mid., 1838, p.
810,) says nothing of those that  were operated upon before  the 
LITHOTRITY.
1011
year 1830.  According to M. Franc, on the contrary, (Extrait des
Calculs, &c, p. 10,) who  has  frequented the  hospitals of Montpe-
lier, out of those operated  on by lithotomy, as many die as are cured.
It must be admitted, however,  that the accuracy of these propor-
tions is not placed beyond all dispute, and that the facts which serve
as their basis, are not accompanied with all  the details that are de-
sirable.  The series given by M. Cross is one of the best which we
possess.  Out of 704 patients mentioned by him there were :
  Children from 1 to 10 years,  281 cases,   262 cures,  19 deaths.
     "      "  11 " 20  "     106   "     97   "     9   "
  Adults    "  21 " 50  "     143   "    125   "   18
     "      "  50 " 80  "     174   "    127   "   47   "
  c. The weight of calculi.-^-Oui of 271 patients in whom the calcu-
lus  weighed more  than 5 gros, 215 were  cured and 56 perished.
Out of 529 in whom the  calculus weighed less than  an ounce. 47
succumbed and 482 were cured.  Being desirous of ascertaining if it
was possible to estimate the dimensions of a calculus by means of its
weight, I took  several of those that are in the museum of the Facul-
ty of Medicine, and after having requested M. A. Thillaye to examine
them, I obtained the following facts:

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

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

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

  From whence it follows that every calculus of half an ounce in
weight ought to have nearly an inch in diameter.
  d. I owe to  the politeness of M. Castara, an  unpublished  table,
which is still more valuable than that  of M. Cross, and which  I pre-
sent on the following pages.  It relates to the patients operated upon
at Luneville, from the year 1738 to 1828, and  must be received as a
guide or supplement to  that of Saucerotte. 
1012
NEW ELEMENTS OF  OPERATIVE SURGERY.
Hospital of Luneville.
	Number of calcu-	Sex.		Deaths.		Mortality	Mor-tality	Mortality		
										
Age.	lous		g		£	among	among		in the	Operated on a second time.
	patients	w	~3	«	H	Males.	Fe-	two sexes.		
	operated	"5	s	"ed	£		males.			
	upon.	17	1	S3 3	£			1 in 6		
2 to 3	18					1 in 5 2-3				2 1 after 1 year 1 after 3 years.
3" 4	82	79	3	4		1 " 19 3-4		1 '	20 1-2	2 1" 6mos. 1 " 3 "
4" 5	135	131	4	8		1 " 7 5-8		1 '	7 1-2	2 1" 6mos. 1 " 4 "
5" 6	145	141	4	10	i	1 " 17 5-8	1 in 4	1 "	15 2-3	2 1 " 6 mos. 1 " 4 "
6" 7	144	139	5	16		1 " J3 9-10		1 "	14 2-3	
7" 8	119	113	6	5		1 " 18 5-6		1 "	19 5-6	
8" 9	119	116	3	0		1 " 23 2 5		1 "	23 4-5	1 after 2 years.
9 "10	88	84	4	11		1 " 8 2-5		1 "	8 4-5"	2 " 6 mos. 1 " 9 "
10 " 11	76	73	3	13		1 " 6 7-12		1 "	6 10-11	
11 " 12	52	49	3	6		1 " 16 1-3		1 "	17 4-3	1 " 2 years.
12 " 13	72	70	2	6		1 " 11 2-3		1 "	12	1 " 6 mos.
13	52	48	4			1 " 8		1 "	8 2-3	
14	28	27	1	2		1 " 27		"	27	
15	36	34	2	4		1 " 17		1 "	18	
16	36	35	1	5		1 " 8 3-4		1 "	9	
17	30	30		9		1 •' 6		1 "	6	
18	33	33		2		1 " 3 2-3	V	1 "	3 2-3	
19	20	20		4		1 " 10		1 »	10	
20	20	20				1 " 5		1 "	5	
21	14	14		3		1 ■• 14		1 "	14	
22	15	15		2		1 " 5		1 "	8 1-2	
23	17	15	2	2		1 " 7 1-2		1 "	8 1-2	
24	12	11	i			1 " 5 1-2		1 "	7	
25	7	5	2			1 " 5		1 "	7	
36	7	6	1			1 " 6		1 "	3 1-2	
27	7	7				1 " 3 1-2		1 "	6	Strictly speaking we ought not
28	6	6				1 " 6		1 "	6	here to include in the necrology of
29	6	6				1 " 6		1 "	2 1-2	cystotomy three patients operated
30	5	4	1			I " 2		1 "	3	upon, who died, one on the 21st
31	3	2	1			1 " 2		1 "	3	day after the operation, from a
32	3	3				1 " 3		1 "	3	confluent small-pox ; the second at
33	3	3				1 " 3		1 "	1 1-3	the end of a month, from an abscess
34	4	3	1	2	i	1 " 1 1-2	1 in l	1 "	5	in the kidneys and colliquative di-
35	5	5				" 5		ii	6	arrhea ; the last on the third day,
36	6	5	1	1		1 " 5		I "	2	but in a state of marasmus, with
38	4	4		2		1 " 2		1 "	3	the kidneys and lungs in a state of
39	3	3				" 3		1"'	5	suppuration.
40	5	4	I			" 4		!•	2	On making the post-mortem ex-
41	2	2				" 2		u	2	amination of a child 8 years of age,
42	2	2				" 2		ii	2	a calculus was found in the ura-
43	2	2				1 " 2		1 "	2	chus of a different nature from the
44	2	2				" 2			4	one extracted from the bladder.
45	4	3	1			" 3		ii	2	
46	4	4		2		"		1 «	1	
47	1	1				" 1		■i	4	
50	4	4				" 4		ii	1	-
51	I	1		1		1 " 1		1 »	1	
52	1	1				" 1		ii	2	
53	2	2				" 2		u	3	
54	3	2	1	I		1 " 2		1 «■	4	
56	4	4		1		1 " 4		1 "	2	
58	2	2				" 2		1 "	1	
56	1	1				" 1		ii	2	
60	2	2		1		1 " 2		1 «	2	
61	2	2				" 2		»	2	
62	1	1				" 2		«	3	
63	3	3		1		1 « 3		1 «	1	
64	1	r				" 1		it	1	
65	1	l				" 1		n	2	
66	2	2				" 2		u	1	
68	1	1				" 1		i<	2	
70	3	3		1		1 " 2		1 "	2	
73	2	2				" 2		u	1	
74	1	1				" 1		it	1	
76	"	1				" 1 r		tc	1	
78	1 1492	1 1433	V 59	148	2	" I		u	1	
Total,						1 in 9101-148	1.29 1-2	lin	9 71-75	
TF 
LITHOTRITY.
1013
Table of Operations in Private  Practice.
	Number of calcu-	Sex.		Deaths.		Mortality	Mor-tality	Mortality	
									
Age.	lous		0i		.£	among	among	in the	Operated on a second time.
	patients	a	7-	V	ri	Males.	Fe-	two sexes.	
	operated	d	g	~S	s		males.		
	upon.	3 1	*	a	fa			-----	
5tol§	1								
5': 6	4	4	—	—	—		—		1 a year after.
									
6" 1	5	5							
7" 8	6	4	2	—	—		—	____	1 a year after.
									
8" 10	4	3	1						
10	2	2							
11		1							
12		1							
13		1	1						_;
17			1						
19		1							
20		1	1						
2-2		1		1					
24		1							
25		1							
30			1		1*				
36		1		1					one year after.
40		2							
45 50			1						8 months after.
		2							
51		1							
55		1							
60		1							
62		1							
65		1		it					
68 1			1						
Total,	46	37	9	3	1				
  * We would remark that this woman died from phthisis pulmonalis, the 30th day after
the operation.
  t This old man, who had suffered fdr a long time, was exhausted by fever and  diarrhoea;
his bladder was much affected.   He  sunk quietly a  month after having been operated on.
The operations on the males were performed with the improved gorget of Hawkins, save one,
who was operated on by the recto-vesical method.  Of the nine female patients, five were
operated on by the bi-transverse incision of the urethra and neck of the  bladder, three by
the vertical incision, and one by the  vagina.   An old man of 62 years of age, and a woman
of 68, remained with incontinence of urine. 
1014         NEW ELEMENTS OF OPERATIVE  SURGERY.
  e.  M. Castara adds, that out of 1433 patients ofthe male sex, 1103
were operated upon by the method of Marianus, or that of the great
operation;  of these  119  perished, which makes the mortality 1 in
every 9„\\ parts, while 7 had fistulas follow.   There were 330 cut
with the improved gorget of Hawkins; out of these 29 perished, or
1 in every 1 lfVVV' and 3 had fistulas.   Out of 59 ofthe female sex ope-
rated upon, it was effected by dilatation of the urethra in 50 cases;
there were 2  died, and 9  were submitted to the bi-transverse incision
ofthe urethra and neck ofthe bladder. The majority of these calculous
patients were furnished by the towns and communes situated to the
south in the Department  of La Meurthe.   Their frequency appears
to have diminished in this department.  The town of Luneville fur-
nished  between the years 1738 and 1828, 90 cases, of whom 6 died
in consequence  of the operation.
     1st.  In  a period of 30 years, 56, or 1 and -ff per annum.
     2d.  In  a second period,     30, or 1           "
     3d.  Finally, in a third period, 4, or       y^     "

  From whence it follows that there  has taken place a diminution of
j| in every period of 30  years.  It  will be remarked, says M. Cas-
tara, that the table published  by Saucerotte differs from mine in re-
spect to the  number upon whom lithotomy was performed, and in
what relates to  the results of the operation.   The registers of lithot-
omy in our hospital do not go back  beyond the year 1738.  I have
made  an exact  transcript  of them.   I have myself  collated  the
copy with the original, and with those documents which came 'into
my possession from  my  ancestor, Sebastian Castara, who was  sur-
geon of the Hospital of San Jacques and lithotomist of the founda-
tion  of King  Stanislaus,  at the same time with Saucerotte.  I have
carefully abstracted quite  a  considerable number of patients, who
were  not  operated  upon,  or  who  died before  the operation, or
who are found in this list only under the head of fistulous cases.  It
results from this, that from  the year 1738 to 1828, there  were but
1492 calculous  patients operated upon, of whom 59 were  of the fe-
male sex.   I  do not know where Saucerotte derived his information
of an anterior date, but I am induced to believe that in his work he
has fallen into a number of errors.   He states that up to the time at
which  he wrote, there had  been 1629 operated upon, and  683  after
the time he become  attached to the hospital as lithotomist.   Now it
was in the  month of August, 1765, that he performed his first opera-
tion  in lithotomy, and from that epoch to the date of his book in  1801,
even if we include  that  year, there were but 653 operations; of
which  624  were on the male sex and 29 on the female.   In the first
there were 63 deaths, or  1 in 9^| operated upon; in the other  there
were but two:  the mortality in the  two sexes united, is one out of
every  lOgj.  It is in this  catalogue that are found the 194 calculous
patients operated upon by Saucerotte  and his colleagues by means
of the  modified  gorget.   I consider however that we may reckon the
cases at 196, and 12 deaths instead of 10, which gives a mortality of
one out of every 16^.  I do not desire to depreciate the advantages
of the  cutting  gorget, for it  is the instrument to which I give the
preference; not Desault's  modification, but  the gorget which was 
LITHOTRITY.
1015
used by my  grandfather and  father,  and which is  quite similar
to that of Scarpa.   My only desire is to establish the facts  and ap-
proach as near as possible to  the  truth.  A  mortality of 1 out of
every 16, would still be a satisfactory result, in uniting together the
persons operated upon at every age; but the statistics in this respect
are based upon too small a number of observations to allow us always
to hope for so favorable an issue.  I find in fact a succession  of 20,
30,  and even 50 operations by the  great operation, without  encoun-
tering  a single  death.  Could we conclude  from thence that we
should not lose but 1 out of every 20, 30, or  50,  by the  process of
Marianus ?  Certainly such a result could not  be  possible.  Failures
immediately  afterwards make their appearance, and  soon  destroy
our hopes and dispel our illusions !  With the  desire of ascertaining
the difference in the chances  of success between the two operative
processes, (Marianus and Hawkins,) I have divided into three periods
of 30 years each, the space between the  years 1738 and 1828.  In
the first there was  no other  than the  great  operation;  the second
embraces both methods; while the third, in fine, includes only those
cases that were operated  upon by the modified gorget, except two
cases by recto-vesical lithotomy.
  First period,   836 operated upon, 96 deaths, or 1 in every 8ff.
  Second period, 538       "        45    "      1    "   ll^f
  Third period,   118       "         9    "      1    "   13|.

  C.  Like all those operations which some persons undertake to per-
form under the title of" speciality, lithotrity soon became the object of
mercenary speculations  much more than it did  the subject of re-
searches purely scientific.  From that  time it became quite natural
that they should make light of its inconveniences, at the  same time
that they exaggerated the dangers of lithotomy.  Having seen per-
formed, and having  myself practised both the operations to a very
considerable extent, I am enabled to compare their value in all their
relations.
  B.  Dangers of Lithotrity and Lithotomy.—I. The danger of litho-
trity is ascribable, even in the modern processes to:
  a. The pain, which is  sometimes very acute.   Some  persons ex-
hibit more impatience under it than in lithotomy, and complain as much
at each sitting, as they would from this last operation.  This pain appears
to be produced by the distension and the straightening of the urethra
which the lithotritor, which necessarily occupies a straight  position
under the pubes, causes the patient to experience  in the membranous
and prostatic portions of this  passage.
  b. To the nervous symptoms.—Certain patients experience so much
distress  during the  broiement, that such severe  nervous symptoms
are thereby speedily produced as to result occasionally in death. M.
Larrey and M. Leroy have each given  a case of  this kind.
  c To the fever.—A fever, which shows itself under the form of an
intermittent, is frequently the  consequence  of any attempt at litho-
trity, whatever may be the method we adopt.  It  is frequently an-
nounced by chills and a violent trembling ; the  hot and afterwards
the sweating stage arrive, and the accident may stop there, but it is
not unusual to find a febrile pulse continue for two or three days. 
1016         NEW ELEMENTS OF OPERATIVE SURGERY.

  d. To the arthritis.—Pains  in the joints  similar to rheumatism
and  which  sometimes  become the source  of dangerous  purulent
arthropathy, in some cases succeed to these exacerbations of fever.
  e.  To the urethritis.—The irritation which lithotrity leaves in the
urethra frequently confines itself to the production of a slight blenor-
rhagic  exhalation, which disappears in the  course of two or three
days.   In some cases also  the  pain is so acute in the perineum  as to
occasion suffering when the urine is emitted, and to oblige us to defer
the sitting to the expiration of  a week or more.
  /.  To abscesses of the prostate.—When there has been very con-
siderable contusion and pressure upon the urethra, the  prostate itself
may inflame and terminate in abscess.  Instances of this result have
been related by several practitioners.
  g. To the tearing and laceration of the urethra.-+-The straighten-
ing which we  are obliged to give to the curved portion of the ure-
thra, frequently  causes this passage to be  excoriated, or torn, or
lacerated, from whence is produced a sensation of burning, which is
very painful at the time the urine and  fragments of stone are pass-
ing through it.
  h. To the urinary infiltration, which is almost a necessary conse-
quence  of the preceding accident.
  i.  To the collections of the same nature, which unavoidably follow
upon the urinary infiltration, and the serious danger of which is well
understood.
  j.  To the orchitis,  which  very frequently takes place, and which
succeeds, as in blenorrhagic orchitis, to the irritation  established in
the prostatic  region of the  urethra,  but which  is not  in general of
long duration and does not always prevent our repeating the opera-
tion.
  k.  To the phlebitis,  instances of which have been related by M.
Leroy  and some other  practitioners, and which either as a cause or
effect, is neither more nor less dangerous in this than it is in all other
cases.
  /.  To the cystitis, which has  been frequently observed and pointed
out, and which  is explained either  by the  repeated contact of the
instruments, or by the angular  condition of the fragments deposited
in the bladder  by the breaking up of the stone.
  m. To the perforations  of  the bladder,  even  the  possibility of
which has  been denied, but  instances of which were noticed in the
patient  Turgot, and in other cases mentioned  by MM. Breschet, Tan-
chou, Bancal, &c.
  n. To wounds of the rectum, which can scarcely exist without the
preceding injury, and the least dangerous result from which would
be a recto-vesical fistula.
  o.  To the pinching up or lacerations of the mucous membrane of
the neck or body ofthe bladder.  From being obliged to pass through
a common  sheath and to make friction against each other at their
root near the calculus, the branches whether of the forceps with two
branches, or the  noose of Jacobson, or the straight litholabes, and in
fact of all lithotritic instruments, expose to the risk of this inconveni-
ence, which, whatever may be said to the contrary, frequently occurs,
but fortunately is rarely attended with serious consequences. 
LITHOTRITY.
1017
  p.  To the hemorrhage, which apart from a slight exhalation from
the urethra, but rarely takes place, but of which MM. Tanchou and
Blandin alone, however, relate four instances in which it became of a
serious character.
  q.  To the retention of urine, which is attributable to the irritation,
congestion and lesions of every kind, which take  place  at  the neck
of the bladder and in the prostatic region of the urethra, or it may
be owing to fragments of calculi which have become arrested under
the pubes.
  r.  To the incontinence of urine, which  arises  from the contusion
and distension of the same parts.
  S.  To the impotency, which is explained in  the same manner from
injuries to the ejaculatory ducts and their relations with the prostate.
  t.  To the fragments arrested in the urethra, sometimes behind the
meatus, in the fossa navicularis, which is not serious, sometimes in the
prostatic  region, which is much  more grave, and which frequently
occasion  excruciating pain,  and the  greatest degree  of embarrass-
ment.
  u. To the fistulas of the rectum, perineum  or  urethra, which are
nothing more  than the results of some other lesion.
  v.  To  the  necessity  of dilating certain contracted  parts of the
urethra, or that of incising its meatus.
  x. To the inflammation of the  ureters and kidneys, which is attri-
butable to the same causes as the cystitis, and which is scarcely any
other than an  extension of this last, but is usually fatal.
  y. To the peritonitis, of which instances are related by Dupuytren,
MM. Tanchou, Leroy, &c.
  z.  To the  instruments having  got  injured, or from their having
been broken in the organs, an accident which happened in  cases of
MM. Leroy, Heurteloup, Hervez and Maunoury, and which in more
than one instance has. rendered  lithotomy necessary, or resulted in
death, as in the officer mentioned in the English Journals.
  aa. To the sinking and the  typhoid state of the patient, whether
unaccompanied with  any apparent serious lesions, or whether  pro-
duced by purulent infection, which [typhoid state1] is an accident that
has been frequently  observed, and which I  myself have witnessed
in a certain number of instances.
  bb. To the  return  of the disease, which was seen in from 12 to  15
of the  patients of M. Civiale, in France,  and  in nearly the same
number among those who were  operated upon in  England ; these
last have been mentioned  by MM. Chas. Bell, Liston, A.  Cooper.
Key, &c.
  cc  To the  difficulties of the operation, which are sometimes very
great, in consequence of the sensibility, small calibre and diseased
condition of the urethra or bladder, or in consequence of the indoci-
lity or want of reason on the part  of the patient, as for  example,
in children.
  dd. To the total duration of the operation, winch is  generally from
six weeks to three months, and which may extend  even to six months
or a  year.
  II. The accidents and danger of lithotomy are especially ascribable :
  a.  To the hemorrhage, which is infinitely more common and more 
1018          NEW ELEMENTS OF OPERATIVE SURGERY.
dangerous than after lithotrity, and which is  explained  by the fact,
that a certain number of vessels are unavoidably wounded.
  b.  To the wounding of the rectum, either by incision or by con-
tusion, and which leaves a recto-vesical fistula as its consequence.
  c.  To the peritonitis, which takes  place  frequently, and which  is
almost always fatal.
  d.  To the urinary infiltration, and the inflammation of the cellu-
lar tissue of the pelvis, an accident which forms an exception in litho-
trity, but is very common here.
  e.  To the phlebitis  and purulent infection, which are also more
common than after the broiement.
  f.  To the perforation of the bladder.
  g. To the cystitis.
  h. To the sinking of the patient.
  i.  To the fistulas, which are caused by the wound in the perineum
or that  of the rectum.
  j. To the urinary and purulent  infiltrations  in the scrotum and
perineum, but which are quite rare.
  k. To the various kinds of erysipelas, which only occur as  an ex-
ception, but which  are not unattended with  danger.
  /.  To the incontinence and impotency, which are scarcely more
frequent after lithotomy than after lithotrity.
  m.  To the nervous symptoms, and which  may prove fatal.
  n. To the pain,  which is acute but of short duration, so far as the
operation is concerned ; as to the pain which  is subsequently  caused
by the  wound and  passage  of the urine, it is scarcely of  a more se-
rious character,  than  the  painful  sensation  in the urethra after
lithotrity.
  o. To the return of the disease, which is  almost impossible, except
by the  formation or arrival of another stone in the bladder, inasmuch
as the surgeon  may satisfy himself directly, both with the finger and
the instruments, whether there is anything more remaining in the or-
gan which he has just opened.
  p. To the re-establishment of  the course of the urine through the
urethra, which is sometimes delayed to a long period.
  q. To the necessity of keeping the patient in bed during the space
of 20 to 30 days.
  r. To the necessity of a course of diet, or of quite a severe regi-
men during the space of from 8 to 15 days.
  s. To the ureteritis, nephritis, orchitis, and collections in the pros-
tate, which are not less common  here than  after lithotrity.
  We perceive by this parallel, that all things being  balanced, litho-
tomy and lithotrity have but very few advantages over each other,
in relation to the pain, nervous symptoms,  inflammation  of the urin-
ary passages, incontinence and impotency, perforations of  the blad-
der, and  the  sinking of the patient;  that  the exacerbations of  in-
termittent fever, the mild or purulent form of the arthritis, orchitis,
abscesses in the prostate, lacerations of the urethra, pinching up of the
bladder, infiltrations, external urinary deposits, retention  of urine,
calculi arrested in the urethra, the necessity of dilating or incising
this  canal,  and  the danger from  instruments  that have  become
injured or become broken  in  the  organ, belong almost exclusively 
CALCULI IN THE  KIDNEY AND URETHRA.
1019
to lithotrity;  that as a return of the disease may be caused by a por-
tion of calculus  overlooked in the bladder, it must be incomparably
more frequent after lithotrity than after lithotomy ; but that lithoto-
my, while it  is more exposed  to  the  risk of fistulas, lesion  of the
rectum and phlebitis, is  rendered more especially dangerous by he-
morrhage, peritonitis, inflammation ofthe pelvis, and the necessity of
establishing a wound, which requires a repose  and regimen foreign
to the habits of the patient.
  III. From whence  it  follows, that provided the bladder is  sound,
the urethra free, the  patient of no more  than ordinary sensibility,
the calculus less  than the size of an egg, and of a moderate degree of
hardness,  lithotrity is in  its aggregate  less dangerous  than litho-
tomy.  Such is  the formula which I  supported in  1835 before the
Royal Academy of Medicine, and which  I  have no reason  at the
present day to modify, whatever anxiety may have been evinced by
a considerable number of busy-bodies to pervert it.   This language,
we will admit, scarcely corresponds with that of lithotritists,  but I am
convinced that it expresses the truth, and that after lithotrity has once
been adopted into the common domain of surgery, it  will find in
this formula a more exact interpretation than it does  in the ipse dixit
of its interested  partisans.
                        CHAPTER II.

         URINARY CALCULI EXTERNAL TO THE BLADDER.

           Article  I.—In  the Kidney and Urethra.

                       §  I.—Nephrotomy.

  Science possesses numerous instances of calculi, which after  hav-
 ing become arrested in the kidney itself, have there acquired a con-
 siderable degree of development, in such manner as to ultimately
 result in the death of the patient.   From  hence came the  idea of
 nephrotomy, which may be described as an  incision into  the organ
 through the sound tissues, or the  incision of a purulent  collection
 over  which we  have  been enabled to  feel  through the lumbar
 region; or it may consist also of a simple  enlargement of a renal
 fistula, with the view of  favoring  the escape or extraction of the
 foreign body.  It cannot be denied that it would be possible to reach
 the kidney on its  posterior side, between the last rib and the crest
 of the ilium on the one hand, and the sacro-lumbar mass  and the
 posterior border of the oblique muscles on the other.  I have many
 times  laid it bare by following this process.   Though it be  next to
 impossible to satisfy ourselves by any physical means of the  exist-
 ence  of the stone in the kidney;  though the reasonable signs of
this should be  deceptive ;  though on the  other hand after the  pre-
sence  of the calculus is once established, it may still be required to 
1020         NEW ELEMENTS  OF OPERATIVE SURGERY.

know whether it occupies the  entrance of the ureter or the pelvis,
rather than  the  tissues of one of the  walls of the organ ; whether
it  is or is not accompanied  with ulcerations, and purulent dissolu-
tion, or any disorganization whatever; finally, though we may be
forced to renounce nephrotomy, so long as there is no point exter-
nally  which indicates the locality upon which we should direct our
researches, it is also  certain that since the labors of M. Rayer, the
diagnosis of calculi in the kidney is no longer a  matter  of such dif-
ficulty, and that  the presence of a  tumor in the flank, with  a prom-
inence in one  of the lumbar regions, together with the signs of cal-
culous nephritis, would authorize additional essays in nephrotomy.
There is, moreover, no proof  that this operation  has ever  been  at-
tempted.  The passage which is quoted from Hippocrates in support
of it,  does not seem to  have reference to it.  Nor can  the  opera-
tion,  performed  upon  the free archer,  which has  been so much
spoken of, be deemed any longer of any weight in a question of this
kind.   What confidence in fact can we  accord to this  story, when
we see that Mezerai  makes this criminal come from Bagnolet, while
Pare, who relates the circumstance  from the chronicles of Monstrelet,
makes him come from  Meudon; when  some authors state that he
lived  under Charles VIL, and  others under Louis XL ; when Collot
and the author of the  History of  France believe that  nephrotomy
was performed upon him, while Rousset and  Sprengel suppose that
he was cut for stone  by the high operation; when Mery, on the con-
trary, considers that  he was cured by the perineal operation, while
Toilet asserts that the only operation performed upon him was mere-
ly gastrotomy  for a volvulus ?   The  case  of the consul  Hobson
(Transact. Phil. Abr., vol. IV., p.  116,) who is stated to have been
operated upon by Marchettis, is  hardly more conclusive.   Bernard,
who relates it, had no other proof of the fact than the  assertion of
the patient and his wife,  while Marchettis himself, in  his  Observa-
tions Rares, says not a word of it.  It is to be hoped therefore  that
the discussions  raised in the schools of surgery in  1754,  by Mas-
quelier and Bordeu,  and  by Cousinot a century before, to  ascertain
whether nephrotomy was or was  not practicable, will  not again be
revived.   The operation  cannot, in reality, be proposed, except in  a
small number  of cases, as  in  those in which  the flank, which has
become the seat of  an evident fluctuation, after the existence of
various signs  of calculous affections in the kidney,  would ena-
ble us to reach the morbid  collection with facility and certainty ; or
in those cases also in which a  fistulous ulcer should have enabled us
to come into immediate contact with the, stone by means  of an ex-
ploring instrument;  or finally, where the  calculus itself projects at
the exterior, and may be recognized  through the integuments.  In
such cases the operation  is so  simple and  is reduced to  so small  a
matter, and has moreover to be modified by so many controlling cir-
cumstances, that it would be useless to describe it in detail.  All that
can be said is this, that after having made openings of sufficient ex-
tent, or enlarged those which already existed, by means  of the bis-
toury alone, or  by  this  instrument guided upon the director, we
should search for the stone with  caution,  and in order to displace and
extract it, make use either of the ordinary forceps, the polypus for- 
                        URETHRAL CALCULI.                  1021

ceps, hooks or scoops, or the dressing forceps, or  the  fingers alone.
Lafitte, (Mem. de FAcad, de Chir., X. IL, p. 170, 1819,) has very ju-
diciously described the cases which may require  this operation, and
it might probably have been performed with advantage upon the  pa-
tient mentioned by Billebaut, (Acad,  de  Berlin, X. IV., App., p. 32.)
I have attempted it upon two calculous patients, and in both instan-
ces confined myself to the  first stage, that  is to say, that I  stopped
after making an opening into the vast lumbar  abscess, and that  the
patients then finding themselves relieved, would  no longer  listen to
an operation.

                       §  IL—Ureterotomy.

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

                Article  II.—Urethral Calculi.

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

  Should a  calculous concretion have developed itself between the
urethra and vagina, an instance  of which  has  been  related by M.
Macario, and should it  have been  possible in any manner whatever
to have established its presence, its extraction might be effected by
incising through the  vulvo-uterine  passage, and  to the extent  re- 
1022          NEW  ELEMENTS OF  OPERATIVE SURGERY.

quired, the entire thickness of the cyst which should separate it from
the urethra.
                    § IL—In the Prostate.

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

                     §  III.—In the  Urethra.

  Calculi have been met with in every part ofthe excretory duct of
the urine, in which duct, however small their size  may be, they soon
give rise to the occurrence of accidents.  When behind  the  meatus,
where Bernard  (Trans. Phil. Abr., vol. IV., p. 109) has  met with
them in two instances, or when they are in the fossa naviculars, where
I have frequently seen them, it rarely happens that the efforts of  the
bladder and the volume of the urine will not be  found sufficient to
expel them.   Upon the  supposition however that it should  be other-
wise, we should proceed to search for them by the dressing forceps,
the point  of  which is  somewhat  concave  and flattened;  or, as
Sabatier recommends, by gliding underneath them a noose  of iron or
brass  wire;  or by means of a small scoop shaped like  a  hook, and
which M.  Civiale used on Boisseau in September, 1828 ;  or finally, if
these  should  be attended with too many difficulties,  by  incising  the
lower wall of the urethra in front of the stone, by means  of a narrow 
URETHRAL calculi.
1023
bistoury introduced into the interior of the canal and brought from be-
hind forwards, unless we should prefer making use of a kind of conceal-
ed bistoury known under the name of uretrotome.  An indispensable
precaution, whatever may be the process we adopt, is that of fixing
the penis firmly with the forefinger and thumb placed behind the cal-
culus, in such manner as to be enabled to favor the expulsion of this
last, or at least to prevent it  from escaping backwards from before
the instrument. The forceps, which has  been employed with success,
and the  manipulations  so much extolled  by  M.  Polh  of Moscow,
(Gaz. Med., 1839, p. 168,) possess no peculiarity which has not been
already essayed by others.  The articulated scoop of M. Leroy, (Rev.
Med., 1835, t. IV., p. 118,) either simple or with a sheath, together
with the  respective  forceps of Hunter, Ravaton, or Weiss, and also
aspiration, either by means of the mouth or in any other manner, as
had already been mentioned by P. Alpin, would  be suitable in these
cases  as well as in those which will be mentioned farther on.  A dis-
secting forceps terminating in  claws would succeed still better, should
the calculus be small and be situated at less depth than two inches.   I
have used it with advantage in five instances. M. Wigan, (Encyclogr.
des Sc. Med., 1839, p. 273,) with the view Of dilating the urethra in front
ofthe calculus, in the case of a child, employed with advantage a forced
injection.  When the stone is arrested in the commencement ofthe cor-
pus spongiosum, the surgeon also commences by securing its posterior
portion by means of one of his hands, and then endeavors to draw it
towards him by means of the  noose of Sabatier or Marini, in the way
it was employed  successfully by M. E. Rousseau.  If this should not
answer we have recourse to the sheathed  forceps, the  branches  of
which being dentated, slender, resistant and concave, do not separate
until they arrive  at the anterior side of the calculus, as if for the pur-
pose of dilating  the urethra  and  to cause  the foreign body, when
pressed upon by the finger, to lodge itself between them with facility.
M. Civiale, in order  to be  certain that  the forceps  is  properly
placed, and not  to  expose to the risk  of  shutting it  up uselessly,
recommends that it  should be'explored by a stylet, the head of which
separates the branches apart while it  is being withdrawn towards the
sheath.   By means  of this stylet  the operator finds out where the
calculus  is and displaces it, even if it is  not properly  seized, and
incurs no danger  of wounding the patient.   When it is once firmly
grasped it is to be extracted, taking care to proceed with gentleness
if it is somewhat large, and in such manner as to cause not the slightest
laceration possible.   When the calculus has  established itself in a
cul de sac on one side, it may convey the idea of a contraction of the
urethra, and  cause  its extraction  to be attended  with  serious diffi-
culty.  A patient who was sent to my care from Guadaloupe, and who
had suffered during the space of ten years, and  undergone all kinds
of treatment without any one ever having been enabled to penetrate
into the  bladder, and who urinated only in a very fine stream, was
immediately cured as soon as I had extracted from the membranous
portion of the urethra  a calculus of  the size of a small green pea.
Should its volume have rendered its extraction difficult, which is a
rare occurrence, inasmuch as its presence in  the urethra could not
have existed a sufficient length of time to have sensibly increased its 
1024         NEW ELEMENTS OF OPERATIVE SURGERY.

size, we should have recourse to broiement, or should traverse it by
means of a perforator introduced in the place of the  stylet, in order
afterwards to break it down with greater facility.
  A calculus mentioned by M. de Renzi, (Gaz. Med., 1834. p. 538,)
and which was two inches long and a half an inch thick, and  which
surrounded the bulbous portion of the urethra, could not be extracted
until an incision was made into the tissues, and after the stone  had
been broken up.  Calculi also that become  arrested  in the bulbous
portion should be treated upon  the  same principles.  It is evident
that we should experience more difficulties in the  membranous por-
tion, in which part,  however, they are most frequently lodged.   If
the preceding attempts, which  could  be modified by  making  use,
for example, of a curved forceps, should not succeed, and if the ac-
cidents were alarming,  an incision into the urethra would  be  the
only remedy.  The same may be said in respect also to all the cases
which  have just been described, and  for which extraction  or  broie-
ment constitute only the first means to be made trial of.  Who could
otherwise than by an  incision, extract  a calculus  developed  in  the
urethra around a brass ring, as in the case of M. Liston, (Arch. Gen.
de Med., X. I., p. 268 ;)  or a calculus which should  have acquired an
inch and a half in diameter in the fossa naviculars, as in the patient
of M. Schwartz, (Bull,  de  Fer., X. XIV., p. 204) ?  When the neces-
sity of an incision has become apparent, the following is the mode
in which we should proceed.  Should the  stone occupy the second
portion of the urethra, it is necessary that  an  assistant should keep
it fixed at  this point by means of two  fingers introduced into  the
anus.  The surgeon with a straight bistoury divides the integuments,
which  have been  previously stretched, then the cellular tissue  and
all the  parts contained  in the base of the recto-urethral triangle,  and
finally  in this  manner  comes  down upon the foreign body.   After
having sufficiently enlarged the incision, he  extracts  the calculus by
means of suitable instruments, and  for fear  that other  calculi may
exist in the bladder, or  in the prostate, or  in  the remainder  of the
urethra, he explores  all these regions  with the  grooved sound, or a
female or any other  catheter.   Behind the scrotum the envelopes of
the corpus spongiosum  of the  urethra are so movable that their
division in general is attended with considerable difficulty.   It is for
this reason that it is advisable to introduce  down to the stone  and
through the natural passage a strong grooved sound, then to raise
up  the scrotum as much as  possible, to  stretch the tissues carefully,
to have the calculus secured by the fingers of an assistant  behind it,
and  to give to the incision of the integuments a much greater  extent
than to that of the urethra itself.  All this  must be  done in the  first
place, to reach the foreign body with greater certainty, and secondly,
to prevent infiltrations.   The same course should  be adopted in re-
spect to calculi in front of the scrotum,  with this difference, that  the
scrotum should in that case be pushed back  towards the anus.   It is
ijnportant in these different cases to open the urethra over the stone
only in one point, and  afterwards to enlarge this incision  upon  the
grooved sound, either  in front or behind.  If we pursued an oppo-
site course we should have a contused wound with fringed borders,
but little favorable to cicatrization ; while the process recommended 
LITHOTOMY--LITHOTRITY.
1025
furnishes one which is regular, and the best possibly adapted if not for
immediate reunion, at least for a union that is sufficiently prompt.  As to
the advice of Philagrius,  (Peyrilhe, Hist, de la Med., p. 701,) who
recommends, with the view of avoiding fistulas, that we should open
into the urethra upon the  dorsal surface of the penis, it could not be
applicable at most but to  small calculi arrested in front of the scro-
tum, and  cannot, as I conceive,  be revived again under any title.
Moreover, is it very certain that Philagrius intended to speak of cal-
culi and opening into the urethra, rather than of calculi and opening
into the bladder ?   Fistulas are much  less frequent after the urethral
incisions, which I  have just described,  than would  be imagined.   M.
Civiale relates the history  of a patient  who was operated upon at La
Pitie by an interne of that hospital, and who had three large  sized
calculi in the urethra, viz. in the bulbous, membranous and prostatic
portions.  The operation was protracted and laborious, and left an
irregular wound ; nevertheless it was  not followed by fistula.  It is
true, however, that this wound  will sometimes remain fistulous, and
that its cicatrization in certain cases is attended with great difficulty.
In a patient operated upon  in  September, 1838,  at the hospital of
La Charite, and in whom,  however, there was only a very small cal-
culus in the bulbous portion of the urethra, the fistula  notwithstand-
ing still continued for the  space of five months.
  E. Between the glans penis and the prepuce.—Children are quite
liable, as we have elsewhere said, to  a contraction of the prepuce,
which part in them is naturally very long.   It results  from this that
the urine is  effused there  as it were into a sac, in coming out  from
the urethra,  before making its escape  externally, and that there will
be formed here quite frequently calculous concretions, which  have
been noticed also in adults, though more rarely.   They may acquire
a volume which is  really  astonishing.   Morand preserved a speci-
men of one which was almost as large as an egg,  and which had on
its upper surface  a little gutter  for the passage of the urine.  Saba-
tier had in his possession a similar one which was still larger.  The
extremity of the penis in  such persons becomes swollen and heavy,
and usually pendant like the clapper of a bell.   The extraction of
such calculi  is an  easy matter.  All that  is  required  is to intro-
duce between the prepuce and  the foreign  body a grooved sound,
upon which we conduct a  straight bistoury which  incises and divides
the tissues from within outwards.  We might also incise them from
without inwards  by coming down perpendicularly upon the stone.
It was an operation of this kind which made so much  noise in Swit-
zerland  at the commencement  of the last century, and which was
given out by some persons as a case of supra-pubic lithotomy.

                [LITHOTOMY—LITHOTRITY.

  Lithotomy preceded by partial lithotrity.—The first operation
of lithotomy ever performed in  China, was,  according to our coun-
tryman, Dr.  Parker, (see a memoir by  him entitled Notes of Surgical
Practice amongst the  Chinese, in Cormack's Monthly Journ., Edinb.,
June, 1846, p. 393, 394, &c.,) that which was performed by him about
the year 1844, at Canton,  upon  Si-Yau, a resident of that city, aged
                                65 
1026         NEW ELEMENTS OF OPERATIVE SURGERY.

35.   The stone was first  crushed by a lithotritor  about a year be
fore, and was now extracted in two fragments  by the lateral opera-
tion.  They weighed  together one ounce and a drachm,  and  mea-
sured 5^ inches in their united circumference one way, and 3f the
other.   The patient was well on the 18th day.  The success of the
operation produced a great sensation among the Chinese.
  Dr. Parker afterwards performed the operation of lithotomy in the
course of the years 1844 and 1845, upon the following among  other
Chinese: His second case was Chau Wei, aged 21, 2 stones, one an
ounce and the other one drachm.   The rectum wounded, which in-
duced the  surgeon to divide the sphincter immediately.  Notwith-
standing this and the  presence of  large worms in great numbers in
the  stomach and alimentary  canal, and the  consequent irritability,
the  young man finally recovered perfectly, with only a small fistula
in the urethra.  Third case, Lui Kwan, aged 34, had had calculus for
23 years.   Operated upon May  13, 1845; stone  about 5 inches in
circumference, and weighing 2- ounces.   The  patient exhibited un-
paralleled  fortitude, scarcely appearing to notice the incisions.   The
calculus was smooth,  spheroidal,  and  of chocolate color.  Though
but a few ounces of blood were lost during the operation, a sudden
movement  of the patient  on the 9th day,  brought on  considerable
hemorrhage, yet the  cure was complete by  June 6th.  Fourth, Hu
Pin, aged  28.   The  stone, which  was 4 inches by 3  in circumfer-
ence, and  weighed 5  drachms, was extracted by Dr. Parker, June
18,  1845, by the lateral operation.  It  was ofthe  mulberry variety,
with a surface as rough as sand-paper, showing brilliant minute crys-
tals under  a strong light.   Like other Chinese, says Dr. Parker, this
man acted most heroically, uttering no complaint, and smiling when
the  stone  was  shown to him.  The next  day additional  fragments
were removed.  Though severe  reaction ensued  and continued for
several days, the patient was discharged cured  on  August 3d.
  As hemorrhage in perineal lithotomy constitutes the cause of one-
fourth of the fatal terminations by this process, it is, as M. Begin re-
marks, important to devise some efficacious  means for arresting it.
Deeming its source, from its slow exuding character, to be in a pre-
ternatural enlargement of the arterial capillaries in the perineum and
vicinity of the bladder, he  has suggested, where ligatures and torsion
cannot be used, and has in two instances eminently succeeded by a
process which consists (Arch. Gen. de Med., 3e ser.,  t. XIIL, 1842,
p. 372) in  maintaining, by means of a gum-elastic syphon, a contin-
ued current of cold water in the wound.
  Supra-pubic  lithotomy  was recently successfully performed  by M.
Segalas (Arch. Gen., Oct. 1844, p. 250) on a man who had been af-
flicted with stone from his childhood, but  during  an interval  of 22
years  experienced  no inconvenience  from  it!    It  weighed  107
grammes.
  A new process for supra-pubic lithotomy.—In the same  way as we
deem ourselves bound to  give circulation in an elementary work of
this description, to every new suggestion that may appear to  be ra-
tional, we  feel  equally under, a conscientious obligation to condemn
in unequivocal  terms whatever carries on the face of it positive error
or harm, especially where it emanates from  names justly possessing 
LITHOTOMY--LITHOTRITY.
1027
a high authority.   Such we consider the process of supra-pubic litho-
tomy, in two  stages, again  revived  by M. Vidal de Cassis, (Arch.
Gen. de Med., 4e ser., t. III., pp. 219, 220,) and this to be performed,
not by the bistoury, but by the tedious, successive, painful and danger-
ous applications of  Vienna paste and chloruret of zinc, gradually in-
flaming the tissues,  in order that they may consolidate, and thus pre-
vent urinous infiltration, after the bladder is opened into !
  Lithotrity.—Dr.  J. Randolph, in addition to several other cases of
lithotrity,  recently, it is  stated, performed  this  operation  (Amer.
Journ. of the Med. Sc,  July, 1846, p. 263, &c.,) on  a man aged 30,
with complete  success ; having effectually  crushed, pulverized and
brought away the stone  in four sittings, of a few minutes each, during
the space of a month, and without any pain to the patient.  He used
Heurteloup's percuteur,  and also a modification of this.
  M. Leroy d'Etiolles has lately laid  before  the  Paris Academy of
Sciences, (sitting of April 27, 1846, Gaz. Medicate de Paris, 3e ser.,
t. I., May 2, 1846,  p. 354,) a  memoir  describing  a new set of litho-
tritic pulverizing instruments, (pulverisateurs oscillants) and a new
process which he has been in the practice  of for the  last two  years,
by means of which, where the stone is alone, and of  large size, he is
enabled, by making a lateral oscillatory movement, which presents
the instruments successively upon all the  points  of  the  calculus, to
crush it into powder in a few minutes.   The  instruments consist of
rasps,  blades, &c.  When the  stones are numerous and  small, he
continues to use the method of  ecrasement, which he has  now em-
ployed successfully, it is stated, in  over one  hundred cases.   This
last method is made more effectual by associating  with it artificial ex-
traction.  By means of a stone-breaker (brise-pierre), with large and
deep scoops (cuilliers),  he  is enabled, every time he withdraws the
instrument, to extract nearly two millimetres, cubic dimensions, of de-
bris of calculus ; so that under favorable circumstances, a calculus of
35 millemetres of diameter, (15 lines,)  may be broken up and remo-
ved at a single sitting.  M. Heurteloup read at the   same  sitting a
memor on the immediate pulverization and extraction of calculi, in
which  he states that he has succeeded in a great number of cases, in
effecting immediate and  complete extraction of fragments of the stone
through the  natural passages, frequently in much shorter time than
would  be required  by lithotomy.  His  reasons  in favor of this new
modification, rather than leaving the expulsion of the fragments to
nature, are:  1, because in simple  breaking  of the  stone, there is a
chance that the fragments may be lost in the bladder ; 2, because the
broken fragments too frequently get lodged in the neck ofthe bladder
or in the urethra, giving rise  to  serious accidents, and requiring sub-
sequent operations  much more painful and difficult than  the principal
one; 3, the fragments, if left, may give rise to catarrhal  inflamma-
tions of the  bladder, which may endanger life; 4, in quite a great
number of patients, the  simple  breaking  up of the  stone  would be
injurious unless there was some  mode  of immediately extracting the
frao-ments; and  5,  because the membranes  of the  urinary organs,
when inflamed, are  liable to make large deposits of phosphate of lime.
Inflammation, therefore, should, as  far as  possible, be excluded from
this operation.  His percuteur  courbe a marteau, so much extolled 
1028          NEW ELEMENTS OF OPERATIVE SURGERY.

by Sir Philip Crampton, (see  Dublin  Quarterly  Journal of Med.
Science, Feb., 1846,) as preferable  to any other lithotritor, is  the in-
strument upon which  he chiefly relies.  By this powerful  instru-
ment the stone is seized between two planes, one of which is render-
ed immovable by its  connection with  the fixed  support, while  the
other is movable   By recent modifications he is enabled to measure
with accuracy the size of the stone  to be extracted, and  to reduce
it to the diameter of the two approximated scoops  (cuilliers), that is,
to the diameter of the urethra itself.   Percussion is the great feature
of his new method, and  he effects the  closure of  the scoops  by  the
hammer, in the  same way that he breaks the  stones with his  percu-
teur.  But the use of the hammer  requires a  point d'appui, in order
to keep the instrument which holds  the stone  fixed and immovable,
and which latter, from being movable, also becomes fixed and immov-
able.  Now  this point d'appui exacts an apparatus to support it, and
in which it may be moved, and  become instantly fixed or movable at
pleasure.  He effects  this by means  similar to those which he has
long since made known,  under  the names  of  point fixe and lit rec-
tangle, but in which he has made several important modifications.
  M. Deleau, also, at  the  same sitting of the Academy, broached a
new process for lithotrity, which consists in introducing into the blad-
der a sort of artificial pouch or bladder, in  which he causes the cal-
culus to enter, and in which this latter is then broken up and pulver-
ized  by  the  ordinary  instruments, or submitted  to the  action  of
chemical agents, without  any danger  of wounding the organs.
  M.  Taroni, of the department  of the Aude,  France, relates a
recent case which is calculated to inspire farther dread in the applica-
tion  of a severe crushing  force to  lithotritic instruments.   After
succeeding in nearly crushing  up a stone of 32 millemetres diam-
eter  with one of  Charriere's  No.  2  stone-breakers, (Journ.  des
Conn. Mid.-Chir., Mars 1,  1846, pp. 101, 102, 103,) he found, after
the fifth time of  fracturing the pieces, and during which he made no
false or stronger movement, that he  could  not, to  his  utter dismay,
withdraw the instrument.   He  however succeeded in getting  the
broken branch lodged in the perineal portion of  the urethra, from
whence  he  succeeded in effecting  its  removal from  the bladder.
This is a serious warning in regard to the  selection  of instruments,
when the processes most  in vogue require, as we  perceive, a great
augmentation of crushing power.
  Lithotrity  in children.—Though lithotrity, for the various reasons
given in  the  text  by our author, cannot be conveniently applied to
children, or at least was thought to be obnoxious  to persons  of this
period of life  at the time M.  Velpeau  wrote, some doubt may perhaps
be expressed in regard  to that  judgment  in the  present  more
advanced state of this new mode of relieving calculous patients.  M.
Segalas exhibited to the  Royal Academy of Medicine, Jan. 4, 1841,
(Arch. Gin.  de Med.,  3e  ser.,  t. XIIL, 1842,  p. 243,)  a child two
years of age, from whom he had extracted, by broiement,  a stone of
considerable  size, in twelve  sittings.   The stone guaged fourteen to
■fifteen lines of diameter.   Other successes of  the same kind  induce
M. Segalas  to consider extreme youth no exclusive objection to  the
process in question. 
LITHOTOMY--LITHOTRITY.
1029
  A new lithotriteur has been invented recently by Dr. Arthault of
Paris, by which it is stated (Lond. Med. Gaz., May, 1846, p. 843)
that a stone of the size of a pigeon's egg was crushed up into -an im-
palpable powder in  the  space of three minutes, the operation  being
performed on the dead body at the hospital, in the presence of several
surgeons!
  Statistics  of Lithotomy and Lithotrity.—Dr. Wm. Keith (Edin.
Med. and Surg. Journ., vol. LXL, 1844, p. 123) furnishes one  ofthe
most impartial  and lucid tables we have seen of the  comparative
merits of lithotomy and lithotrity.   Out of 23 cases of lithotomy and
16 of lithotrity operated upon by  him at the Royal Infirmary of
Aberdeen, Scotland,  between March 20, 1838, and March 20, 1843,
there were among the former 1 death in 1If, and of the latter 1 in
15.  The average time of treatment of the first was  60ff days, and
in the second 44-§-.  The average age in  the first 56^, in the second
56&.   The  average weight of the  stone in the first  8 dr. 14 gr., in
the second 3 dr. 8 gr.  Out  of 19 of the cases of lithotomy aged from
50 to 78, only one died.  In the ten years Dr. Keith ha,s  practised
lithotrity, no accident of any  kind  has ever  occurred to him.  He
dispenses with  many of  the instruments and with injections of the
bladder.   He  has usually however selected the  best subjects  and
small stones for lithotrity'  Out of 42 cases of stone, the whole num-
ber received in the years mentioned, only one was a female!
   One of the latest statistical tables on lithotrity, furnishes yet more
favorable  results for this operation  than the  general text  of the
author.  M. Cazenave of Bordeaux, at the sitting of the Paris Royal
Academy of Medicine,  Nov. 11, 1845, (Arch. Gen., 4e ser.,  t.  IX.,
Dec, 1845, p. 496,) gives as the result of 52 operations by lithotrity,
in his practice in  the last 15  years, 43 cures and 8 deaths.   One only
continued to suffer after  the operation, though two large calculi had
been  removed from  him.   Of the 8  deaths, this result in 3  was
caused by circumstances foreign to the operation.
   New Process for Extracting the Stone from the Bladder.—Cys-
tectasy or lithectasy, so called, being a name  given to a new process
proposed by MM. Jno. Douglass, Dr. Wilson, Mr.  Thos. Elliot, &c.,
(see Edinb.  Med. and Surg. Journ., January, 1843,)  and which con-
sists of crude,  painful attempts, persisted in at  the hazard of the
patient's life for  24  hours,  at dilatation,  by  introducing through a
small wound in the perineum and membranous portion of the urethra
a distensible pouch into the bladder, which is to be filled with liquid
and left there, is one of those daring and irrational attempts to revive
an obsolete practice which must be generally reprobated.
   Chemical action on urinary calculi.—In the opinion of MM. Pe-
louze and Gay-Lussac, (see their report on the communications of M.
Leroy d'Etoilles,  Arch. Gen. de Med., 3e ser., t. XIIL, pp. 502, 503,)
acid and alkaline chemical re-agents act but very feebly on urinary
concretions, and  chiefly on  their  uniting animal matter.  Besides
which, this reaction itself may give rise to new concretions, in  con-
sequence of the  saturation  of the  free  acids,  or  acid salts  of the
urine.  Neither in drinks, baths, or  injections, can they be of great
efficacy, and moreover in the last form are  dangerous, though they
would  have, however, in association with lithotrity, the advantage, 
1030          NEW  ELEMENTS OF OPERATIVE SURGERY.
from the calculus  being broken into fragments, of allowing the in-
jected chemical solutions to act on a far greater extent of surface.
  Gastric juice has been proposed as a simple solvent of calculi.__
We are not aware that the suggestion of M. Millot, to inject dilute
gastric juice,  (i. e., diluted with  an equal volume of tepid water,)
where lithotritic crushing instruments have failed, has ever been car-
ried out in practice.  M. Millot found  (Arch.  Gin., X. III., 4e ser.,
p. 361) this solvent had a powerful  disintegrating effect  even upon
the surface of mural calculi, which had resisted every kind of instru-
ment.  The idea of dissolving calculi by injecting chemical (not sim-
ple) solutions, had long since  suggested itself  to  Fourcroy.  Upon
this principle  it was, that Mr. S. E. Hopkins,  (see Transactions of
the Royal Society of London,  1843, Part I. ;  also Arch. Gen. de Med.
de Paris, 4e ser., t. III., 1843,  p. 103—105,) availing himself also of
the well known fact of the affinity of lead for the phosphates, and of
the common practice with country people of drinking hard cider in
gravelly  complaints, instituted a  variety of experiments, the result
of which was, that a mild combination, which he calls nitro-sac-
charate of lead, had a sensible effect in dissolving portions of calcu-
lous phosphates, and precipitating them  under the form of phosphates
of lead.  Injected into the bladder of sheep,  the solution of this com-
pound produced no unpleasant effects.
  Urinary calculi, according  to M. Civiale in  a late work, (Traite-
ment Medical and Preservatif de la Pierre  et  de  la Gravelle, Paris,
1840,) may alternate with each other.   Thus cystine may be formed
at one time, and  the other principles  of the urine at another.   So
uric acid  and the  oxalate of lime.   This may occur without any
known cause  or change of food  or medication.  Hence, according
to the experienced author, the doubtful efficacy of medicines directed
against this or that calculous diathesis.  Stone and gravel, moreover,
may co-exist simultaneously.   Here there must be a more profound
lesion of the urinary function, so that after the breaking up and extrac-
tion of the stone, the gravel will, by aggregation, reproduce another
stone, a certain lapse of time  after the operation, thus often leading
to serious misapprehensions.  It is of the utmost  importance, there-
fore, in cases of gravel, or its persistence, that the exploration should
be extremely minute.   Contrary to M.  Segalas  and  others, M.
Civiale considers a particular  attention  to the instrument to  be  used
a matter of importance,  and  for  this purpose recommends, where
gravel is in too large concretions to escape  by the urethra, that we
should make use of the lithoclast, as modified, in order to ascertain its
actual morbid condition.   In atrophy of the bladder we  must recur
to the  trilabe.  It is therefore a matter of great moment to resist if
possible the formation of such gravelly deposites or sediments, by
some  conservative course of medical  treatment, if any  such exist.
The  red sand and pulverulent  deposites, constitute,  M. Civiale
thinks, the first stage of gravel.  This may be  induced by a preter-
natural excitement of the kidneys, caused perhaps by some morbid
condition of some portion of the apparatus ; thus, contraction of the
urethra, or a spasmodic closure, or neuralgic state of this canal or of
the neck of the bladder.  Hence,  the utility  he has found  in cupping,
leeches and emollients to the kidneys, general baths, copious  use of 
LITHOTOMY--LITHOTRITY.
1031
drinks that are  slightly diuretic, certain  mineral waters, and purga-
tive medicines in divided  doses.  In the gravel of uric acid, the
most  common of all, M. Civiale classifies the disease  under three
varieties: 1,  emission of gravel spontaneously and without pain;
2, nephritic colics  with emissions of gravel; and 3, nephritic col-
ics without expulsion of gravels.  The disease in  these, and also in
the forms of cystine, oxalate of lime, and  of white  or phosphatic
gravel, may go on in spite of the medical treatment, and then the
difficulty may arise from  some morbid state which paralyzes the
efforts of nature and of art.   Thus, the gravel may not be  enabled
to make its escape, because it is retained in  the kidneys or ureters,
or in  the bladder.  In the last mentioned, this  retention  may be
caused:  1, by a.  spasmodic contraction of the urethra or neck of the
bladder; 2, by one or more contractions in  the deep-seated portion
of the urethra; 3, by a tumefaction or other disease of the prostate;
and 4, by a paralysis of the  bladder.  Age, sex, climate, and  food,
have  also a great influence on calculous affections.   An important
point  is, that M.  Civiale pronounces decisively against the prevailing
opinion in relation to  the influence of nitrogenized food in the pro-
duction of gravel and stone.   He wholly rejects all attempts at cure
by chemical remedies, either internal  or external, and especially by
alkaline  preparations.
   Urinary calculi.—The number of urinary calculi preserved in the
museum  of Guy's Hospital, and which, as given by Dr. Marcet about
30 years since, amounted to 228, had in April, 1842, (see Guy's Hos-
pital  Reports, April, 1842,) increased, according to Dr. Bird, to 363.
Of these  : 245 have for their base uric acid ; 17, urates of ammonia
or of lime; 45,  oxalate of lime; 11, cystic oxide ;  and  21, earthy
phosphates.
   Mr. Syme, in  a woman aged 75,, who  had suffered from urination
for 20 years, found on examination a stone which  had  occupied  a
distinct pouch between the urethra and Vagina.  There was  an aper-
ture  into the  pouch  from the urethra,  through which the morbid
cavity was laid open along the whole extent of the urethra, and upon
the stone, and without wounding or  opening into the vagina.  The
calculus  was oval, and an inch and a quarter long, and the woman
rapidly recovered.    (See  Cormack's Monthly Journ., Edinburgh,
Feb., 1846, p. 83.)   T.] 
1032         NEW ELEMENTS OF  OPERATIVE SURGERY
    PART  EIGHTH.

DISEASES OF THE  URETHRA.
                         CHAPTER I.

                         CATHETERISM.

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

  Article I.—Examination of  the Methods and Instruments.

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

                              §1.

  Copper catheters, (sondes en cuivre) which were formerly made
use of,  and which had the inconvenience  of oxydating and becoming
covered with verdigris, are universally replaced  by silver catheters,
(algalies.)  The fragility of glass catheters as proposed  by  M. Zavi-
ziano, would  incur  the risk of too much danger for any person to
venture  to make use of them.   Flexible catheters made of horn,
leather, or metallic  spirals, having been  contrived or used only for
want of better, must also remain in the oblivion into which they have
fallen since the invention of elastic catheters  by  Theden, Pickel and
the watchmaker  Bernard.  Catheters of silver  or those  of maille
chort, and those of  gum or ivory that are flexible, are therefore the
only ones which deserve to be retained; the first for those cases
which  require solidity and where  the instrument is not to remain
more than a few minutes in the organs;  the second for those cases
where, after the operation,  it is desirable not  to  withdraw them im- 
          EXAMINATION OF THE METHODS AND INSTRUMENTS.    1033

 mediately from the bladder.   The  length of metallic sounds  for an
 adult male is about twelve inches.  If they were shorter they might,
 in certain old men, not reach as far  as  the bladder.  If they were
 longer, they would expose moreover to the risk of wounding the organs
 and perforating the bladder.   Their diameter should vary from two
 to three lines.  They penetrate so much  the better when every other
 proportion is attended to, as their volume is more considerable.   For
 children we have them from a line to a  line and a half in diameter,
 and five to eight inches long.   If their wall has too little thickness,
 they may bend or become deformed, or break even  upon the slight-
 est effort.   A contrary arrangement would take  up too much of their
 canal, and would interfere with the flow of urine if the instrument
 did not possess a corresponding large calibre.  Their free extremity,
 which is ordinarily flaring in the manner of a pavilion, is furnished
 with a ring on each side, in order that we may, if required, attach to
 it cords or threads.  At a few lines from the other extremity, which
 is blunt, are  found two lateral elliptical openings, in place  of the
 simple apertures which were formerly made there.   Those in which
 this extremity is replaced by the head of a stilette, which latter is
 pushed forward in order to open the catheter, and  drawn back to
 shut it, are scarcely any longer used at the present day.   The  same
 remark applies to those which are open and free at their vesical ex-
 tremity.   The curvature which ought to be given to a catheter has
 given rise to  a great deal of discussion.   If they are straight it is an
 easy matter to push them  forward  like a cylinder by rotating  them
 upon their axis, and to overcome with these  instruments obstacles
 which the others could not surmount. But this advantage is more than
 counterbalanced by the pressure which their point makes upon the
 floor of the membranous and prostatic portions ofthe urethra, and by
 their tendency to escape into false routes.  If they are curved  they
 cause less pain, penetrate better, and are  in every respect preferable.
 The S shaped catheter of the  ancients and of Erisistratus, (Macll-
 wain, Observ.  de Chir., Sf-c, p. 31,)  and which'was revived by  J. L.
 Petit, and intended to  give less  fatigue  to the canal when it was
 required to leave it there, has become of  no value  since science has
 possessed the  flexible  catheters.  If the  curvature should be  very
 great and very much elongated, it serves no good purpose and inter-
 feres with the movements of the hand.   The catheter which has the
 curvature  only upon  its end, as was  advised by Rameau, and  since
 recommended by M. Key and  M. Stanley, (Ibid.,  p. 27,) penetrates
 with more  facility than a straight catheter, but  scarcely makes any
 less traction upon the infra-pubic portion of the  urethra.  The most
 commodious  are  those which  are  curved  only in their posterior
 fourth, in such manner as to form an arc, the cord  of which has not
 more than three to four inches in  length, and the radius not  more
 than one to two inches.  The axis of their beak brought back in such
 manner as to cross  at  a right  angle the  imaginary prolongation of
 their body, is the shape that I have found  the best, in  cases especially
 where the prostate is enlarged.   The  more it  is turned  backwards,
 the more difficult is it to  enter  into the bladder or  to avoid our
 butting against the  lower wall of the  canal,  to  count from the
perineal aponeurosis.   The silver  wire  which  they are provided 
1034         NEW ELEMENTS OF OPERATIVE SURGERY.
with is  scarcely ever of any utility, and does not even possess the
advantage of enabling us  to clear out the  apertures or to cleanse
their interior when foreign  substances accumulate there.

                 §  I.—Position of the Patient.

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

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

               § III.—Difficulties  of the Operation.

  Catheterism is sometimes attended with a great deal of difficulty.
It is an  operation which requires practice, accurate anatomical know-
ledge, and a certain number of precautions.  If the beak of the sound
fell too much upon the lower wall of the urethra, it would not  glide
without difficulty, and might be arrested at the fossa navicularis, then
in the bulbous cavity, afterwards by the prostatic depression, and de-
viate into the bottom of either  one or the other of these dilatations.
In forcing it to follow uninterruptedly the upper wall, such accidents 
          EXAMINATION OF THE  METHODS AND INSTRUMENTS.    1035

will not have to be apprehended, unless we raise it up too much and
in place of keeping its axis in relation with that of the  canal, it should
fall  upon  a  more or less open  angle  upon the plane which it is to
pass over ; moreover, this  bad direction, unless it should be exces-
sive, would  not be attended with any actual inconvenience except
on arriving  between the roots of the corpora cavernosa at the ante-
rior  surface of the symphysis.   The  important point,  therefore, is
to make the  catheter follow in the axis of the urethra from the meatus
up to the bladder, by pressing it with some slight force upon its dorsal
portion.   In this respect there  can be no fixed rule, because there
are no constant relations between this axis and that of the body.  In
certain patients it is necessary that the pavilion of the  catheter
should, so to speak, remain parallel with the walls of the belly, while
we  are passing  through the spongy portions of the organ ;  while in
other patients we are obliged to place it at the beginning, in the plane
of the lower strait.   Force  moreover is  never required.   The in-
strument should go forward as much under the influence of its own
weight as from the action of an external power.  If it meets  with
resistance, we  withdraw it a little, in order to incline or direct it in
another route.   In pulling  over  it the  urethra from below upwards
and from  behind forwards, as a number of authors  recommend, in
conformity to  Le  Dran, we  create obstacles instead of destroying
them.   This precaution cannot be of any utility except in the penic
portion of the canal.   Farther on it flattens it, and has a tendency to
efface  it  against the  border  of the infra-pubic  ligament, and  must
necessarily favor its laceration.   The mode of  entering the bladder
with certainty,  consists in allowing the catheter to descend freely to
the origin of the membranous portion, that is to say, to a line with
the lower border of  the symphysis, in such  manner  that it may not
depress either  the upper or lower wall of the urethra against the
perineal side of the horizontal aponeurosis, then to make it vibrate
suddenly though without effort, by depressing its pavilion from before
backwards,  to  such degree  that it  may  become parallel with the
axis of the thighs.   This movement conducts it forcibly into the uri-
nary bladder, provided its extremity is no longer on this  side the
pubes.  In the  opposite case it butts against the front part of the
articulation. The penis stands at an angle and the instrument springs
back in place of advancing.  The difficulty most usually arises from
the operator being fearful of depressing the outer portion too much,
and from scarcely reflecting  how much it is necessary to raise up its
point, in order that we may not  be interrupted  by the posterior bor-
der of the prostate.   However little  resistance we   may meet with
in approaching the symphysis, the left hand should   proceed to dis-
cover  the cause of it,  by raising up the scrotum and exploring the
perineum, and  by endeavoring  to identify the  beak  of the  catheter
through the  canal  by means of  the fore and middle  finger, and by
following all its movements.   Should the instrument  have advanced
a little farther than this, the forefinger should be introduced into the
anus and intestine.   Serving as a guide and  explorative means as
above  it indicates precisely in what direction the efforts of the  other
hand are tending, or whether we are yet in the membranous or in the
prostatic portion.  We discover by the thickness of the intervening 
 1036         NEW ELEMENTS OF OPERATIVE SURGERY.

 tissues, if there is reason to presume that we have made  a false
 route, and the finger may if necessary assist in making  the catheter
 take a direction towards the bladder.   We must, nevertheless, not
 deceive ourselves  upon the value of this manoeuvre, which is in  no
 respect applicable to  rectilinear catheterism.    By  raising  up the
 prostate the finger increases the curvature of the urethra, has a ten-
 dency to apply it with greater force against the infra-pubic ligament,
 and  naturally presents its soft or lower wall against the beak of the
 catheter.  To derive all the advantage from it  possible, it is  impor-
 tant, as soon as we have ascertained the  state  of the parts and  are
 desirous of  exercising  the slightest degree of force, that we  should
 withdraw the pulp ofthe finger a little  to the front, in order to fix it
 upon the  convexity of  the instrument  at  a little distance from  its
 extremity.  In this manner the  portion of the  canal  which remains
 to be traversed does not sustain  any pressure which can  augment its
 curvature, while the combined action of the two hands  is no longer
 attended with the slightest danger.

                              § IV.

   The signs which announce the entrance of the instrument into the
bladder, are  so evident  in most patients, that  they speak for them-
selves, and  do not require to  be  described.   But in certain cases
many of them may be wanting,  and the diagnosis is then so obscure
as to give embarrassment to the surgeon.   If thick mucosities, san-
guineous concretions, &c, become  lodged  in the  apertures   of the
catheter, the urine does not  flow.  M. Berre, (Arch. Gin. de Med.,
t. XVIL, p.  105,) after having spoken  of  a patient  affected with re-
tention or suppression of urine,  during the space of six months, and
 who should not have been surprised at the case of M. Mathieu, (Ibid.,
t XVIL, p.  279,) relates, that in applying the catheter to another, he
saw nothing  escape  by  the instrument, and that this was owing to
the bladder  being filled with blood.  Catheters  which have a strong
curvature, remain sometimes  so  closely applied  against  the anterior
wall of the bladder that they continue immovable, and shut up  as high
up as above the upper strait.  When  the urinary bladder is  empty,
retracted and very narrow, we  penetrate  to so little depth, and the
 movements of the  catheter of depression, elevation  and  rotation, and
to the right  and left are  so  limited, that  we are induced to doubt
in respect to  the  place that  the instrument occupies.   A consider-
 able mass of blood accumulated in the  anterior half of the bladder,
 an instance  of which M. Mathieu affirms  that he has  seen, would
 be well calculated to lead to deception, since  we would be  obliged
 to pass through the whole thickness  of  this  before reaching the
 urine.  On the other hand, it has been noticed that the catheter, after
 having become entangled to a great depth in the tissue  of the recto-
 vesical septum, has been susceptible of  movements almost as exten-
 sive  as if  it  had been free in the bladder.  We are still more liable
 to this error, when in consequence of a large ulceration in the floor
 of the urethra, a cavity or accidental pouch of  considerable size has
 been made in the tissues of the  perineum  in front of the rectum, a
 remarkable  example of which  I saw in an adult man, who  died in 
        EXAMINATION OF THE METHODS AND INSTRUMENTS.    1037

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

             §  V.—The raising up of the Bladder.

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

                             § VI.

  After having tried in various ways, it is advisable, if the  instrument
does not penetrate, to select another  whose  curvature is different,
and  either  greater or less, according  to the indication which  we may
believe  to be presented, and  also to find one of larger calibre, which, 
1038          NEW ELEMENTS OF OPERATIVE SURGERY.

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

                   §  VII.—Flexible Catheters.

  With flexible catheters we traverse  the urethra in the  same  man
ner as with the preceding.  It is  nevertheless true, that as a  general
rule they penetrate  with less  facility than silver catheters.   If  we
have to introduce them into a tortuous canal,  we remove  the stilette
from them,  in order that they may inflect upon all the deviations that
are to be overcome.   On the contrary, we insert  into them a metal-
lic stem, which should be  as strong and as regular as possible.  This
stem, which is curved like the ordinary catheters, becomes their con-
ductor, and ought to occupy them as far as to their inner extremity, 
        EXAMINATION  OF THE METHODS AND INSTRUMENTS.     1039  V-.■

and to go beyond their  outer extremity, where it is usually termi-
nated in a ring.   It is important to guard with care that it does not
escape through the apertures of the catheter, for it would expose to
the risk of wounding the urethra.  Though  it may be easy when  it
passes under the pubes to increase its curvature  by means of the fin-
ger slipped into the rectum, it is  more  prudent  however to give  it
before commencing the operation  the direction that may be required.
All that is required  to withdraw it is  to bring it back towards the
abdomen with the right hand, while the left  hand secures the cathe-
ter below and pushes it toward the  bladder.  If this  manoeuvre  is
sometimes more painful than  the operation itself,  it is from its having
been badly executed.  It does not take  place if we make the stilette
on coming out describe the same arc of a circle that it did on enter-
ing.   Some  persons after  the manner of Hey, have succeeded very
well after they have  reached the pubis, in acting  no longer.on the
stilette, but in holding it fixed with one hand  while with the other we
Dush exclusively on the catheter, the blunt and flexible beak of which
passes with more  facility through  the remainder of the urethra when
it  is  thus by itself alone, than if it  was conducted by the stilette.
Others improving upon an idea of Physick, make use of such flexible
catheters as  have  their beak tapered out in the shape of a long conical
point, which is pliant and solid,  and  extends beyond the stilette.
Hey, with the view of irritating the bladder less, proposed  to give a
permanent curvature to these catheters, which modification various
French surgeons  have adopted, and  which in my opinion has no
other inconvenience  than  that of being too  great.   As catheters of
gum-elastic or flexible ivory are employed only in those cases where
it is desirable to leave them remaining in the bladder, they are  enti-
tled in this  respect to all the attention of the practitioner.  In the
first place, their composition  ought to be such that  no inflection can
break or chafe them, or  destroy  the  polish  or smoothness of their
surface.  Unless this were the case, they would soon become rugose
in the urethra, and too speedily acquire  an incrustation from the uri-
nary salts;  while  any body may understand what  may be the  con-
sequence if a fragment of one of them should fall into the bladder, as
has but too frequently happened.  The best  test  that we can  put
them to, is that of bending them or twisting them suddenly on their
axis.  If they resist and do not change in their aspect, we may em-
ploy them with confidence;  in the contrary  case, they are  to be re-
jected.  The  projection of red wax, which  is found on  their outer
extremity, is for no other  purpose than  to form  a groove  there for
the cords which we  use  in attaching them; it would prevent them
also from passing  completely into the urethra, and  of escaping to-
wards the bladder should the hand let go its hold  upon them.  We
cannot at first understand how it could be possible for a catheter of
10 or  12 inches long, left to itself, to  escape  entire  into the urinary
bladder; but there exist  indisputable  evidences  of this fact, and M.
Roux was compelled to perform  cystotomy for  an accident of this
description. 
 1040         NEW ELEMENTS  OF OPERATIVE SURGERY.

                             § VIIL

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

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

  In former times  lithotomists and the great surgeons had a peculiar
 manner of performing catheterism.   In order to introduce the  cath-
 eter, they turned its concavity  downwards, and only brought it  back
 again towards the abdomen by a half turn of a  circle at the in-
 stant when its beak arrived under the pubic  ligament.  The rest of
 the operation did not differ from the one  above described, and the
 improvement  consisted  in making the  circular pass  imperceptibly
 into the vibratory movement, which alone could justify the expres-
 sion tour de maitre.  It was for a long time thought that this method
 had no other object in view than that of concealing from the eyes of
 the assistants the true nature of catheterism ;  but it would appear to
 comprehend  something  more.   The extremity of the catheter con-
 ducted in this  manner executes in the curved portion of the canal  a
 movement of rotation  which  unquestionably facilitates its passage
 under the symphysis, and we combine by this means  the advantages
 of straight catheters with those which  are possessed by the curved
 instruments.   As however it is a delicate manipulation, which would
not be unattended  with danger in the hands of every  one, it has gen-
 erally been proscribed or reserved for some special cases.   It is ren-
 dered necessary, for  example, where there is an extreme projection
of the belly, or when in lithotomy we place ourselves in front of the
 patient in order to introduce the catheter.  Even there,  however, it 
         EXAMINATION OF THE METHODS  AND INSTRUMENTS.     1041

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

                 § X.—Catheterism in  Women.

  Female catheters have but five or six inches in length and scarcely
any curvature.  Their introduction in general is a matter of extreme
facility.   The canal  that they have  to pass through is so short and
regular, and so easy to find and to follow, that it scarcely  resembles
in anything that which exists in man.  The patient when laid on her
back is more  conveniently situated than when she is standing up or
seated on the edge  of her  bed.   The surgeon, on  his part,  being
placed to the  right rather than to the left, causes her  thighs to be
widened apart and her legs to be gently flexed ; placing his left hand
in pronation upon the mons veneris, he opens the labia minora,  by
means of his thumb and middle finger ;  raises up the clitoris and ves-
tibulum with  the forefinger, the nail of which is to remain turned to-
wards the meatus urinarius ; takes the catheter, wThich has been pre-
viously oiled, and holds it  in the manner  of a pen in his right hand;
passes it underneath the corresponding  ham, if the breech and vulva
appear to be too deep ; presents its beak with the concavity upwards
to the orifice of the urethra and depresses it a little in order to pass it
underneath the symphysis ;  then  immediately raises it up, and  with
one movement enters into  the bladder.
   A.  Having pointed out the  mode of keeping the instrument in its
place, under the article of  Vesico-vaginal  Fistula, and in Vol. I., of
this work, I will not here return to this subject.   This operation is so
alarming to the modesty of certain females, that it would be a fortu-
nate thing if  we could perform it  without exposing their persons to
view.  This thing is generally practicable and  even easy of execu-
tion.  If after the left hand  has been placed as above described, the
beak of the catheter is placed upon the nail of the forefinger, all that
will afterwards be necessary will be to make it glide gently upon the
vestibulum by following the  median line from above downwards, by
which means it falls almost inevitably into the meatus.  We  should
succeed with more certainty still, by directing the catheter from be-
low upwards, supporting  its extremity upon the pulp  of the right
middle finger, while the ring finger of the same hand serves in some
respects as a sentinel or exploring instrument.  In fact this finger
recognizes the fourchette, then  the entrance, and  afterwards the an-
terior columna  of the vagina,  the  termination of which latter,  and
which is more or less dilated in the form of  a tubercle, is found im-
mediately below the  urethral orifice.  Having arrived at this  point,
the ring finger stops.  The  other fingers cause  the  sound to glide
upon its  pulp and make use of it as a conductor.   The meatus cannot
be at a greater distance than a line or two.  We feel around a little,
and almost always enter into the canal without any difficulty.
  B. In women'who  have had many  children, in old age, during
pregnancy and after  delivery, the finding ofthe urethra is sometimes
attended with considerable difficulty.  Having receded into the  pel-
                              66 
 1042         NEW ELEMENTS OF OPERATIVE  SURGERY.

 vis behind the pubes, it becomes very oblique, or is even Taised up
 completely against the symphysis.  In such cases we seek for its
 meatus quite deep under the pubic ligament, and if it does not show
 itself at first, we endeavor  to  bring  it into  view by drawing, by
 means of the forefinger, upon the vestibulum and base of the clitoris
 above, at the same time that the middle finger and  thumb draw the
 nymphae with considerable force to the outside.  The catheter having
 been introduced, it becomes necessary to depress its pavilion quickly.
 We are even sometimes obliged to make use of one of greater cur-
 vature, or to have recourse to a male catheter.  In conclusion, even
 when the parts  are deformed, as during the first days  succeeding
 delivery, for example, if the surgeon  calls to mind that  the meatus
 urinarius  is always situated at the anterior  border of the vagina, at
 the point of union of the circumference of the vulvar opening of this
 canal with the base of the vestibulum,  that is to  say, of the little tri-
 angular cavity which forms the limit to the inner  side ofthe nymphae
 and lower side of  the clitoris, he will find that catheterism is  in no
 respect an operation attended with any serious difficulty in  persons
 ofthe female sex.  The thesis of M. Larcher, (No. 339, Paris, 1834,)
 and what I have elsewhere said on this subject, (Art des Accouch.,
2d edit., Paris, 1835, t.  II.,) will serve as a supplement to this article.

                             §XI.

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

               CONTRACTION OF THE  URETHRA.

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

               Article I.—Forced  Catheterism.

  By forced catheterism  is meant  at  the present day two kinds of
operations, which are quite  different  from  each other.   In one we
make use of a blunt-pointed  instrument, but one that is conical and 
FORCED CATHETERISM.
1043
sufficiently sharp  to penetrate with considerable force into the blad-
der in passing along the track of the urethra; in the other we employ
a cylindrical  large sized instrument, with  the sole view of  dilating
the natural contracted canal.   One is used for retention of urine and
the other for contractions of the urethra.

       § I.—Forced, Ordinary or Evacuative Catheterism.

  When there is a complete state of ischuria, and when the obstacle
which  causes  it cannot be overcome  by any manoeuvre, either by
means  of the metallic  or  gum-elastic sound,  the straight  or the
curved, the hollow or the solid, nor by means of  the various  kinds
of bougies, and that the symptoms are urgent, the surgeon has no
other choice left than puncture of the bladder or forced catheterism.
This operation had already been recommended at the time of Deaz.
To perform  it they had recourse to a sound which terminated in a
trochar point.  At  present, those who  venture upon  this operation
make use of a strong conical sound, which is properly curved.   The
idea  of this  operation is ascribed to Desault and  Boyer; but Cof-
finiere, who  warmly contested their pretensions,  avers  that it be-
longs to him  and that he had made it known in 1783.   In France,
M. Roux is almost the only person who, since the time of Boyer, has
undertaken to advocate it; with the exception of Physick, who, ac-
cording to Dorsey, had followed this practice since the year  1795, it
has had nothing abroad but opponents.  It has  been supposed that
by endeavoring to remove obstacles in  this  manner, the sound would
lacerate the  canal and make a false route  much oftener than it would
perforate through the  coarctation, and with those who know the
dangers of urinous infiltrations, the idea of such lacerations  seemed
exceedingly  alarming.   In  this respect I consider that the  greater
number of practitioners have not been in  error.  Notwithstanding
his dexterity and  skill, M. Roux has in  more than  one instance had
an opportunity of verifying the dangers of  his method.   I have my-
self had an occasion of opening the dead body and of dissecting the
urethra of a man whom he  had  treated in  this  manner, and who
died  of urinous abscesses caused  by a  false route.  Nevertheless, it
appears certain that the dangers  of this process have been exagge-
rated.  The  instrument if properly conducted, does  not always, in
passing through the resisting point, deviate from the natural track.
Again, when it actually forces itself through it in place of reopening
it, the instrument, if it  actually escapes from  the urethra, does so in
most instances only to re-enter it  again  at a few lines beyond.  Fi-
nally, upon  the supposition that  it does not reach the bladder until
after having been working its way for a long  time  through the body
of the  prostate, the accident  is still far from being always fatal.  A
sound left remaining in, may transform  the false route into a new pas-
sage, without the  system being scarcely affected  by it, an instance of
which  I saw in 1830 in one of the hospitals of Paris.  Nor is it a rare
circumstance to find the urine resume its course, after the lapse of a
few  hours or some days, through  its natural canal, and I cannot say,
in fact, if forced catheterism  with a conical sound  ought  not to have
the preference over puncture of the bladder, with all such surgeons 
1044          NEW  ELEMENTS OF OPERATIVE  SURGERY.

as are sufficiently sure of their hand and in their anatomical know-
ledge, not  to have  any appprehension of making  a false passage
while traversing the perineum.
  A.  Operative process.—The patient  and surgeon are placed in
the same way as for ordinary catheterism.  The heavier and more
solid the sound is, the better it will penetrate.  The ordinary sound
exposes to the risk  of laceration  more than any other, and would
not re-enter into the urethra with sufficient facility,  unless the form
of cone which it has, tapered gradually back as far  as the pavilion.
If this cone was limited only to the vesical extremity, it could not
progress with sufficient facility.   If it once  got out of the canal, it
would advance too rapidly in  the midst of the tissues.  In general,
force is  not required until we leave the bulb and line of the sym-
physis.  The right hand is then to approach the glans penis, and the
instrument to be  seized  rather by its  body than at  its extremity, in
order that  it may vacillate less, and that it may be  held with more
facility, and with  all the firmness desirable ;  it is  then pushed  for-
ward exactly in the  known direction of the urethra, without allow-
ing it to make the slightest deviation, or to progress  except  in pro-
portion as the fingers or one of the fingers  of the left hand,  applied
over the perineum or into the  anus, shall watch over its movements,
and  can appreciate its  progress, and  convey to us the assurance
that its beak has but slightly deviated from the centre of the mem-
branous and prostatic portions of the passage which is to be trav-
ersed.
  B. False routes.—The short sound, in lacerating the urethra in its
bulbous portion, runs the risk of tearing also the whole extent of the
perineum and recto-vesical septum, or may go even so far as to per-
forate into  the intestine before it  again finds the urinary canal, or
it  may  not enter into  the bladder at all.  The false route is then
so much the more  dangerous, inasmuch as it does  not even afford
egress to the urine.   Should the laceration have taken place above,
and the point of the sound have got between  the posterior surface of
the symphysis and the front part of the bladder, the mischief would
be still greater, for the  infiltration which  would take place in the
pelvic  cellular tissue,  would  almost unavoidably  result  in  death.
False routes through the prostate are infinitely less  dangerous : 1st,
because the tissue of this gland makes  greater resistance to  the con-
tact of urine and generally prevents its infiltration; 2nd, because the
instrument, though  it has slightly deviated from  the channel which
is to  be liberated,  almost always  re-enters  into  it before  having
caused any particular injury, and before having passed to any great
extent outside of it.  When  it has been ascertained that we have
made a false route,  we must, should it not be complete, withdraw the
sound towards us, and do every thing  in our power to find the  ure-
thra again, and to re-enter into the natural passage ; or if this route
has made a communication with the bladder, we must leave the instru-
ment in, until it is in our power to replace  it by a gum-elastic cathe-
ter, which should be left to remain there  for the  space of several
days.   When infiltration has taken place, and the accidents, and
tumefaction, and inflammation have commenced, whether the blad-
der be empty or not, or whether it be  possible or not to place a ca- 
FORCED  CATHETERISM.
1045
theter in the urethra, we must  no longer hesitate, but make a free
incision upon the presumed track of the laceration,  and endeavor
to cut down upon the urethra.  It is  the only way to limit the ex-
tension of the mischief, and  to prevent the mortification of the tis-
sues.

            §  IL—Forced and dilating Catheterism.

  A new mode of treating contractions of the urethra by catheterism
has been introduced into practice since the year 1830.   M. Mayor
of Lausanne, author of this method,  (Cathet. Simple et Force, &c,
1835,) laying it down as a  principle that the sound in order  to be
enabled to penetrate, ought to be so much the more voluminous as the
contraction is more considerable, created at first much astonishment
among practitioners ; but having invoked to the support of his axiom
some arguments that were specious, together with a certain  number
of facts, it soon found partisans even in the hospitals.  Having, on
my part, noticed that frequent trials of this process were being made
at Paris, I deemed  it proper to examine the question  under its dif-
ferent aspects.   I soon perceived, as was established  also by M. A.
Vidal, (Journ.  Hebdom., 1835, t. IV., p. 353,) and as was  maintained
by M.  Gaillardet, (These, No.  342, Paris, 1836,) a  short  time  after-
wards, that this new method taken  in  its literal  acceptation was a
dangerous  one,  that the successful results obtained  from  it were
more apparent than real, and that they were ascribable to a confu-
sion of terms.   With M. Mayor's sound in fact, we cannot  succeed
but in two kinds of cases.   1st. When there  is no  contraction, and
when we use the process I pointed out in 1832.  2nd.  When the ob-
stacle  is purely valvular,  because  an incomplete  diaphragm,  as it
may be more easily straightened and spread out in a  passage regu-
larly distended, ought to  be ruptured with more facility and  with
more  accuracy by a large and heavy sound than by a slender and
slight instrument.  Otherwise,  and in real coarctations,  the  Mayor
sounds cannot  penetrate but by tearing up and lacerating the tissues,
and by  exposing the patient to serious dangers.
   Had not the proof of what I here advance been given by MM.
Vidal  and  Gaillardet,  I could  produce it in the cases themselves,
presented by M. Mayor and his disciples.  What do we see, in fact,
in what has been published on this subject 1   The instruments of M.
Mayor are of pewter, and either hollow or solid, curved according to
the direction I have given  for  them,  and divided  into six varieties
or numbers, counting from two lines to four  and a half lines.   In
the first of the cases  related by this surgeon they  began without
difficulty with  No. 1 ;  which, according  as it seems to me, does not
authorize us to assert that the urethra was actually contracted.  The
second  patient  was an  Englishman,  whom a cauterizer could not
sound,  but who by means of a large catheter succeeded in sounding
himself.  In the third patient they employed in succession three
numbers of the elastic sounds, and afterwards the numbers of the
pewter sounds.  The fourth had undergone puncture of the bladder
for ischuria ; M. Mayor sounds him ; the patient dies, and it is as-
certained that his urethra was  perfectly  free !  No. 1  entered with 
1046          NEW  ELEMENTS OF OPERATIVE  SURGERY.

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

                Article II.—Forced Injections.

  A means to  be made trial of when there is retention of urine, be-
fore proceeding to paracentesis of the  bladder, and one which is not
attended with  the same dangers as  forced evacuative catheterism, is
that of distending the urethra by means of a liquid thrown up from
before backwards.   Trye, who was the first to make this sugges-
tion, namely, in  the  year 1784, states  that he derived the greatest 
INCISIONS AND SCARIFICATIONS.
1047
benefit from it, and Soemmering mentions that where the finest bou-
gies cannot be made to overcome the contraction, he injects oil into
the canal, then immediately shuts up its orifice, and afterwards makes
pressure from before backwards, in order to push along the liquid.
The method  of Brunninghausen is somewhat different.  At the mo-
ment when the patient  has  a desire to urinate, he  forcibly makes
pressure upon the urethra behind the glans penis, compels the fluid to
retrograde,  and in  this  manner expects to  destroy the  contrac-
tion.  In  1822, M. Despiney of Bourg proposed a liquid which was
purely emollient, and which  was to be pushed  up with a syringe.
M. Citadini,  (Rev.  Med., 1826, t. IL, p. 493,) who has published a
memoir  on  this subject,  introduces a catheter down to the point
of resistance, holds the  urethra firmly applied  upon it, and makes
use of it as a  syphon to inject into the canal tepid water or any other
suitable liquid with all the force that may be  required.  M. Amussat,
who considered himself the inventor of forced  injections, proceeds
nearly in the  same manner as M. Citadini.  He recommends that we
should apply  a compress around the penis, in order that no void may
be left between the catheter and the walls of the canal, that we should
afterwards attach to the pavilion of this catheter a  caoutchouc bottle
filled with water, and that we should push up the  injection by making
pressure upon the elastic bag by means of a tourniquet; but it is rea-
dily perceived that after  the  principle  has  been  laid down, it is a
matter of little importance whether the liquid be projected by means
of a syringe, a gum-elastic bag, or by the finger or any other mode.
This method, though rational and of undoubted efficacy in certain
cases,  is far  however from deserving those  eulogies which some
persons have bestowed upon it.  If the urine, which is a sort of natu-
ral injection  thrown  from behind forwards, cannot  overcome  the
coarctation, nor make it disappear nor prevent  it from manifesting
itself, how can we hope  that any liquid whatever, merely from the
fact that it is  propelled in  an opposite direction, can triumph over all
obstacles ? It is therefore probable  that the successful results that
are imputed to it, might have been full as well obtained by means of
catheters or bougies introduced in a proper  manner, and that in  the
majority of the cases injections might  have been dispensed with, if
the ordinary processes had been employed in a more judicious man-
ner.  Nevertheless, as they are of easy employment and  unaccom-
panied with any inconvenience, I see no reason why they should not
be made trial of, and even without waiting until all the other means
have failed.

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

  The practice which consists in applying a cutting instrument to the
interior of the urethra to destroy its contractions, though it is already
quite ancient, and one which Muzell (Rougemont, Bibl. Chir., p. 375,)
still eulogized the benefits of, in the last century, has never had many
partisans.  Besides the almost  utter impossibility of reaching only
the contracted point, the  danger of incising sound rather  than  dis-
eased parts, and the  alarm which it must  necessarily give the pa- 
1048         NEW ELEMENTS OF OPERATIVE  SURGERY.

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

                    §  I.—Operative Process.

   Inasmuch  as it  may happen that in spite  of the preceding re-
marks, some persons may, nevertheless, continue to cry up incisions,
and as  they may in the last extremity become necessary, in certain
cases of well ascertained  contractions that  are too hard  and too
thick to yield  to  the  distending action of a bougie,  I  proceed to
point out the manner in which the operation should  be performed.
Dorner, to  whom Siebold  and  Soemmering ascribe  the  honor of
this process, recommends that we should make  use  of a sort of
lancet,  which  is to be  introduced through  a catheter.   Physick
speaks  very highly of an instrument of the same kind :  it  was  a
stem terminated in a  small fleam (flammette),  enclosed  in  a can-
ula of  sufficient  length,  and which  was pushed out  by  making
pressure on its  free extremity.  We find in Dorsey's work two ure-
trotomes of this description, one  which was without any curvature,
and which  was designed for coarctations of the straight portion of
the canal, and the other, which was somewhat  more strongly  curved 
INCISIONS  AND SCARIFICATIONS.
1049
near its point than a  female catheter, and which was destined  to
attack the contractions of the bulb and membranous  portion.   Ran-
dolph alleges that  M. Gibson has obtained from these instruments
successful results, that no other  method  could have possibly pro-
cured.  But who does not perceive  that the cutting fleam (onglet)
of Physick or Dorner, would, in most cases,  whatever address we
might use, become involved  in the  tissue of the canal, than in the
centre of the obstacle itself,  and that in a great number of instan-
ces it would leave the  contraction  itself wholly  untouched.  M.
Despinay, (Bull, de Fer., X. X., p.  278,) who  allows of incision only
in cases of narrow contractions in form of a bridle, and at the an-
terior portion of the urethra  or neighborhood of the fossa navicu-
laris, for example, recommends that we should make it with a straight,
very narrow  and blunt-pointed bistoury.  The bistoury of Bienaise,
or the small concealed uretrotome of M. Civiale, would  evidently
fulfill this indication better.  No one,  moreover, can question the ad-
vantages of this operative method over that which was followed  by
Physick.  As the incision would  be made by a lateral movement,
and from behind forwards, it  could not expose to  the risk of false
routes, like that which is effected from before backwards, and beyond
the conducting instrument.
   M. Ashmead, adopting the  suggestion of the practitioner of Bourg,
has had  constructed a concealed bistoury like that of F. Come, the
sheath of which is  prolonged into a blunt or probe point in order  to
go beyond the obstacle, while the blade has  a cutting edge only  to
the extent of six or eight lines near its extremity, in order that when
opened it may incise only the contracted part, and which instrument
its author supposes could be applied to every  portion of the urethra.
M. Guillon, (Trav.  de  la Soc. de Med. Prat., 1831, '32, p.  33,) who
appears to have been well satisfied with scarifications, has contrived
for this purpose  sarcotomes  and  uretrotomes, which  are  still  more
ingenious than those of M. Ashmead.   M. Tanchou has also invented
some.   M. Raybard,  (Proc  nouv. pour guirir par  Fincision  les
retrecissements du  canal de  Furetre, Lyon,  1833, in 8vo.,) also  in
resorting to the incision of contractions of the urethra, makes use  of
a bridhcutter or uretrotome with  one or with  two cutting edges, and
which are terminated  by a  probe-pointed  stem  contained  in the
interior of a  catheter.  Others, as Dzondi at first and M. Amussat
afterwards, have contrived  a stilette with four, six or eight cutting
crests parallel to its axis, which project to the distance of half a line
or a  line at  most  from  the  circumference of its vesical extremity,
which latter should be a little dilated  to the extent  of six or eight
lines.  The intermediate  grooves are filled in with ointment,  lhis
stilette is introduced into a straight canula, through which latter it is
conducted down in front of the obstacle.  Having reached that point
it is pushed upon, protrudes from  its  sheath and enters into the con-
traction   The ointment melts or recedes before the resisting point.
The small crests thus denuded, slit the contracted circle on different
portions of it in the manner of a scarificator.   The instrument is then
withdrawn   A flexible catheter or bougie is  then immediately sub-
stituted in its place and  left  to remain there for the space, of at least
twenty-four hours, after which it  is to be reintroduced from time to 
 1050         NEW ELEMENTS OF  OPERATIVE SURGERY.

 time until the cure is completed.  In order that an instrument of this
 kind may penetrate it is necessary that the coarctation should exist
 to a very slight extent, for its point, which has to pass first, and which
 is without a cutting edge, has a diameter of nearly two lines.  As the
 introduction of a sufficiently large bougie could not then be attended
 with any difficulty, it would be in vain here to try to discover a rea-
 son to justify uretrotomy.  The same objection is to be made to the
 instrument of M. Ashmead, as well as to the process of M. Despinay ;
 with this difference however, that, this last mentioned uretrotome, from
 being capable of assuming the  form of a bougie or a probe, passes
 through  the obstacle in the manner of a catheter, and does not divide
 it until afterwards as a secondary operation.   As it unites the advan-
 tages ofthe uretrotome with those  of conducting catheters or dilating
 bougies,  it may be directed only upon one point or may divide several
 of them  successively at  various distances, according to the pleasure
 of the operator.   This is the instrument  therefore,  or  one of those
 which will  be found in the atlas of this work, which would be most
 applicable should it  be absolutely necessary to have recourse to the
 method of incision.
                              § II.

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

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

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

  Planque (Bibl. de Med., X.  III.,  p. 253,  in 4to,) has published the
instance  of a surgeon who had the boldness to lay open the urethra
 from one end of it tofl\e other, in order to cauterize and change its
interior, and who afterwards united the wound upon a catheter by
 means of several points of twisted suture, and thus it  is said cured his 
EXTERNAL INCISIONS.
1051
patient, which practice was  generally adopted at Livourne at the
time of Solingen.  In place of incising it throughout its whole length,
a great number of practitioners adopted the method of dividing the
urethra only at its contracted portion.  J. L. Petit, who was a parti-
san of this method, did not leave the wound to cicatrize on his  S
shaped catheter, except after an operation of this kind ; while Lassus,
according to M. Dolivera, substituted, in 1786, a gum-elastic catheter
for that of Petit.   M. Levanier of Cherbourg, (Arch. Gen. de Med.,
X. IX., p. 413,) encountering an obliteration which was almost com-
plete, ventured to revive the process of Petit or Lassus, and his bold
attempt was crowned with success.   Had  not several surgeons en-
deavored to bring this practice into repute  again, it could  have been
dismissed in two words ; but it has been too frequently made trial of
for several years past to allow me to pass it over in silence.

                    § II.—Operative Process.

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

   When  there  is a  complete  obliteration, or the discovery of the
aperture of the canal is attended with too much difficulty, M. Groni-
ger recommends that we should incise at hazard as far down nearly
as to the prostate, that we should then penetrate through this gland
into  the bladder by a narrow bistoury or trochar, in such manner as
to create an artificial canal, which is to be  kept open by introducing
into it through the meatus urinarius, as in  the preceding case, a  ca-
theter which is to be left there, and  upon which  the whole wound is
to close up.  If, as Shaw lays it down, (Bull, de Fer., X. \l., p. 80,)
the contractions were always to be found anterior to the membranous
portion of the  urethra, and that there constantly exists a dilatation
behind them, the operation thus projected  might be performed with
considerable facility so far as relates to its  first stage; but this is far 
1052          NEW ELEMENTS OF OPERATIVE SURGERY.

from being generally the case, especially in those contractions which
succeed to ruptures.   M. Cox,  (The Lancet. 1828, vol. I., p.  278.)
who recommends the same method, cites in support of it a fact which
he considers among the most conclusive, but which in reality shows
rather  the extent  to which  the  temerity  and fatuity of some prac-
titioners will lead  them.  The fact  is, that the  urethra is scarcely
ever completely closed up by its organic contractions.  In admitting
that the simple button-hole slit may  be sometimes indispensable, and
that forced catheterism, when we find it impossible to pass a bougie,
should  not be preferred to it, we  may at least affirm that this incision
ought,  with an experienced  person,  to be  sufficient  to lay bare  the
continuity of the canal.   Puncture of the bladder would certainly be
less dangerous, more prompt, and far less painful than the process of
MM. Groniger and Cox.  I doubt moreover if any French practitioner
at the present  day  will find himself under the necessity of adopting a
course like this, or that the  simple  button-hole incision itself will be
very often had recourse to by them.   I would add that this canal of
a new  formation would not be kept  open, and that it would shut up
in spite of all our efforts.

                   Article V.—Dilatation.

                       § I.—The Process.

   The treatment of coarctations of the  urethra by dilatation, and
which  is the most ancient known, was  for a long time  the  only  one
in use.   The leaden bougies formerly employed, and again  extolled
by M. Herzberg,  (Bull, de  Fer., X.  XIV.,   p. 205,) together with
those which Schmidt had constructed with a mixture of lead and of
tin, being, though flexible, too hard and too heavy for the urethra to
support them  without  inconvenience,—the  wax bougies, and  those
of gum-elastic, are the only ones which have continued to be used in
practice.   The first, which were formerly made  of different substan-
ces, were  especially extolled  by Lamna, in  1551, and by Daran in
1745.  Since the utility of their  medicated  properties  has been de-
nied, and that  their mechanical properties only have been considered
of any value, the resolvent,  astringent, desiccative, and  other  mate-
rials of which they were composed  have  been replaced by yellow,
white,  or  red  wax, which is reduced to a flexible state.   The only
qualities  exacted  of  them  at the  present  day, are that  of  being
supple, smooth, insusceptible of melting in the organs, capable of adapt-
ing themselves to all the inflexions of the canal, and free from any ten-
dency  to break.  The leaden wire which some persons place in their
centre, in order to increase their solidity,  is without any utility.  A
fine and delicate catgut  is better, if we absolutely decide upon not
using  those which are  made with emplastic tissue.   M. Guillon,
(Trav. de la Soc Med. Prat., 1831-2, p. 32,) with a view of having
such as were  sufficiently strong, though at  the same time very deli-
cate, and  with a cylindrical,  olive-shaped, conical, and dilated (a
ventre) extremity, &c, had some  fabricated of whalebone.   The
fact is, I have seen him succeed  with bougies of this kind  in cases
where every other description had  failed.   Dilating bougies and va- 
DILATATION.
1053
 rious kinds of dilators for the urethra, moreover, have been con-
 trived by M.  Montain, (Therap. Mid.-Chir., p. 19.)
   A. The gum-elastic bougies, which  are smoother, more flexible,
 and still less irritating than wax bougies, have on the other hand the
 inconvenience of fatiguing the urethra more by their elasticity itself,
 and their tendency to straighten out, however small a volume they
 may have ; from  whence  it happens, that even in their character as
 foreign bodies, they cannot be substituted  in  every respect for em-
 plastic  bougies, as Soemmering and most moderns allege.   The bou-
 gies and  sounds of  ivory,  rendered  flexible, as  made  by MM.
 D'Arcet and Charriere, from their possessing  the pliancy and solidity
 of the gum instruments, and from their susceptibility of dilating, by
 imbibing humidity in the passage, would have been generally intro-
 duced into practice, in such manner as  to remedy the inconveniences
 of bougies hitherto employed, were it not  for their tendency to be-
 come dissolved.   Both these kinds are  of various forms.   They are
 either cylindrical, dilated, or conical, &c.  The conical bougies, in-
 creasing in volume in proportion as they penetrate, possess the  ad-
 vantage of dilating the constriction rapidly, and of not easily bend-
 ing in the passage; but they have the inconvenience of a tendency
 to escape from it, of filling it up too entirely, and  consequently of
 fatiguing it in the direction of their base; and moreover, if they are
 very much elongated, of protruding to a distance into the bladder be-
 fore they have acted  in a proper manner on the  contracted portion
 of the urethra.  It would be necessary that their point, which should
 at first be sufficiently delicate, should not be  farther than 12  to 18
 lines from the body of the cone, and  that they should afterwards be
 nearly cylindrical as far as to their base ; it being well understood that
 the bougies below 8 or 6 do not need this modification, which would
 weaken them  without giving them any  real advantage.
   B. The  bellied  (a ventre)  bougies  deserve  to be  more frequently
 used.  The fusiform dilatation of their fifth vesical portion, does not,
 when it is sufficiently elongated, prevent our making  them conical
 in this  direction, while from the manifestly less considerable volume
 of their stem,  they concentrate almost their entire action upon the
 contraction itself, cause but little irritation in the urethra, and are kept
 up without difficulty.  M.  Desruelles, (Journ.  de Prog, des Sc. Med.,
 X. XVIIL, p. 143,) adopting this  suggestion, has  gone  so  far  as to
 propose that we should substitute for  bougies a metallic canula of an
 inch or two in length, which should be left at the centre of  the con-
 tracted point,  after having introduced it there by  means of another
 instrument, and in such manner to  be enabled to retain it by means
 of a thread fastened outside.  But the bellied  bougie answers a bet-
 ter purpose.   As it enables us to increase the dilatation to such ex-
 tent as we desire,  it causes less pain than the conical bougies.  The
 action of bougies or sounds on the contraction  has not always been
 regarded in the same point of view :  at the present time we  allow
 nothing more  to these instruments, than the property of ulcerating
 and  that of dilating.  This is evidently an error.  The excentric
 compression which they make, from  its tendency to promote  inter-
stitial absorption, may dissipate the inflammation which in  so many
cases sustains  the callosities in the urethra,  at the same time that  it 
 1054          NEW ELEMENTS OF OPERATIVE SURGERY.

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

                    § II.—Operative  Process.

   When the urethra is  very much contracted, the passing of a bou-
gie is not always an easy matter.   If it is too small it bends before
the slightest obstacle, while if it is a  little larger, it is not possible  for
it to enter.  The catgut bougies, which  are  stiffer and have more
force under a smaller volume, present some advantages under such
circumstances.   Delpech recommends that we should flatten  and bite
their point  a little, in order to transform them into a kind of supple
and flexible pencil; after passing through the obstacle  he withdraws 
DILATATION.
1055
them at the expiration of two  hours;  he then introduces one a little
larger and renews this after the same interval, and replaces this again
the same evening when he considers it practicable, by a bougie  or
sound  of gum-elastic.   The  distension they undergo  gives  great
value to a dilating instrument under such circumstances ; but as they
become twisted, softened and  knotty, we  should incur the risk  of
breaking them  or of abrading the  urethra, should we delay chang-
ing them every two or three hours.
  A. Hollow Bougies.—In many cases also a small catheter or hol-
low bougie is more convenient to commence with.  The stilette,
which it is furnished with,  ought to be well  curved as far as to  its
point and possess all the strength possible.  The whole is  then to  be
introduced into  the  bladder according to  the rules of catheterism.
Moreover it is  prudent to have at  the same  time in our case, ca-
theters, bougies and catgut-sounds, in  order to  be enabled,  when
necessary, to make use of these instruments in succession.  There
cannot  be any  fixed  position  for  the  patient.   We  sometimes
leave him standing up, or  make him sit down,  or  place him in a
horizontal position.  The  penis, which is generally  held slightly
raised  up, requires  in other cases to be a little depressed  or drawn
forward.  The patient, guided by the sensation he experiences and
the resistance he feels as soon as the  point  of the bougie deviates
from the axis of the  canal, will sometimes succeed with the instru-
ment at a time when the most skillful  surgeon would have failed.
The failure of a first attempt is no argument in respect to the second.
A thousand particularities,  which practice alone will enable us  to
distinguish, may oppose us at first and a moment afterwards enable
us to succeed.   In  fine, we proceed nearly in the same manner as
for catheterism.   The  penis is held  in the left hand  and the bougie
pushed  in with the right.  The smallest kind easily become caught
at the bottom of the lacunae of Morgagni, or in the slightest  dupli-
cature  of the canal.  Should there  be ever so little  resistance, we
must, after having withdrawn it a few lines, turn it in the manner  of
an axis  between our  fingers, while continuing to push it forward
near the  difficulty.   A  cul de sac, or fold, or false direction, or  ru-
gosity, or the projection formed by  the coarctation itself, may arrest
its march.   It  is under such  circumstances, particularly,  that  we
must make it progress with caution, bring it back towards us, vary
its inclination, turn it between the fingers,  and favor its passage  by
means  of the forefinger resting  upon  the perineum.   We know that
it  has entered into the  contraction when, without any inclination  to
advance  farther, it has  no tendency  to recoil, and  is found as it were
compressed at its point.  We may be  certain of the contrary, when-
ever it springs back as soon as wre  cease to  make pressure upon it,
and that it offers no resistance to the hand  when  we are disposed to
withdraw it.   A practised person will not be deceived, and will ap-
preciate  better than can be described, the difference which  exists
between a bougie which is fastened  in the coarctation and  one which
is only stopped by it.  In the  first case, as  it  can  only be  prevented
from passing  on by its excess of  volume, we have nothing more
to do than to replace  it by a  smaller one, or to fix it at the point in
which it  has entered.   In the  second  case, we repeat our attempts 
1056         NEW ELEMENTS OF OPERATIVE  SURGERY.

in every possible way, using a larger or a smaller bougie, or one of
another form or  of another description.   Finally, we  may fix  it in
the point of the urethra which it has entered, provided its extremity
has  not bent up.  It  not unfrequently happens that when arranged
in this  manner, it will of itself overcome the obstacle, and  that at
the  expiration of a half an  hour we  shall find that we can make it
advance to a considerable distance with the greatest  degree of  fa-
cility.   This  course, which was  adopted by Dupuytren,  enabled
him to  succeed in numerous instances,  and in  some cases where
success was unhoped-for.    Should the  passage appear to  be  too
much irritated or in too painful a state, or if it should bleed copiously
or become spasmodically contracted, every manoeuvre is to be sus-
pended, to return to them at a subsequent period when  these acci-
dents shall  have subsided.   Those emplastic bougies,  in which we
have taken Xh6  precaution to give them a curve near their extremity,
cannot, it is true, be any longer rolled between the fingers, but they
accommodate  themselves better to the  direction of the  parts, and
in some certain cases surmount a difficulty  which has resisted  all
the  other kinds.   Dipping the penis in cold water, warming  the in-
strument before introducing  it, covering it with cerate after having
oiled it, or besmearing it with pomade of belladonna or opium, will
sometimes render that  easy  which seemed  to  be impossible.   A
long, blunt-pointed probe, with a ring outside, and pushed in while
turning it around, has full as well succeeded with me in many dif-
ficult cases, as it did with MM. Bell and  Vanvelsnaer, who proposed
it in 1814 and 1821.  Its button  extremity is an  excellent means
of overcoming the most  irregular coarctations,  and enables us in
this  manner, as M.  Segalas has remarked,  to measure the extent
of the contraction.
   B. I will now  suppose that the bougie is finally adjusted in  its
situation.   In order to fasten  it we confine ourselves, if it is  an em-
plastic and dilated one, to bending  that extremity which is near the
glans penis into the form of a hook or ring.  When it is cylindrical
or merely conical, it is necessary, moreover,  to invest it with a cun-
dum or a small sac of fine linen, which at the same time  envelopes the
penis.  The gum-elastic bougies require, in this respect, the same atten-
tion as  catheters  that are to be left  to  remain  in, and which have
been mentioned farther back.   The time proper to leave in the first
ones varies according to an infinite number of circumstances, that is,
according as the canal is more or less irritable or sensitive, or sound,
moreover, or diseased, or  whether the person experiences a greater
or less degree of pain from the bougie, or the coarctation has  existed
a greater or less length of time, or is more or less decidedly marked,
and  according to the effect also which we wish to produce.   It rarely
happens however that it is to be left in for less than half an hour, or than
one  or two hours, or more than twelve or fifteen hours, and it may
remain as long  in fact in general, as the  patient can support it with-
out experiencing too much suffering.  If the patient experiences an
urgent desire  to urinate, and the  fluid cannot make its escape be-
tween the walls of the canal  and the  foreign body, the conical bou-
gies have  in addition this  advantage, that by withdrawing them a
little the urine passes  with facility, and that we may readily replace 
DILATATION.
1057
 them afterwards at the same depth as before.   The flexible  cathe-
 ters, whether cylindrical or conical, and the hollow bougies, are val-
 uable in this respect, that it is unnecessary to change them in order
 to empty  the  bladder, and because  certain patients cannot  retain
 their urine over an hour, or even not as long.
   C. Nor can there be any fixed rule in respect to  the interval of
 time between each application.   We are sometimes obliged to wait
 two or three days, while in other cases the system becomes so quick-
 ly habituated to it, and is so  little  disturbed by it, that we may re-
 peat the  application on the following day.  In  renewing them, we
 take one which is of a little larger size, as often as the last made use
 of has begun to pass freely into the urethra, but as the conical bou-
 gies become larger and larger in size in proportion as they penetrate,
 they do not  so  absolutely exact this  reapplication.   The more we
 advance in the treatment, the more frequently do we  make the  appli-
 cations, and the longer do we  protract their duration.   It may be laid
 down as a principle, that  every  contraction which  can be traversed
 by a bougie, however small the  latter may be,  may  be cured by di-
 latation.  This treatment, which is so much the longer in proportion
 as the stricture  is so  much  the more indurated and  more resistant,
 and according as the patient is more excitable or more difficult to
 control, is sometimes not  terminated until after the expiration of two
 or three months;  but I have acquired the  conviction based upon a
 sufficiently extensive  number of observations, that we  may  in the
 majority of patients  succeed in  the space of from 20 to 30 days in
 restoring to the  canal in this manner its natural dimensions, especially
 by means of the conical bougies.
   D. I  have  even  frequently obtained these dilatations in the space
 of 6, 8, 12, or 15 days, in patients in whom the contraction was of
 several years' standing, and in some other patients who had been al-
 ready treated either  by bougies  or cauterization, but in  whom  the
 cure did  not  remain permanent.  Since I have mentioned this
 manner of dilating the urethra, it has found distinguished  partisans.
 M. Lallemand, (Pirondi,  Gaz. Med., 1835,  p. 764,) who employs it
 under  the  title  of sudden dilatation, and who administers copaiba
 with the intention  of temporarily dilating the urethra before the in-
 troduction  of the  first bougie, has derived excellent  results from it.
 M. Lasserre, (Bull,  de FAcad. Roy.  de  Med., Paris, 1839, t.  III.,
 p. 603,) who  with the intention  of suddenly enlarging  a contract-
 ed urethra, introduces successively into the bladder  12 numbers of
 the  sound, does no  more  than follow my practice.  Finally, the
 dilatation which 31. A. T. Chretien (Bull, de Ther., X. XVI., p. 288)
 eulogizes under the title of sudden dilatation, is also scarcely any other
 than an exaggeration ofthe process which I have just pointed out.
   E. Moreover, I know nothing of the dangers with which dilatation
 of the urethra is generally reproached, nor of the pains that certain
 authors  ascribe to it.  When  systematically performed, I have  rare-
 ly seen it produce  severe  accidents.   The mucous, or blenorrhagic
 exudation, that it sometimes occasions, almost always disappears of
 itself after  having lasted  a few  days.  The fever,  preceded  with
 trembling, and followed by sweats as in intermittent fevers, which it
causes in certain cases, has nothing alarming about it.  The nervous
                                67 
1058         NEW  ELEMENTS OF OPERATIVE SURGERY.

symptoms, and engorgement of the cord or testicles, are exceptional
accidents, which are not more frequently caused by the employment
of bougies than by the most simple form of catheterism.   A patient,
however, upon whom I had used this process at La Pitie, was seized
with symptoms which it is proper to notice.   A conical bougie had
been passed after several trials.  One morning this man, wishing to
introduce it himself, by its head, (chef.) could not succeed, and made
the canal bleed.   The exacerbation of fever, which had accompanied
the first attempts, was renewed, and continued  three days, and  did
not cease on the fourth until it was replaced by a violent tibio-tarsal
arthritis, which  was  followed  by an extensive abscess,  and  after-
wards  by anchylosis.   It is true that this leg had  been  fractured
above  the malleoli  six  weeks before.  Was  this  a  coincidence, or
was it  an effect of the same kind as those which are quite  frequently
caused by Menorrhagia ?   The objections which may in  reality be
made against this mode of treatment, are that of exposing to a return
of the  disease, that of requiring that the dilatation should  be carried
beyond the normal  dimensions of the  urethra, and that the bougies
cannot be  abruptly laid aside, but must continue to be made use of
from time  to time during the space of at least several months.
  F. A small cylindrical or fusiform pouch, supported by a probe and
contained in a flexible canula, and thus suddenly introduced into the
contraction and then filled by insufflation, forms an air dilator, which,
according to Ducamp and  M. Arnott, ought  to be substituted  for
dilated bougies,  and presents the important  advantage of forcibly
distending the coarctation without having the slightest action on the
rest of the canal.   At the present day we know that this  is not  the
case;  but  that the small  bladder  necessarily adapts itself  to  the
urethra, and that it  presses full  as much on this  side and  beyond as
upon  the  contracted  circle itself.   M.  Costallat has shown  me
another apparatus of this kind, which is composed chiefly of a long
tube made of fine linen, which  is introduced  into the bottom of the
urethra by means of a flexible tube.  This tube, which terminates in
a cul de sac at  its vesical extremity and is open and  has a ring at
the other extremity, is destined to receive small portions  of lint or
cotton, which, by means of a forked stem, are pushed  and crowded
into the coarctation in such manner as to obtain as  rapid and pro-
gressive a dilatation  as may be desired.   However  ingenious these
inventions may be, I doubt if they will be adopted in practice.  As
bougies almost always enable us to attain  the same object, they
deserve, by their simplicity, the preference that they will probably al-
most always have.

               § III.—Contraction of the Meatus.

  In man the coarctations of the urethra scarcely ever take place in
the prostatic region.   As  this canal,  unless  it  is stretched,  has
scarcely more than  four to five inches in front of this gland, we may
from that  conclude that any operation performed  at more than  six
inches  of its depth, can no longer have relation to a contraction of
the urethra.  At the bulb and in the corpus  spongiosum, and up to
as far  as  an inch from the prostate,  the coarctations of the ure- 
CAUTERIZATION.
1059
thra  should be  treated in the same  way as  those of the membra-
nous portion; but at the meatus they require some special precau-
tions. Their incision isthen so easy a matter that we ought generally
to give it the preference, or make it  the point of departure for the
rest of the treatment.   The ordinary crayon  of nitrate of silver re-
places, under these circumstances, the other instruments.  To effect
the dilatation  we have  no need of a bougie.   A sort of a plug  of
adhesive  plaster rolled up on its spread  side, and an inch long, and
which the patient withdraws and reintroduces himself every time he
has occasion to  urinate, is used in place of a bougie.

                             § IV.

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

                 Article VI.—Cauterization

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

                              § I.

   The nitrate  of  silver, substituted  in the place of sublimate and
other caustics which were first employed, has, it would seem, dimin-
ished its dangers, and reconciled to it a  number of persons.   By
demonstrating afterwards the possibility of touching only the diseased
part, confidence has finally been imparted to the public and cauteriza-
tion of the urethra been made, so to speak, a common method.  It is
not however  to be supposed that Ducamp was the original author of
these improvements.  The impression bougies (bougies d empreintes)
were in use at  the  16th century.   F.  Germain  and L.  Muzell,
(Rougemont, Bibl. Chir., p. 372) also advise that  we should ascer-
tain the  seat and  form of the contraction  with the extremity of an
emplastic bougie, and then withdraw it and remove a layer from its 
1060         NEW ELEMENTS OF OPERATIVE SURGERY.
point, in order to substitute in the place of this some caustic substance,
which is to be reintroduced upon the bougie thus armed into the con-
tracted  canal, in the same way as was  done  at the time of Dionis,
(Cours d'Operat., edit, of La Faye, p. 273.)   The process of Home,
which consists  in attaching a small quantity of nitrate of silver to
the point of a bougie, to be introduced down to the contracted part,
scarcely differs  from that of Germain or Muzell.   We see also that
Pare anticipated Hunter by proposing a canula to protect the urethra,
while we introduced the bougie charged with caustic, and  left it to
act.   Limonnier also, as M. Dezeimeris remarks, knew how to search
out for the difficulty, and to take the imprint of it by means of wax
before proceeding to cauterize.   F.  Roncalli, in the year 1720, more-
over made use ofthe same caustic that Hunter did, or the same process
as Pare, and the practice of Wiseman was so much in use at the time
his countryman was trying it  that Allies, in 1755,  complained of
the fatal accidents which it frequently produced at Paris.  Notwith-
standing the  remarks and modifications  of M. Wathely, the method
of Home, introduced into France by M.  A. Petit in  1818, (Revue
Med., 1837, t. III., p. 360 ; Bull, de la Fac. de Med., 7th annee, p. 106,)
had been so severely censured  by MM. Rawley and Carlisle among
others, that even in  England it continued to be the subject of various
prejudices, and that the memoir of  M.  Arnott,  based upon  the same
principles  as that of Ducamp,- produced scarcely any sensation at
London in 1819, no more than  that of M. Macllwain, published in
1830, will bring into repute the use of potash extolled by M. Wa-
thely  in similar cases.

                              §11.

   Cauterization from before backwards, with or without a conduct-
ing canula, has  almost entirely disappeared from  practice  since the
time that Arnott and Ducamp made known  their method.   If, after
the example of  M. Leroy, any persons should still incline to make use
of it,  the armed bougie of Home and of M. A. Petit, from  its being
flexible, ought to have the preference for those contractions which are
situated near or beyond the bulb.  If it is pushed rapidly in, it will not
without difficulty allow the caustic,  which is  upon its  point, to touch
the walls of the urethra before it reaches the contracted infundibu-
lum ;  we then push it in a little farther; the nitrate  now melts, and
we then draw out the instrument at  the expiration of about  a minute.
When the obstacle is at less depth, the canula of Roncalli or of Hunter
may  be employed  without  any inconvenience.  M.  Chas. Bell and
Shaw considered that the  beak of  a metallic catheter, which should
be straight or curved, according to circumstances, and pierced in the
centre if the constriction is central,  and  on  the side  in the contrary
case,  would fulfill with  more certainty the same indication, by giving
us all the liberty desirable to introduce and  protrude from one of
these holes, a  piece of caustic, either by means of a bougie  or  a
long forked probe, or any other appropriate instrument. 
CAUTERIZATION.
1061
                             § III.

  Lateral cauterization exacts more  precautions, and is performed
by various processes, which all belong to the same method.
  A. The apparatus of Ducamp consists of: 1st, an exploring sound,
designed  for ascertaining  the depth  at which  the  constriction  is
placed ;  2d,  an impression  bougie, having a certain quantity of soft
wax at  its  extremity; 3d, a conducting catheter, having  a platina
socket at one end, and  enclosed in a silver tube at the other ; 4th, a
caustic-holder, consisting of a small platina cylinder, hollowed out by
a slit on one of its sides, and having near its root  a transverse pin, to
prevent  it from  going beyond the beak of the conductor, and also
having a flexible stem,  which it is screwed upon, and which is con-
tinuous  at the other extremity with  a  metallic probe  armed with  a
ring.  The small socket of platina is filled with fragments of nitrate
of silver before screwing  it upon the flexible  stem.   Always taking
care to grasp this between the branches of a strong pair of forceps,
we then place it above a taper or candle with  a steady flame, in or-
der to melt  the caustic slowly, and that it may not bubble up, as fre-
quently  happens when  it is too quickly heated, or when the socket
has not been well cleansed and dried.  Nothing further remains than
to regularize the whole, by grating down the  projections or asperi-
ties  which  may have formed, by means  of  pumice-stone, or the
cutting edge of any instrument whatever.  We may then commence
the operation, after  having accurately determined with the exploring
instrument, the place where the obstacle is situated.  The impression
bougie is the  first  which-is introduced.  It  is  kept  for a moment
against the contraction, when the soft wax  fills it up and  gets lodged
in its passage.  It is then withdrawn, and  the size of its elongated
point furnishes the measure of the diameter which is to be traversed,
at the same  time that the impression  which is  transmitted should in-
dicate to us  whether the coarctation  is central or circular, or in the
contrary case on what part  of the urethra it exists.   The conductor
is then introduced to the same depth, where it is  held with  the left
hand, after which we seize with the right hand the ring of the caustic-
holder, which is  to be pushed in  in such manner  as to protrude the
platina  cylinder,.charged with nitrate, while   turning its socket to-
wards the diseased  wall, so as to make  it enter in fact into the con-
tracted circle.  The wings of its  pin are arrested within  the  socket
of its conductor.  We leave  it a minute, or  only half a minute  in
contact with the tissues.  After having withdrawn it into the interior
of the catheter, we remove the whole  apparatus, and the operation
is terminated.   In acting  in  this manner we cannot, should there be
several contractions existing at the same time, attack the most remote,
until after having destroyed in succession all the others.   The matters
which the organ secretes, from being liable to get into the conductor,
quite frequently dissolve the nitrate before it  can become lodged  in
the contracted passage.
   B. M. Lallemand is one of the  first who  endeavored to remove
this  inconvenience.  His caustic-holder, which is terminated by  a
button and  the whole  of which consists of one piece, together with
the stem which gives it motion, is straight or curved,  according as it 
1062         NEW  ELEMENTS  OF OPERATIVE  SURGERY.

is intended to penetrate to a greater or less distance, and enclosed in
a platina catheter or sheath, having  the  same shape  and a greater
diameter than is necessary, in order that it may be adjusted with ac-
curacy upon the socket or swollen  portion of the stilette.  A run-
ning ring, armed with a pressure  screw, embraces  the conducting
canula.   The stilette has at its other extremity a lenticular button or
nail, which is not adjusted until after having inserted  the instrument
from behind forwards into its  sheath or canula.   By  drawing it to-
wards us, the slight dilatation of its head completely closes up the ves-
ical extremity of the catheter, and  transforms it into a blunt point.
It is introduced in this manner, shut up, into the urethra, and  as  an
explorator as far as the bladder, in order to satisfy ourselves that
there is no longer any obstacle remaining.  If there  are several of
them, we may stop upon the last full as well as  upon  the first, and
cauterize them  from behind  forwards, or from  before backwards,
either in succession or all at the same sitting.  When it is inserted,
we bring down and fasten the running ring on a  line with the mea-
tus urinarius, in  order not to  lose sight of the distance  at which the
contraction is situated.  By afterwards drawing the sheath towards
us, the socket ofthe stilette is  disengaged and strikes naked upon the
diseased tissue.  For the purpose of closing it  up in  order to with-
draw it,  or for pushing it in and bringing it into contact with other
contractions, it is a  matter almost of indifference, whether we make
the sheath move on the stilette, or the stilette in  the  interior of the
sheath, by pushing one in or drawing back the other.   In this appa-
ratus several stilettes are necessary if the instrument is curved, be-
cause from being wholly metallic, they cannot turn on  their axis in
the interior  of the canula, and  that their socket  has necessarily
a fixed point. Thus, it is necessary to have such as have the socket
on the concave border, some with the socket below, and others that
have  it placed on  the side.  We "must also have them of different
sizes, together with sheaths whose calibre must proportionally vary.
  C. M. Segalas, with the  view of preserving the advantages of the
instrument of the  professor of Montpellier, without losing those  of
the apparatus of Ducamp, makes use of a stilette, which in its fourth
inner portion is formed of small links of a chain, like the  lithotritor
of M. Pravaz, and by which he is enabled to execute all the move-
ments of rotation required, and to turn  his  socket towards the dif-
ferent points of  the diseased circle in succession.  Moreover, in or-
der to make it penetrate down to the first contraction,  he incloses it
armed with its sheath in the conducting catheter of Ducamp.
  D.  M. Pasquier, instead of a pin, has  placed a circular border be-
hind the socket of the caustic-holder, in order that he may not  be
compelled to turn at the same time, both the stilette which is charged
with the nitrate, and the conducting tube, as  in the  process  of Du-
camp.  The other modifications made  by this surgeon are of little
importance, and may be  adopted or rejected without  any inconve-
nience.   Moreover, he has disembaiTassed the original method of its
impression-holding  bougies, and its exploring sounds, and, accord-
ing to M. Racine, recommends that the treatment  should be com-
menced with dilatation, by means of ordinary  bougies, in order that 
CAUTERIZATION.
1063
we may at the very first, carry the caustic down  to  the coarctation
which is most remote.
  E.  Some persons have supposed that they could give still greater
facility to the movements ofthe stilette or mandrin, by giving a greater
length to its outer portion which is metallic, by cutting it in the form
of facettes, in order that the pressure-screw  of the pavilion of the
conducting canula might be better adapted to it, or in dispensing with
the necessity of  this screw, by terminating it  in a forceps head,  one
ofthe branches of which would be free, and have transverse grooves
upon  it, which could fix it in a proper manner into the square open-
ing of the pavilion of .the sheath, while the other would be  continu-
ous with the stilette itself.  Others, M. Dieulafoi for example, make
use of a canula,  which is perforated upon  its side, in order that  the
socket, which is charged with the  caustic,  might  by this means
come in contact  with the interior of the canal.  These slight modifi-
cations, in my judgment, are of a character not to be neglected.
  F.  The  stilette (mandrin) which I employ  in preference, when I
do not use the instrument of M. Lallemand improved by M. Char-
riere, is a silver one with a platina socket, and  has no border,  but
is furnished with a  button,  and also  with a  packet of silver wire
rolled round  in  spiral  form,  in order to make them flexible and  less
liable to  break.   Its  free  extremity, which  is  a  sort of watch-
spring, 12  to  15 lines  long,  is inserted in the fixed branch of the
forceps head which I have  just mentioned, in such  manner that it
may be arrested in it by a pressure screw or withdrawn from it at
pleasure.   Its sheath is nothing else than the  flexible canula of Du-
camp, into  which I insert it from behind forwards, but not until after
having curved it, if I consider it necessary, in the same  manner as
a stilette of a gum-ejastic  catheter.  The forceps head .being  ad-
justed, nothing more remains to be done than  to draw upon it in or-
der to shut up the whole instrument, and then to apply the button
of  its cauterizing extremity, over the opening of the conducting
canula at the inner end of this last.  Its flexibility enables us, by curv-
ing it before the  operation, to turn  the  socket  upwards, downwards,
or to the  side.  Its head prevents it from making a false route  and
secures the caustic from the action  of the moisture  of the canal.
All that is  necessary to make it advance,  is to approximate the  two
branches of the  forceps head by  means of the  thumb and forefin-
ger of the right hand,  to attach that which is free alongside of the
other in the  pavilion  of the canula, and  to push them in together
while the  left hand holds the body of the instrument immovable in
the penis.

                      § IV.—Appreciation.

  The principal  advocates  of cauterization  have greatly insisted
upon  the necessity of determining not only the distance at which the
contraction is situated, but also its length, thickness, form and posi-
tion.  In regard to the first no difficulty exists.   Any blunt-pointed
bougie whatever will be sufficient, and will give full as much in-
formation  as the explorator or impression-holder of  Ducamp.   It
is not the  same  with the second question. The emplastic  or gum- 
1064         NEW ELEMENTS OF  OPERATIVE SURGERY.
elastic bougie  charged with soft wax, and which the same  author
advises should be carried down upon all the contractions at the same
time, with the view of thereby obtaining their various impressions by
one operation, does not possess the  slightest value.   A long probe
with a spherical head is infinitely more certain.   This probe, if in-
serted in the manner of a stilette in a  blunt-pointed catheter, or in-
troduced by itself, will come down upon the obstacle.  We then
mark  the corresponding figure  at the meatus urinarius, if it is not
marked at the pavilion of the catheter.  It passes beyond  the resist-
ing point, which stops  it a little, when we withdraw it, and the
extent of which  by this mechanism may be very easily measured,
since  we may mark its point of departure  and point of retreat at the
outside.   The questions of thickness and form present more embar-
rassment.  The impression-holder of Ducamp is a deceptive  instru-
ment, which deserves no confidence, and which can scarcely subserve
any other purposes  than the interests of  charlatanism.   Having
arrived into the urethra, its  moulding wax may be indented  full as
well by the action of a fold, or spasmodic  movement,  or momentary
flattening of the canal, as by the presence of an actual  coarctation,
and I  could never comprehend how upon the evidence of this  instru-
ment  alone practitioners of respectability  could  venture to have re-
course to the nitrate of silver.   How many urethras have been cau-
terized without necessity, because  the bougie of Ducamp, when  it
has come out indented, has given rise to the delusive idea that coarc-
tations existed !  M. Pasquier, therefore, was right in proscribing it,
and it is an instrument, in my opinion, which ought to be banished
from surgery.  M. Amussat (Arch. Gen. de Med., X. XIIL, p. 294) has
proposed to substitute for it a straight canula, furnished with a  stilette
whose extremity,-shaped like  the head of a nail or lentil, shuts up
the opening and constitutes its beak ; but the arrangement of which is
such that the handle  is fixed a little to the outside of the centre of the
terminal plate.  Being once adjusted  in its place, we hold or cause
to be  held the canula immovable with one hand, while with the other
we push forward the mandrin ; the rasp passes through the obstruc-
tion ;  we then turn  it upon its  axis,  and its  cutting border  later-
ally, immediately projects beyond the line  of the sheath ; in bring-
ing it  back we graze the corresponding wall of the canal, which is
sound and regular if it encounters nothing, but diseased on the con-
trary  and contracted in those cases where tissues, or a bridle, or a
crescent-like projection arrest the instrument and separate  it from
the canula.  This instrument,  which does not materially differ from
the uretrotome of Pare, except  that it is  straight instead of being
curved, and  not less faulty,  moreover,  than the bougies   of Du-
camp, would be still more dangerous, and besides could not succeed
except on very wide contractions.   We  shall  see, moreover, far-
ther on, what necessity there  may be  of  such precautions in prac-
tice.   Among so  many instruments  then,  which are those which
ought to  be  preserved ?  The  apparatus of M. Lallemand would
evidently be the best, if it were indispensable to pass in  succession
through all the contractions where  several of these exist.   That of
M. Segalas  would possess the same advantages, if it were less com-
plicated.  Finally,  it is the apparatus of Ducamp, modified  by M. 
CAUTERIZATION.                     1065
Pasquier, or the instrument which I  have made use of, as improved
by the cutler, Charriere, to which I  would give the preference, if it
were necessary to adopt one  to the exclusion of the others.  But it is
the same with cauterization  of the urethra as with all other opera-
tions.   In the hands of a skillful person  all instruments are good,
while in the contrary case there are none that  are convenient.
  A.  Results.—Whatever may be the process adopted,  the charac-
ter of the results produced is always the same.   While the nitrate
is naked in the urethra the patients experience a pain and sensation
of burning or broiling, which is obtuse in some  and very acute  in
others, and which afterwards  continues to a greater or less length of
time.   These differences are owing to several causes: 1 st, because
the cerate, lard or oil which  remained about the caustic have envel-
oped it and prevented it from acting ; 2d, because the indurated tis-
sues of the contracted circle  have almost  completely lost their sensi-
bility ; 3d, because the caustic comes into contact with some part of
the sound tissues and  spreads in front or behind the contraction; and
4th, because the canal is  already the seat of an irritation  or of a
greater or less degree of morbid sensibility.   When there has  been
no false route made and the caustic does not run, the pain in general
speedily subsides, and blood  does not always  make its appearance.
In any event a  general  bath is useful, in order to  prevent the acci-
dents, and should be had recourse to immediately or during the course
of the day.  When the coarctation  exists to a great  extent, or that
the cauterization has  been actively applied, it  may happen  that the
congestion and tumefaction will cause a retention of urine, which in
other circumstances may be produced by flocculi or foreign matters
and eschars that  have become arrested in the centre of the obstruc-
tion.   These are easily removed  by a fine bougie, baths and  tepid
injections.   Should inflammation be threatened we apply leeches to
the perineum.   On the  following, or on the second  or third  day,
thread-like shreds of  a grayish, blackish  or whitish color, issue with
the urine from the urethra, and again render this emission considera-
bly painful.  These discharges, however, do not necessarily occur,
and frequently they are entirely wanting, even though the cauteriza-
tion may have produced a very decided  effect. It is to  be renewed
as soon as the erethism has subsided, that is to say, at the expiration
of three, four, five or six days.   In  the interval some persons  apply
from  time to time a bougie for the space of some minutes, and in this
I think they have reason.   Others  allege that we should not have
recourse to dilating means until after having destroyed  the obstruc-
tion, which latter requires in this  event from four or  six to thirty or
forty cauterizations, and consequently a treatment of from fifteen days
to three or four months.                                        .
   B.  Theory.__The partisans of cauterization, with Hunter at then-
head, maintain that dilatation is nothing but a palliative means, al-
most'always followed by the return  of the disease, but that to obtain
a  cure free from all danger of a return, we must not  efface and  di-
late the induration, but in fact destroy and erode it, which is done by
the employment of caustic.  After which the bougies come in to
regularize and complete the  cure.   Their antagonists reply, that the
loss of substance caused by the caustic must necessarily leave a hard. 
1066         NEW ELEMENTS OF OPERATIVE SURGERY.

elastic, irregular cicatrix, which will almost inevitably reproduce the
coarctation ;  that in this respect the cauterization is still more liable
to be followed  by a  return  of the  disease than dilatation, and that
being incomparably more dangerous, it is not understood what should
give it the preference ; and that in order to act, the caustic-holder re-
quires a canal which still has a width of a line at least, which diameter
always admits of the employment of a bougie, and that these last fre-
quently pass  where the caustic socket cannot penetrate.   Setting out
from the first objection, they demand what advantage  there is in Cau-
terization, since in all cases where it is applicable bougies may be sub-
stituted for it. and that they ought moreover to precede and to follow
it in almost  every case.  These arguments  have not been triumph-
antly refuted, nor could they be by those persons to whom they are
addressed.   To oppose them it has been found necessary to consider
cauterization under another  point of view.
   Nitrate of silver modifies the vitality of  the parts  touched much
more than it destroys them.   In the urethra, it extinguishes the chro-
nic inflammation which has produced and which almost always keeps
up the contraction, in the same way as  it destroys a great number
of inflammations  on the skin, as herpes, zona, and  pustules of small-
pox ; in the same way also as it destroys certain anginas, aphthae, oph-
thalmias, &c.  It is  by this action, and  not  by  ulcerating, that it
dries up ancient discharges, which  are  situated sometimes  in front
and sometimes  behind the bulb of the urethra, and  it is by this that it
has procured such remarkable success in a great number of lesions,
which are  independent of all kinds of coarctation.  But upon this
hypothesis  also,  it would  be necessary, instead of attempting to
ulcerate, destroy, or in a word cauterize, that we should confine our-
selves as much as possible to the simple touching of the  parts with
caustic, and to  consider the nitrate  of silver not as an actual caustic,
but as a special topical application, intended to disperse  (sufflaminer)
the morbific cause, and at the same time to favor the resolution of the
lardaceous engorgement and the absorption of  the matters that have
become effused or concentrated in  the laminae  of  the mucous  mem-
brane or  subjacent tissues.   From  hence it follows that the potash
which M. Wathely  recommends, as a  substitute  for  lunar caustic,
is a dangerous means, which should never have been put in prac-
tice.  We  could explain  in this  manner  the results  obtained  by
the medicated  bougies of the ancients, and how it happens that all
kinds of cauterization have  been enabled to succeed.  With these
principles, and  which are those to which  I  have  conformed  myself
since the year  1828,  (Nivert, These, No. 100, Paris,  1830,) the em-
ployment of nitrate of silver becomes  a matter of extreme facility.
The  impression  holders  are no longer of any value, since  all that
is necessary is to introduce the caustic into the  coarctation by any
instrument whatever, without troubling ourselves to know whether
the obstruction is shorter  or longer, or above or below, since in dis-
solving it spreads itself almost immediately over the entire circum-
ference ofthe canal.   Also, the conductors which are  pierced outside
of the  centre of  the platina socket, which  caps  their extremity, in
order to separate the  caustic-holder from the sound wall of the ure-
thra, and to apply it, on the contrary, with the greater accuracy upon 
TREATMENT BY TOPICAL APPLICATIONS.
1067
the wall which is diseased, thus lose all their value.  The bougies
and the caustic then march in the front line;  the first  to  dilate
and enlarge, and the second to cure  and to restore to the tissues the
characters  which they have in their normal state.  Thus to dilate at
first, and not to cauterize  for the first time until after having  made
use of the application of bougies four or five  times;  to  continue the
dilatation;  to cauterize a second, and then a third and fourth time at
various intervals; and to repeat it even once or twice, though the
canal has been enlarged to its maximum diameter, in order that we
may  remove  the last traces  of inflammation  or morbid  irritation
which may have remained there; these constitute in fact the whole
treatment in a great majority of the cases of organic  coarctations
of the urethra.

      Article VII.—Treatment by Topical  Applications.

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

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

  Should the urethra  have become contracted in consequence  of a
wound, rupture, or any loss of substance whatever, the cure in gene-
ral  is  attended with  an  extreme degree of difficulty.  M. Denis
(Journ. Hebdom., 1835, t. IL, p. 9,) finding that the disease  in a case
of this kind  resisted every  remedy, came to the resolution to leave a
catheter remaining in the canal.   The cure in another case was not
effected until an incision and  the button-hole cleft was had recourse 
1068          NEW ELEMENTS OF OPERATIVE SURGERY.
to, (Journ. des Conn. Med. Chir., X. III., p. 37.)   The same was the
case in the patient of M.  Lefebvre.   I have seen a great number  of
cases of this description.  Dilatation, scarifications, cauterization and
topical applications succeed here at first, as in other cases ; but the
urethra will  not  be left alone three  days before the  disease is
again reproduced.  As there is in the cases  in question a kind  of
fistulous collar, or track of a  new formation, and of tissue which is
foreign to the natural canal, it contracts  as soon as it is freed of the
dilating body and left to itself, from whence it may be conceived how
difficult it must be to effect a radical cure of a coarctation of this
description.  It would be to  these  cases  only that incision, as em-
ployed by MM. Arnott, Jameson, Cox, &c, or excision  of the  cica-
trix, would in fact be applicable.  The thesis of M. Mahot (These,
No.  113, Paris, 1837,) will convey a sufficiently correct  idea of the
coarctation of which  I am here speaking.
  [Organic Contractions of the Urethra.—M. Cruveilhier has been
one of the first to disabuse the public  of the erroneous belief, which
had long prevailed, of the  frequent existence of various forms of orga-
nic contractions of the urethra.   In  a recent work, (Reflexions et Ob-
servations, &c, see Annates de la Chirurgie, No. 14, also Arch.  Gen.
de Med., 3e ser., t. XV., pp. 102, 103.) he  states that he has never
met  with but one single description of these organic alterations, viz.,
the fibrous transformation of the walls of the canal of the  urethra.
This he says may  constitute a mere  circular constriction  or ring, or
it may have a breadth of  from 6 to 12  lines, or even more.  They
may implicate the mucous membrane only, or the  entire thickness  of
the tissues of the canal.  Most  frequently  they are situated in the
membranous, and never in the prostatic portion ofthe urethra.   The
pre-existence of an ulceration is  a more  rational explanation of such
strictures, M.  Cruveilhier  thinks,  than a chronic inflammation, as it is
difficult to conceive how the latter could be so  circumscribed  in  its
extent.  From these data he deduces the following  conclusions  : the
inefficacy of  forced catheterism   and  conical sounds, the preference
of dilatation over cauterization, the necessity of long-continued dila-
tation, the tendency of such contractions to  be  reproduced, and the
absolute incurability of every kind  of urethral contraction.  Other
conclusions resulting from the doctrines ofthe learned professor, are,
1st, that those contractions described by all authors, and consisting
of a more  or less complete valve, or of bridles, or other alterations,
cannot have any real  existence ;  2d, that those barbarous methods of
treatment, borrowed, apparently, from  the  ancients, and predicated
on the late mistaken  notions concerning this disease, are hencefor-
ward to be rejected from  surgical  practice ; and 3d, that  all those
complicated and dangerous instruments invented upon such miscon-
ceptions, must, as a matter of course, be also proscribed.
  M. J. Benique, in a recent  work, (Reflex, et Observ. sur le troitc-
ment des  retrecissements  de FUrethre,  Paris, 1844,) also gives the
preference in  these affections, to dilatation over every other process.
His  method  appears  to be reasonable,  and to be full as  effectual as
the usual  modes, and attended with  much less pain.   He introduces
bougies of several sizes rapidly in  succession,  from small to  large,
and leaves them in but  a  few minutes, and thus repeats the  operation 
POLYPI of the urethra.
1069
daily, beginning each day with  the largest bougie which had  been
applied the day before.   M. L. Gosselin, (Arch. Gen. de Med., Paris,
Fevrier, 1845, pp. 175—189,) however, revives the doctrine of actual
spasmodic contractions of the urethra, as forming a frequent impedi-
ment to the sound and catheter.  He maintains that there are distinct
circular muscular fibres surrounding the  membranous portion, and
having a distinct aponeurotic investment, which, with  the fibres, are
totally different from and disconnected with the levator ani muscle.
He expresses his surprise, that  they  have been overlooked  by the
most distinguished  investigators on these  regions, including Wilson,
Guthrie, Amussat, Leroy d'Etiolles, Mercier, &c.  He imputes to them
the same or greater power of direct constriction of this  portion of the
urethra,  the  only  part  of it in which such  fibres  exist, than is
possessed by the bundle of muscular fibres described by M. Mercier,
(lb. loc. cit.) to exist on the lower segment of the vesical extremity
of the urethra.  These last constitute there a sort of half sphincter,
which, in cases of organic contraction in some part of the passage,
is apt to become  involved in inflammation and  irritation to such
degree as to contract with violence  and form a valve, which momen-
tarily closes up this orifice and prevents the escape of the urine until
the effort of  contraction passes,  through fatigue, into relaxation.
This then,  says M. Gosselin, is also  a  true spasmodic contraction,
but at the vesical termination of the urethra, and to be added there-
fore to the other locality where the  contraction, embracing the entire
contour of the passage, viz.: the membranous portion of the  tube,
may,  according to M. "Gosselin,  also  take place.   The surgeon
should be on his guard in respect to these nice and yet disputed
points in anatomy while in the employment of  catheterism; and on
this subject we would also commend to his  study a recent work of M.
Mercier, entitled Recherches sur  la  nature et  le  traitement d'une
cause frequente et peu connue de retention d'urine, Paris,  1844.   It is
to be  farther noted  that M. Gosselin considers that facts do not yet
authorize us to admit  that perfect spasmodic contraction, that is, an
entire spasmodic or temporary  muscular constriction and closure of
the urethra, can take place elsewhere than in the  membranous  por-
tion designated, and also it does  not occur there except in cases where
there already exists an organic contraction or a Menorrhagia.   T.]

             Article  IX.—Polypi of the Urethra.

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

                        § I.—In Woman.

   In 1825 a  midwife  brought to me a  lady about 20  years  of age,
who had had for some months a pyriform reddish tumor of  slight
consistence  and of the  size  of a small nut,  and which  projected
slightly to the outside by its dilated or rounded extremity, and was
fixed  by its root at the depth of four lines in the urethra.  I seized 
1070          NEW ELEMENTS OF OPERATIVE SURGERY.

this polypus with an erigne, drew it a little towards me, and  imme-
diately excised it without causing the slightest pain.  On the follow
ing day the patient found herself cured.   In 1829 I met with  a case
precisely similar.  A woman, whom M. de Blainville had sent to me
in 1832, furnished a third case of this character.  I have seen  others
in patients  of M. Bonis, M. Yvan, M. Demaziere and M. Comet, and
also in four or five other patients who were at La Charite, (Barthez,
Journ. Hebdom., 1836, t. IL, p.  310.)  M. Wardrop (The Lancet,
1828, vol. I., p. 585) has  seen three  cases of this description.   These
vegetations in women moreover have  been mentioned by  Vogel,
Rosenmuller, Chaussier, and MM. Lachapelle, Kaldebrand, Prochaska
and M. Larcher, and everything leads us to believe that excision and
cauterization,  which I have  always succeeded with, is their true
remedy.

                               §11.

  Man appears to be equally  liable  to this species of polypi.   I have
met with two instances of them. In one the excrescences, which were
three in number, were scarcely as large as barley seeds.  In the second
patient,  who was a young Englishman, whom M. Beaumont asked
me to see, there was also a number  of them and they were still small-
er.  They  were also situated behind the meatus urinarius.  None
of them re-appeared after having been broken  up or excised.  Do
not the polypi which Nicod has  spoken of so  much, belong to
this species of production?   M. Amussat, (Rev. Med., 1835, t. IV.,
p. 428,) has found them as far in as  at the membranous portion of the
urethra.  The small tumor that M. Thiaudiere, (Bull, de Therap.,
t. VIL, p. 240,) took for a pea-shaped cancer, and which was situated
at the bottom  of the fossa navicularis, and repullulated after having
been excised by means of an incision upon the dorsal surface  of the
glans penis, and which disappeared after a second excision followed
by cauterization, was according to all appearance nothing more than
a polypus of this kind.   The  simple tearing it out and cauterization
would have succeeded full as well  as the complicated operation of
M. Thiaudiere.
  [Polypi  of the Urethra.—It is very clear that this subdivision of
the nomenclature of polypi,  can be deemed  little  else than the off-
spring of  that penchant for  refinement and  innovation,  which is
caused at  the present day  by  the great abundance of collabora-
tors in the field of anatomical and surgical  inquiry.   It is certain
that we have  no very authentic  evidence as yet. that polypi, pro-
perly so called, ever do form in the urethra.  Though it  has been
asserted  that they frequently do in  women, as by MM. H. Bavoux,
(Arch. Gen. de Med., Sept., 1845, 4e ser., t. IX, p.  101,) Asson, (lb.,
Oct., 1845, p. 235,) S. Medoro, (lb., p.  236, and Giornale  dei Pro-
gressi, Dec,  1844,) and  Camin, (lb., loc. cit.,) it is  evident that the
cases  in  question by these authors,  were for  the most  part nothing
more  than venereal vegetations, so common in the vagina, on the
glans  penis, prepuce, lips of the meatus, &c.   T.] 
PERINEAL PUNCTURE.
1071
     Article X.—Abnormal Dilatation of the Urethra.

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

                  PUNCTURE OF THE BLADDER.

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

               Article I.—Perineal Puncture.

   The opening of the  bladder through  the perineum, in order to
 remedy ischuria, must have  appeared  a very  simple  matter to the
 ancient lithotomists, who admitted  no  other passage for the extrac-
 tion  of calculi.  So also was it the first  route which was proposed,
 and the only one which was  for a long time followed.   Latta, to
 whom  Soemmering ascribes  the honor of this process, is no more
 the inventor  of perineal puncture than Garengeot is,  who  appropri-
 ated it to himself a half a century before.  Riolan  and  Thevenin
 formally recommend it, and Toilet  had  already performed it in 1681.
 Dionis  also describes  it quite at length, and shows that it may be
 performed in two modes.  An incision an inch long upon the raphe,
in  the  same manner as for  the  great operation,  would  enable us
to  plunge a  long  bistoury into the bladder in front of the anus; to 
1072          NEW ELEMENTS OF OPERATIVE SURGERY.
introduce a sound here while withdrawing the  cutting instrument,
and to leave a canula in the wound  for the evacuation  of the urine.
But Dionis thinks it would be  better, in order to protect the pros-
tate, to prolong the incision a little to the outside, as in lithotomy by
the method of F. Jacques.
   Juncker, Lapeyronie and Heister, suggested  almost  at the same
epoch the idea  of  substituting a long trochar for the bistoury,  and
they considered that they had in this manner rendered the operation
much more simple.  In this respect it is reduced to the first stage of
the process for lateral lithotomy by  Foubert, and  it is performed in
the same manner, that is to say, having  placed the patient in  the
same way as for lithotomy, we plunge the instrument in at the middle
of the space which separates  the ischium from the  raphe, directing it
a  little inwards and forwards in order to fall almost  perpendicularly
upon the side of the neck of the bladder.  The  fear of making a
false route through so many different tissues, had given rise to the
suggestion that we should incise the perineum by means of a bistoury,
and not employ the trochar until after having felt with the finger the
distended  bladder at the  bottom of the wound.   This is a modifica-
tion  which Sabatier recommends  that we should apply to perineal
paracentesis, as Garengeot had recommended it for lateral lithotomy,
and  the result of which would be that we should fuse into one pro-
cess, the  methods of Dionis  and of Juncker.  But  this advice  has
generally been neglected.  While  the  French writers continued to
recommend pure and simple puncture. Incision  did not cease to be
adopted in England,  where it  appears to have been performed in
various ways.  M. A. Cooper,  following in the  footsteps of  Dionis,
incises a little to the  left  of the raphe, depresses the bulb and then
the prostate to the right by means of his left forefinger, while with a
very sharp scalpel in the other hand  he divides the tissues and pene-
trates  into the bladder.   M.  Chas. Bell, when he  thinks he can find
the urethra behind the contraction, lays open this canal as in Chesel-
den's process of lithotomy, and  alleges that in this manner we arrive
into  the bladder with less danger.  M. Brander  recommends that
we should not penetrate except by incising  layer by layer ; but Jones
and Dorsey do not see the utility of so many precautions.  To reca-
pitulate, if puncture with the  trochar is  more  prompt, it is at  the
same time less sure.  If the instrument has  less danger for the vessels
and the ureters or vesiculae seminales, and that it would rather sepa-
rate than divide  them, it escapes with  greater facility also between
t  e organic layers, and may more easily miss the bladder.  In using
a long and narrow bistoury we afterwards  have to  introduce  a sound
into the bladder,  and  then a  canula.   The false routes, though  less
probable, are nevertheless possible, and  the danger of wounding the
organs, which ought to be avoided, is much more to be apprehended.
Incision, properly so called, which is more rational and more pru-
dent, is also  more difficult.   The want of a conductor, which it is
o ut of our power to pass through the natural passages, renders  this
process more delicate and more uncertain  than in lithotomy, whether
we desire to respect the prostate, as in the  lateral method, or whether
we penetrate  through the urethra.  Nevertheless, as in such cases
the bladder is very much distended, and  its excretory duct almost 
PUNCTURE THROUGH THE RECTUM.
1073
constantly enlarged behind the coarctation, I would, if I were ever
under the necessity of opening an  artificial passage for the  urine,
limit myself to finding the urethra and  making a  slit between the
contraction and the anus, even though I had to include the apex of
the prostate in my incision.   This  opening would possess the double
advantage of offering not only a passage for the sound and canulas
that we might wish to introduce into the bladder, but also of enabling
us to pay immediate attention to the diseased canal from behind for-
wards.  The button-hole incision of which I speak, while  it is neither
more nor less dangerous than the  ordinary incision for lithotomy, is
certainly less so  than  the  other modes  of puncturing the  bladder,
which, it is calculated, if I am not deceived, to be successfully sub-
stituted for, in all those cases in which the  morbid or abnormal state
of the perineum does not present  any obstacle to our cutting  down
upon the urinary passage through  this region.

         Article II.—Puncture  through the Rectum

  The fluctuating projection which the bladder forms below the rec-
tum, when it is distended by the urine, is of itself sufficient to suggest
the idea of recto-vesical puncture.   It is even surprising that it was not
sooner thought of, for the finger introduced into the anus must have
frequently felt this fluctuation.  Fleurant, who considers himself to
have been the author of this  operation, and Pouteau, his successor,
with a view  of  retaining the canula  of the  trochar in the organ,
in order not to  be obliged to recommence, if the natural  passage
should be too tardy in becoming re-established, bent the  opening of
the canula of their curved trochar, to a right  angle on the  concave
side of its tube.   By this means it  is found reversed as it were, upon
the perineal groove, in front of the anus, where it is easy to  fasten it
in such manner  that it will not interfere with the stools, nor prevent
the patient from  walking or sitting.  Most of those  authors who re-
commend  leaving a canula in the wound, have adopted the instru-
ment  of the surgeon of Lyon.  Those who, like Hamilton,  consider
that it is better to withdraw it immediately, at the risk of being obli-
ged to repeat the puncture, require nothing more  than  an ordinary
curved trochar.  It is a matter of little importance, moreover, whether
its point is flattened into the form  of a lancet, like that of B. Bell, or
triangular, like the one which M. Howship has  endeavored to bring
into repute among his countrymen.  A narrow bistoury, protected
with linen, would  effect the same  object and would  expose less,
perhaps, to  the risk of  fistulas, and  would  penetrate  better ; but
it is  not so  easy to  manage, and is less commodious  for the pla-
cing of a canula.  The patient, who  is placed in the same position
as for  lithotomy, might,  if necessary, rest with  his belly  upon the
edge of a  bed,  with  his legs hanging down, did not such  a  pos-
ture  add  too much to his sufferings.   The  operator  in that case
would have no necessity for assistants, and would find himself more
at ease  for perforating the bas fond of the bladder perpendicularly.
In both cases the forefinger alone,  or  the fore  and  middle  finger of
the left hand, besmeared with cerate, or any greasy substance what-
ever, and introduced into the rectum, recognize the projection of the 
1074          NEW elements of operative surgery.

bladder and the prostate, stretch the parts, by separating them a little
from each other, and are fixed with their palmar surface turned for-
wards, at a little distance from the gland, while the pulp or  the nail
rests against the distended organ, after which they serve as a gorget,
or conductor to the trochar.   This last introduced with the right hand,
and with its concavity forward, upon the intestinal side of the trigo-
nus, betwreen the peritoneal cul de sac and the base of the prostate, is
suddenly plunged in, as if it were with the intention of pushing it to
the umbilicus, that is to say, obliquely upwards and forwards.  When
it has passed through the tissues,  and its point  has entered  into the
bladder, its lateral groove allows  some drops of urine to escape, and
gives us the assurance  that we  have not made  a false route.   The
stilette is withdrawn ; the liquid runs out, and the bladder being once
emptied, the operation is terminated, unless we  decide upon  fixing a
tube in the wound.   In this last case, a flexible catheter, which is very
pliant, and which should be protected by lint in order by means of
some compresses, and  a T bandage, to keep it  immovable upon the
perineum, ought to have the preference to the canula of the  trochar,
which latter, however, could  serve as a director to introduce it.
But it is doubtful if a derivative tube would then be necessary.  In the
patient of Hamilton  the wound reopened  of itself.   In the contrary
case a second puncture would probably involve fewer inconveniences
than the protracted presence of a foreign body in the rectum and
bladder. Rigidly considered, it would be at least useless to leave the
canula beyond the time necessary for the cohesion ofthe tissues, that
is to say, beyond the space  of 12  to 24 hours ;  for  the  inflammation
which takes place in the little wound does  not  after that permit the
urine to become infiltrated into the tissue of the  recto-vesical septum,
while at the same time it opposes  no serious obstacle to its escape.

             Article III.—Hypogastric Puncture.

  The  principles  advanced on this subject in the last century by
Hoin and Noel, prove that puncture above the pubes, which must
have originated at the same time with hypogastric lithotomy, had not
yet found but a very small number of partisans.   Tolet, Drouin, Tur-
bier, Mery, Morand and a fewr others were, according to M.  Belmas,
the only persons who practised it.  But the authority of F. Come,
Bonn and Paletta, and  especially that of Soemmering, who declared
himself its  unequivocal champion, ultimately brought  it into vogue
throughout all Europe, in spite ofthe efforts of Murray and Mursinna
to bring into repute recto-vesical puncture. It was almost the only
puncture employed in France  for a long  time.  The case of punc-
ture by  the rectum found in the thesis of M. Duplat, and the two exam-
ples which M. Cabanellas has cited from the practice of M. Magnan,
are exceptions which passed unnoticed.   As the straight trochar which
was  first employed might wound, and as the point of its canula left
remaining might uleerate  the posterior wall of the bladder, which
necessarily contracts upon itself after the evacuation of the  urine,
the curved trochar of F. Come has been generally adopted,  whether
we confine ourselves to puncture without  previous incision, or in im-
itation of Abernethy, divide the  hypogastric wall with  the  bistoury 
HYPOGASTRIC  PUNCTURE.
1075
before having  recourse to the trochar.   The  operation, moreover, is
so easy that the preparatory incision is in reality only calculated to
embarrass it.  The patient is to be placed horizontally on the  long
edge of his bed.   The surgeon first looks for the upper border of the
pubes and the  median line ; he then directs the point of his trochar to
a point about an inch above the symphysis and plunges it with a single
movement  from above downwards and from  before backwards into
the  bladder, where he  arrives  after having passed through a space
which varies according to the embonpoint of the patient and the par-
ticular arrangement ofthe parts.  The stilette having been withdrawn,
the  urine escapes, and  the canula,  which is to be shut up with a peg,
is afterwards fastened around the body by means of cords which are
attached to the lateral parts of its pavilion.  But this canula is still
more dangerous above the pubis than in the rectum.   If it  is too long
it ulcerates the organ ; and if too short, its  point having been left by
the bladder which contracts upon itself, becomes arrested in the sur-
rounding cellular tissue.   If it  is not changed  from  time to  time, it
may become encrusted with calculous concretions, by which its remo-
val will be attended with difficulty.   After having withdrawn it, it
is not always  an easy matter to place it in  again.   As a gum-elastic
sound introduced into the bladder through the metallic canula and
left there in place of this last, is of a  smaller diameter, it  would not
completely fill up the wound and would therefore allow the urine to
filtrate between the tissues  and  the  foreign  body.   The  flexible
sheath serving as a chemise to the instrument, and which M. J. Cloquet
introduces at first, in such manner  that in withdrawing the stilette, to
allow the urine to escape, and afterwards its canula, it, is found alone
in the solution of continuity, is but an imperfect remedy for this diffi-
culty.   It has to  be shorter than the silver  tube, on the external sur-
face of which its lower extremity always forms  a  projecting cir-
cle which is more or less irregular, whatever care we may take to
attenuate and  regularize it.   From whence it is, that there exists a
series of projections or borders, rendering it more difficult to push it
through the tissues.  Moreover it would be incorrect to suppose that
 a tube, whose  circumference is exactly fitted to the contour of the open-
ing through which it has passed, would for  any length of time remain
in this precise contact.  After  the expiration of a few hours this is
already  found to be no longer the case,  and the fluids pass  with
 facility between the canula and the wound.   The bougies and sounds
in the urethra daily afford evidence of  this, a fact which I also  again
saw in the patient, who, in the year 1822, at the Hospital St. Louis,
contrived the  modification of which I have just spoken.  Such con-
siderations all go in support ofthe practice of those who do not con-
sider it proper to leave any thing in the wound, and  who. when cir-
cumstances make it necessary, prefer to repeat the puncture as soon
as the bladder is  again distended.  I would be wholly of their opinion
if the puncture ofthe abdominal walls, which agglutinates more rap-
idly than that of the bladder, did not  expose to  the risk of the  filtra-
tion of a few drops of liquid  into the  pelvic cellular tissue, and it
after the expiration of about twelve  hours the  inflamed state of the
wound had not already transformed it into a sort of fistula.  A patient
in whom I had recourse to puncture twice in the space of three days, 
1076
NEW ELEMENTS OF OPERATIVE SURGERY.
died on the sixth of a peritonitis.  A dark colored collection of small
extent was found between the  lower  part of the hypogastrium and
the front part of the bladder.  A case  of hypogastric puncture of the
bladder,  however, related  by M. Franc, (Extract des Calculs, &c,
p. 5,) was not followed  by any accident.  This puncture, which was
successfully performed in 1828, by M. Vaust, (Mem. de I'Acad. Roy.
de Med., by M. Voltens, Dec, 1838,) was again repeated on the same
patient, by M. Voltens, (Ibid., Dec, 1838,) in 1834.   The patient ope-
rated upon wears a gum-elastic catheter and experiences no inconve-
nience from it.   He was afterwards operated upon at the perineum
and his urethra appeared to have closed up.  M. Nick, (Gaz. Med..
1839, p.  185) relates the case  of a man 72 years  of age, in whom
hypogastric puncture was  performed to relieve an ischuria, and who
was obliged to wear a canula up  to the time of his death, which
took place at the expiration of twelve  years.

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

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

                              § I.
  Recto-vesical puncture, without being as formidable as Soemmer-
ing alleges it to be, is far  from being as  innocuous as Murray and
Schmucker (Rougemont,  Bibl. Chir., p. 40,) consider it.  Tumors
in the neighborhood of the  anus, and also the thickness of the septum
at the entrance of the intestine, may render it painful, or its  execu-
tion uncertain, or even impossible.  The instrument may escape be-
tween the bladder and rectum into the pelvic cellular tissue, or it
may  perforate  the peritoneum when this  membrane descends too
near the prostate or if we puncture a  little  too high, or if we go too
far down or to the side, we may wound the vasa deferentia and the
vesiculae seminales, or even the  ureters.   As  the organ is  incised
very near the urethra, and consequently near the seat ofthe disease, we
incur the risk of aggravating the accidents in this  respect.   Finally,
the wound may  remain fistulous, and  allow the  stercoral humidi-
ties to  enter into the bladder  and produce  fatal  consequences.   It
is true  that the greater part of these difficulties will in most cases
be overcome by a skillful hand, and that the dangerous consequences
which I have just mentioned are  not all unavoidable; but the fistula,
which the address and intelligence of the operator cannot prevent
taking place, as  is proved by the cases related  by Bonn, Paletta,
Angeli, &c, is alone of itself a very serious disease, and the cure of
which is attended with too much difficulty  to allow us to run the risk
of its occurrence when it is possible for us to avoid it.   In  exchange
for so many inconveniences, puncture through the intestine has the
advantage of being generally easy, of penetrating the bladder at its
 most depending point, of traversing only a small extent of tissues,
 and  such as are  too condensed to lead to any serious apprehension 
PARALLEL between the  DIFFERENT PUNCTURES.      1077
of the  infiltration of urine or abscesses, which however have been
sometimes seen to  take  place, especially in a patient  mentioned by
M. Nauche;  the advantage  also of giving facility to the use of a
canula, in the manner, recommended by  Schmucker, (Rougemont,
Bibl. Chir., X. L, p. 40,) and  of not absolutely confining the patient
to his bed: a case of a man is related, who had undergone this ope-
ration  twenty times  without experiencing any  accidents from it,
(Bull, de Fer., X. XII., p. 240.)

                              § II.

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

   Puncture through the  perineum is incomparably less certain than
 at the  hypogastrium,  and endangers the vesiculae seminales and ure-
 thra in the same way as puncture at the rectum.  It  may strike too
 far forward  and between the  pubes and  bladder, or too far back-
 wards, and thus penetrate into  the peritoneal cul de  sac or into the
 intestine, and thus not arrive into the distended reservoir until after
 having lacerated their walls.  Nor are the vessels of  the peritoneum
 or the°prostate safe from the  instrument.  Infiltrations and abscesses
 are not altogether impossible, and in no region is the presence of a
 canula more irritating.  The only advantages of this puncture are,
 that it  opens  into the  bladder upon  a  depending  point, without
 exposing to the risk of fistulas as that by the rectum does ; of making
 a readier passage for the  urine, without incurring as much  risk of
 urinary  inflammations as puncture at the hypogastrium.  Such ad-
 vantages, though small in number, are important; and if we had not
to purchase them at so dear  a price, or if they were  actually of any
great value,  perineal  puncture ought perhaps to be preferred to the
other two modes.   Now it appears to me that a simple button-hole
incision  at the urethra  possesses  these advantages in a still  higher
degree and that it even  enables us, almost with a degree of certainty,
to  avoid all  the neighboring organs.   As  it  has no  other inconve- 
1078         NEW ELEMENTS OF  OPERATIVE SURGERY.

niences than that of being a little more delicate, and  somewhat  less
prompt, I consider it preferable in all cases where the form or con-
texture of the perineum is not  too much changed from the normal
state, and where the  surgeon has some experience in operations.   In
the other cases supra-pubic puncture should have the preference, and
recto-vesical puncture would be reserved for exceptional cases,  and
would  not  be had recourse to except in those instances in which
some particular obstructions were interposed to the introduction of
the instrument through the two principal passages.

                             §IV.

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

                             § V.

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

                       URINARY FISTULAS.

             Article I.—Recto-Vesical Fistulas.

  Recto-vesical fistulas, which are equally as obstinate as  those of
the vesico-vaginal septum, are  moreover treated precisely in the
same manner and by the same processes.  In these  cases however 
FISTULAS OF THE  URETHRA.
1079
 the surgeon begins, if the urethra is contracted, by restoring it to its
 natural dimensions; by depressing the prostate with the redresseur
 of MM. Tanchou, Leroy or Pravaz, should  its size be such  as to
 interfere with the  passage of the urine; and by destroying, in fine,
 the  obstructions that  the  bladder encounters  in  evacuating  itself
 through the  natural passage.  Desault cured recto-vesical  fistulas,
 following the operation  of lithotomy by incising  the  parts situated
 between the wound of the  perineum and: that of the intestine, com-
 prising in this incision the sphincter of the anus, in such manner as to
 transform the whole into one single wound.   But if the first incision
 had been cicatrized for a long time, this process would be no longer
 applicable  or would at least require  some  modification.   In  such
 cases we might  imitate with advantage the conduct of M. A. Cooper,
 who again laid open through the perineum, upon a  grooved sound the
 prostatic portion of the urethra from before backwards, in order that
 the urine, finding a means of escape anteriorly, might allow the pos-
 terior opening to close up, in which operation he succeded perfectly
 in one  instance.  The incision with the bistoury,  extended from the
 fistula to  the perineum and on the groove of a sound, as in recto-
 prostatic lithotomy, would be more easy and more certain  perhaps
 than  the  oblique  operation  of  Desault, should the  process of M.
 Cooper not appear to be sufficient, but it would expose to the risk of
 wounding the verumontanum and the ejaculating  ducts. In a youth
 14 years of  age, a rod of iron, which had penetrated through the
 anus, laid open the bladder to a great  extent.  Two years after, M.
 MacFarlane, consulted by this patient, (Arch. Gen. de Med., 2e ser.,
 t. IL, p. 281,) had recourse  to cauterization,  and effected a cure in
 the space of two months.   The same surgeon mentions a child  of 12
 years, whose bladder  had  been wounded by the  thrust of a  bull's
 horn, and who was not over six weeks in getting cured of his fistula.

                 Article II.—Internal Fistulas.

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

            Article  III.—Fistulas of the Urethra.

  It  is not altogether the same with  fistulas  of the urethra, as  it is
 with the fistulas  in the preceding cases.  In the corpus spongiosum
 they rarely fail  to disappear spontaneously as soon  as we  have
 adopted the  precaution  of re-establishing  the dimensions of this
 canal.  At the fossa navicularis, where M. Barthelemy, (Bull, de Fer.,
 X. XIX., p. 74,) has seen  them open in  the manner of the spout of a
watering pot, they may almost always  be dried up  by not permitting
the patient to urinate for some days except by means of a catheter,
as was done by  this surgeon,  in adopting  also  the precaution to 
 1080         NEW ELEMENTS OF  OPERATIVE SURGERY.

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

                 § I.—Injections.—Cauterization.

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

  Derivative catheterism  can scarcely succeed except in those fistu-
las which are unattended with, or  have but a very slight loss of sub-
 stance, whether they  have or have not  been  preceded by contrac-
tion  of the urethra.  The gum-elastic catheter  left to remain in, i&
not always unattended with inconvenience, which  may be said also of
the metallic S shaped catheter, which was used by J. L. Petit, the one
with a fixed  curvature as  recommended by  Hey,  or  that which
is strongly curved as Physick advises when the prostate is engorged,
as also of that which has a free direction, like  the one generally em-
ployed in France since the time of Desault.  If it  remains open in
order that the urine may escape in proportion as  the ureters deposit 
FISTULAS OF THE  URETHRA.
1081
it in the bladder, its point  presses against the posterior wall of this
organ, and irritates, and ulcerates, and sometimes even perforates it.
If it is kept shut up, a small quantity of the urinary fluid, which al-
most constantly makes its  escape between it and the walls of the
canal, will be  found sufficient in many cases to prevent the fistula
from becoming obliterated.  This is  a fact which has been  perfectly
well demonstrated by Asselin in his Thesis in  1803, and  which is
confirmed by the experience of M. Caffort.  It is, consequently, bet-
ter to catheterize the patient, or  for him to learn  to  do it himself,
with a silver catheter in preference, as often  as  he is under the ne-
cessity of urinating.   A patient whom I had in vain submitted to the
use  of permanent catheters,  at  La  Pitie in 1830, was  radically
cured at the expiration of three days,  as soon  as I  decided upon
catheterizing him every four or six  hours, and then immediately re-
moving the instrument.  Cauterization  may be  combined  with ca-
theterism, and becomes indispensable as  soon as the cure is  delayed
beyond a week or two.  If after six weeks or two months the dis-
ease continues, we may, without fear of being charged with precip-
itation, have recourse to the final expedients.

                              § HI-

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

                             §  IV.

   The suture is applied here in the same way as  in any other region.
We commence by transforming the fistula into a button-hole incision,
or one which is somewhat elongated, but less  so on the wall of the
urethra than at the integuments.  After  having  abraded its borders,
removed the callosities, and approximated the two lips upon a flexible
catheter, which is  destined to  remain  in place, we  keep  them in
contact by means of a sufficient number of points  of twisted suture,
which points should not be more than three lines apart, if we do not
wish the  urine to infiltrate between them, and which, for  the  same
reason, ought  to be  tightened sufficiently if we  wish  the aggluti-
nation to take  place wholly by first intention.   We afterwards fill up
the perineal depression with compresses or lint, in  order to support
the whole by a gentle compression.   If everything goes on well, we
remove the needles on the  fourth or  fifth day, beginning with those
at the angles.   The other is left in a day or two longer.  This, in its
turn, is  removed, and the  patient wall  be found  to be  cured.  M.
Cloquet has been successful in  one  case of this kind, (Journ. Heb-
dom., t. IV., p. 45.)  Unfortunately we have not always as happy a re- 
1082          NEW  ELEMENTS OF OPERATIVE  SURGERY.

suit, as is proved by the fruitless essays of Chas. Bell.   It frequently
becomes necessary to repeat the operation several  times ; also it is
not unusual to find that all the efforts of the surgeon, and all the per-
severance of the patient, result in nothing more than an enlargement
of the fistula.   I have  elsewhere mentioned what  uretroplasty (see
Vol. I.) in vain attempted, by M. Green, (The Lancet, vol. IL, p. 669,)
has obtained, up to the present time in the hands of MM. A. Cooper,
Earle, Alliot, &c.  M. Dieffenbach, (Rev. Med., 1826, t. IV.,  p. 123
—Arch.  Gen.  de Med., 1836  1837,) after making  trial of cauteriza-
tion by  itself,  suture  after cauterization, abrasion and interrupted
suture, abrasion  and twisted  suture,  suture  of a fold  of the skin,
the borders of which were united over  the fistula, and also  of cir-
cular strangulation of the contour of the ulcer, has, by submitting the
fistula at last to a final test with  the suture, anaplasty and cauteri-
zation under all their forms, succeeded in some instances;  but he has
also seen a great number  of urethral  fistulas, and even such as were
of the smallest kind, that have obstinately resisted  all his efforts.
and persisted in continuing in spite of every remedy.

                   Article IV.—Hypospadias.

  Urethra] fistulas from birth, somewhat near  the glans penis, require
no other  remedy  than the  creation of a new canal  in the tissues of
the penis, by which process M. Rublach (Bull, de Fer., X. X., p. 159,)
states that he succeeded in one instance.  In, a case of a very large
fistula, which  formed under the  glans penis, in consequence of ah
ulcer, M. Heller (Gaz. Med., 1834, p.  747,)  divided  the  bridle
and abraded the sides of the incision,  then  inserted seven  points
of suture, and thus completely succeeded.   M.  Perrin, (Arch. Gen. de
Med., April, 1839, p. 485,) in order to cure a hypospadias, caused by
an ancient stricture  of the urethra, confined himself to the excision
of the prepuce and pendant portion  of the  glans.   A child 8 years
of age, who had  brought  on a hypospadias by constricting his penis,
was cured  of it by M. Pauli, (Gaz. Med., 1838, p. 807,)  by means of
excision  of  the prepuce, and  by  detaching the integuments of  the
penis, and then inserting six points of suture.  As to  hypospadias,
properly so called, I am not aware that it  has been often treated by
an operation.   The  abrading  of the sides  of  the furrow which pro-
longs it in front, then detaching them  a little, in order to bring them
to the median  line, and afterwards  uniting them  by suture  upon a
catheter, which is to be  left  in the  urethra,  would enable us, per-
haps, to effect a cure in some instances;  but I doubt if the hollowing
out  of  a new  canal  through the glans penis, either  from  before
backwards or from  behind forwards, would present much  prospect
of  success.   Moreover,  we  should not  be justified in attempting
such operations,  except only  at  the period of puberty or in adult
age.  M. Begin, however,  (Elem. de  Chir..  2d  edit., t. I.,  p. 565,)
like M. Rublach, had recourse to it  in a child who  urinated only
through a capillary aperture, situated at a finger's breadth behind the
fossa navicularis.  A probe having been introduced into the passage,
and directed towards  the glans, a hydrocele trochar  was  applied
to the point where the  meatus ought to have existed, and  plunged in 
HYPOSPADIAS.
1083
until  it came in  contact  with the probe.   The canula was left in,
and  on the day after a gum-elastic conductor of Ducamp wTas sub-
stituted in the place of this. The fistula, after being cauterized, cica-
trized, and the cure was the result.  Might we not, says the  same
author, (Ibid., p. 563,) apply to hypospadias the following process:
abrade the borders of the gutter of the penis, by detaching the skin
on each side;  and then reconstruct for the  canal a lower cutane-
ous wall, either by means of elongating the skin, and uniting it upon
a  catheter,  or by taking a  flap  borrowed  from the neighboring
parts, and brought down  upon the penis ?  This suggestion has not
been  tested in practice.
  [Cure of Hypospadias.—It was M. Ricord who invented the in-
genious process for the cure of a hypospadias, or destruction ofthe low-
er wall of the urethra, to the  distance of three centimeters from the
meatus, and which interfered  with erection.  He made a small in-
cision into the membranous  portion and  passed the urine off by
means of a catheter through  this  artificial  route, until  by abrading
the lips of the defective portion of the passage and uniting them by
suture, he had  effected  their  agglutination.  The case (Arch. Gen.,
3e ser., t. XL, 1841, p. 109,) completely succeeded, and the  incision
into the membranous portion soon healed up.  The  erections after-
wards took place without difficulty.   The dangerous point in this
process is that of closing up the new or temporary aperture, and also
the risk of  urinous infiltration, as well as the exposure  to a greater
number of  accidents from having two wounds  under treatment in
the same organ.
  Foreign  bodies in the  bladder and urethra.—Modem surgery in
its minute researches has added one remarkable fact  to the chapter
on foreign  bodies  in organic cavities,—or at least a fact which, had
it ever occurred before, has hitherto escaped  observation.   Dr. Ar-
taud,  (sitting of the Acad.  Roy. of Medicine, Paris, Jan. 27, 1845,
Arch. Gen., Fev.,  1846,  pp. 213-216,) on ascertaining, at Cherbourg,
in May, 1840,  from a female unmarried  patient  aged twenty-six,
troubled with amenorrhea, and burning pricking sensation in the
kidneys and  urinary passages, with numbness along the right crural
nerve, ischuria, &c, that  she  had passed  a worm (strongle geant)
with her urine, catheterized her and after withdrawing a large  quan-
tity of lactescent whitish  urine, found the retention of urine, on the
following morning, complete.  On catheterizing again he perceived
a foreign  body, and  substituting  Hunter's forceps, cautiously ex-
tracted a  reddish colored flattened worm, (twenty-two centimeters
long  and four millimeters thick.)   Near a  year afterwards on the
recurrence  of similar accidents, he extracted in the  same manner a
fleshy body of the size of an almond, and during  the ensuing eight
months, fifteen  of these bodies of various  size, and also seven more
strongle worms.   Finally, by aid of dilatation, he seized  and brought
out another fleshy body of the size of a large chesnut, pierced  in its
centre and  containing five smaller bodies in its cavity.  Syncopes,
hysteria and hematuria, with  some pain in the right lung and he-
moptysis, succeeded, with intense fever and delirium.   About eight
months after the  suppressed catamenia  were  imperfectly  resto-
red,  when  a false membrane thirty  centimeters long, forming  a 
1084         NEW ELEMENTS OF OPERATIVE SURGERY.
cylindrical tube,  (conduit cylindrique,)  large enough to  admit the
finger, came out spontaneously from the urethra.  She now enjoyed
good health for several months, until in the latter part of 1841, when
the symptoms again returned, and  she again passed three strongles.
She was, however, still living January 27, 1845.   (Ib.)
  M.  Segalas, in  his report to the Academy, as one of the commis-
sion on this case and its  specimens, confesses, while admitting the
facts as incontestable proof of the generation of strongles geants in
the urinary organs, their inability to explain Xhe fleshy bodies, (masses
charnues,) whether they were the residuary of organized fibrine from
hemorrhagic  deposits, or portions of the substance  of the nearest
neighboring muscles, detached by the verminous affection.  In refer-
ence to the last branch of this  question, M. Segalas  alludes to the
case of three worms, two to seven inches long, found imbedded (lar-
des) in the substance of  the lumbar muscles,  also to a strongle geant
found by M. Blainville in the kidney of a weasel, (marte,) and which
was over twenty-nine inches long and two and a half lines broad, and
only half a line in thickness.
  The suppression of the catamenia appears, in our judgment,  to
furnish a satisfactory explanation to most if not all of the phenomena.
The discharge  of regularly organized false membranes, during the
violent, sharp,  bearing down  pains of the paroxysms of dysmenor-
rhea, which recur just anterior to the menstrual period, is no uncom-
mon event in unmarried  young women  in whom the catamenial
function continues to be but imperfectly performed.  In one  remark-
able case I attended,  of a married colored  female, in  the  Bahama
Islands, and in whom this affection had existed for years, the bearing
down pains were excessively acute, and more so even than  those of
severe labor, from which in fact they  were scarcely distinguishable.
Enemata of laudanum, injections of the same into the vagina, and
large doses internally, with the hot bath, &c, scarcely procured any
relief.  Little or no menstrual blood would come away at these pe-
riods,  and in the intervals there was  more or less of the usual sub-
stitute, fluor albus.  But the great effort of nature to make up for the
deficit, and in this case an anxious desire also to become  impregna-
ted, explain perhaps how the violent contractions of the womb aided
in separating  the fibrine from the other portions  of the blood con-
tained  in the vessels on the inner surface of this cavity, and  in thus
forming the abnormal membrane.  The case of Dr. Artaud in ques-
tion, exhibited this same abnormal organized membranous formation,
in fact a tubular one corresponding naturally to the cylindrical shape
of the urethra, as the same finger of glove-like tubes of membrane
are seen in croup, dysentery, &c   (See also our note on this subject
in Vol. II. of this work.)  The same diseased action which made the
urethral cylinder, may very readily explain  the fleshy  fibrinous de-
posits expelled or extracted from the bladder.  And were in fact the
supposed strongles  geants  anything  more than one of the urinary
cylinders as it were consolidated ?   Therefore not worms, but all
morbid products  of the same altered condition of the blood, (i. e.,
highly surcharged with fibrine and gelatine,) from  the suppressed
and retained catamenial blood, however true it may be that the con- 
IMPERFORATION.
i„85
dition of this latter recrementitious and quasi venous fluid in its nor-
mal state is such that it does not coagulate out of the body.
  Three inches of a gum-elastic sound, which  had broken off and
slipped  into the bladder in a man  aged 50, December,  1836,  (Dr.
Buchanan, in London Lancet, July, 1840,) after occasioning much irri-
tation and purulent discharges from the  bladder  and urethra, for the
space of over a year, finally made its way in three  successive por-
tions at  the meatus, from whence they were extracted  by means of
the forceps and probe.
  In the case of a young man aged 25,  who while  playing with a
metallic tube which he had introduced into the urethra, let it slip into
the bladder, together with  the pen within the tube, M. Dieffenbach
(Caspar's Wochenscrift, 1843, No. 1) was obliged to make a  small
puncture above the pubis  before he could  extract it.  We cannot
however conceive  why this surgeon should have first found it neces-
sary before making the  puncture, to  resort to the  lithotritic forceps
passed through the urethra, in order  to hold the tube in a fixed posi-
tion.  This part ofthe manipulation appears to us to have been quite
unnecessary, as one end of the tube probably could have been so se-
cured by two fingers in the rectum, as to make the other project above
the pubis, and thereby designate the point to cut down upon with the
bistoury.  The more important was  it not to make any uncalled for
irritation in the bladder itself, from the admission by M. Dieffen-
bach himself; that he preferred a simple supra-pubic puncture with
the bistoury to the operation of lithotomy at the perineum or rectum,
because, as he says, of the greater danger of this operation in cases
of foreign bodies that have been introduced into the bladder.
   M. Leroy d'Etiolles, by means of lithotritic instruments, succeeded
in.breaking and extracting from the bladder of a woman (Arch.  Gen.,
Aout, 1844, p. 522) a  round piece of wood, 93 millimetres long and
10 to 11 mill, in diameter.   It occupied a transverse position.   T.]
     PART  NINTH.

DISEASES OF THE  RECTUM.
                         CHAPTER I.

                 DEFECTS OF CONFORMATION.

                  Article I.—Imperforation.

  We sometimes find in young girls that the rectum opens into the
vagina, or near the posterior part of the vulva, instead of terminating
with an anal opening in front of the coccyx.  Still more frequently
we find  in new-born  children of both sexes, that the intestine ends in
a cul de sac above its natural termination, and at a  greater or less
height in the pelvis.  The first case, which belongs to the varieties of 
1086         NEW elements of  operative surgery.

artificial anus, is, all other things being considered, not so necessarily
fatal as the second.   The meconium extravasated into the bladder be-
comes diffused there and may be expelled from it during the course
of a few days.  An infant whom I saw, and who evacuated it by the
urethra, lived for the space of  several  weeks.  The opening, how-
ever,  from the  depot of faecal  matter, and the canal  by  which  it
is excreted, are not in such cases  sufficiently large for life to be sus-
tained when the matters have  attained a certain  degree of consist-
ence,  and so  much the more so because  the urinary organs are not
capable of supporting for a long time and without danger the imme-
diate contact of stercoral substances.  I have seen the anus in three
instances open into the urethra, and in two into  the bladder.  M.
Bonet, (Revue Med., 1829, t. IL, p. 398,)  M. Willaume, (Journ. des
Prog.,X. VIIL, p. 238,) M. Randolphe, (Encycl. des  Sc. Med., 1839,
p.  195,) and Bravais (Soc.  de  Sante de  Lyon, X. IL,  p. 97,) have
also  met  with  cases where its  orifice  terminated in the excre-
tory duct of the  urine.   In patients mentioned  by M. Fristo,  (com-
municated by the author, 1838.) it opened  in the loins in  one case,
and upon the dorsum of the penis in  another.   M. Palmer men-
tions a case  of imperforate rectum where  the  intestine terminated
on a line with the sacro-vertebral  angle, after having made several
zigzag turns, being the  case of a  female infant  who lived four days,
and in whom the operation  for imperforate anus  was performed
without success.   In another infant the rectum terminated in a cul
de sac, and by a filament at the  upper part of the sacro-vertebral an-
gle, (Lieutaud,  Bull, de la Soc. Anat.,  May,  1839,  p.  86.)  In the
case of M. Olinet, (Journ. Univ. des Sci.  Med.,  Feb. 1820,)  the anus
was prolonged by means of a canal to as far as within  two lines of
the vulva, where it opened.   In the case of Littre, its exit was at the
hypogastrium; in those  of Mery and Hartmann,  at  the umbilicus ;
in those of Schurig, Bonne, Desgranges and M. Dieffenbach, it was
at a point on the vagina; in the two cases  quoted by M. Champion
and M. Ribes from Cnoeffelius, La Faye and  M. Lacoste, it perforated
through the  sacrum ; in the  case of M. De la Salle,  at  the membra-
nous portion  of the urethra; and  in that of Desault and a number
of others, in the bladder.  The cases of  artificial anus perforating
the  sacrum  have, moreover, been  met  with in several  instances,
whether, as in  the  cases of Cnoeffelius  (Eph.  contre nature,  Dec.
1, an. 4, 5, Obs. 65, 1773-4)  and  M. Fristo, there was  no accompa-
nying opening at the natural place, or  whether, as in the patients
of La Faye, (Princ de  Chir..  &lc) M. Lacoste, (Bull, de la Soc.
Med.  d'Emul, Oct. 1822, p. 417)  and M. Ricord, (Rev. Med., 1834,
t. III., p. 473,) there was only a  simple hernia of the rectum, which
had or had  not  ulcerated through the sacrum.  The recto-vaginal,
recto-vulvar, and all other kinds of external  anus  from defect of
conformation, are disgusting infirmities, but do not necessarily cause
death.  On  the  contrary, the  infant dies  by  necessity in a short
space of time when the  intestine is entirely deprived of an exit, or
when it opens into an organ which does not communicate with the exte-
rior.  In both cases art has but two kinds of remedies to make trial of:
1. To re-establish the anus in its natural position  ; and 2. To make an
artificial one on some other point of the abdominal cavity. 
fMPERFORATION.
1087
             § I.—To  re-establish the Natural Anus.

   A. When the anus is closed only by the skin, or by a layer which
 does not  however possess but  a few  lines of thickness, its resto-
 ration is  never a very difficult  operation.  A projection  and a blu-
 ish spot generally point out  its  seat, and the  obscure  fluctuation
 which is  sometimes perceived there by the finger enables us to act
 without any apprehension.   In  place of circumscribing it by a cir-
 cular incision, as recommended by Levret, the surgeon should plunge
 the point  of a straight bistoury or trochar into the centre ofthe spot,
 in the direction of the rectum,  and down to the seat of the  me-
 conium.   Having  enlarged  the  puncture in the antero-posterior
 direction  and transversely, he excises the four flaps;  he then places
 in it a tent of lint or linen, or  in fine, a suppository, in order to  pre-
 vent it from closing up again, and afterwards continues to dress  it in
 this  manner with dilating bodies until it has perfectly cicatrized.  A
 certain number of cures have been obtained in this manner, and are
 such as would justify no delay under such circumstances.
   B. We should also act in this  manner in those cases where, though
 the  anus  may exist, the intestine  has been closed   up  by a  sep-
 tum at some distance above.  Only that it would be advisable in
 such cases to surround the bistoury with a linen bandage, unless we
 should prefer the trochar recommended by J. L. Petit, or the pha-
 ryngotome, advised by M. Martin.  In cases  of this  kind the exci-
 sion of  the angles of the crucial opening is no longer possible.  The
 operation for this deformity was successful in  the case of Pistor in
 1764, as it had been before, and as it has since been in the hands of
 Moncelot, Loyseau, Demarque, Underwood, and  M. Ouvrard.  The
 instances  of cure related by MM. Phelys, (Bull, de la Fac. de Med.,
 4th year, p.  102,) Laracine,  (Bull, de la  Soc. Med. d'Emul, 1824.)
 Sandras, Duparcque, Forget, (Rev. Med., 1835, t. IL,  p. 284,) Jodin,
 (Journ. Hebd. Univ., X. III., p.  413,) Salmon, (Gaz.  Med.,  1838, p.
 456,) and  Bouyer, (Bull, de FAcad. Roy. de Med., X. II., p. 818.)  also
 probably  belong to this class.  The  infant, however, that was ope-
 rated upon by  M. Goyrand, (Journ. Hebd., 1834, t. III., p. 245,) died
 in consequence at  the expiration  of twelve days. MM. Wolff, and
 C. Hutchinson, (S.  Cooper,  p. 209—S. Cooper, Diet., p. 208.) have
 both succeeded once  in new-born infants, who had  an imperforate
 anus  of this  description.  The deformity in one of  them was not
 noticed  until the 12th day.   In a case of similar anus, M.  Miller,
 (S. Cooper, Diet.,  p. 210, edit. 1838.) was obliged to repeat the ope-
 ration eleven times before he succeeded.
  C.  An anus opening at. the fourchette in a little girl, as in the case
 published  by M. Brachet, could  be readily restored  to its natural
 situation.   A straight bistoury guided  by a grooved  sound  through
 the fistula into the intestine, and directed from  before backwards,
 or from the  perineum  to the coccyx,  or from above downwards,
 would divide  all  the tissues  which  had caused the deviation.  A
 canula fixed in the rectum near the  posterior angle  of the wound,
would enable the solution of continuity in front to cicatrize, and the
matters  to reacquire  their normal direction.   The same operation
was  recommended by Vicq d'Azyr  in cases of vaginal  anus.  M. 
1088         NEW  ELEMENTS  OF OPERATIVE SURGERY.

Martin recommends, that after having incised the entire septum from
above downwards, and from before backwards, as in the  preceding
case:  and  after having placed  the  canula  in  such manner that it
may go a little beyond the fistula above, that we should reunite  the
wound on  its  anterior surface by means of the  suture.  This  last
stage of the operation, which  is undoubtedly the most difficult, does
not appear  to me to be necessary.  If the derivative tube is pro-
perly  adjusted, the reunion of the divided  tissues in front will be
effected without the intermediation of the threads.   There would also
be a mode of avoiding this, and  of accomplishing the same result
with  less inconvenience ;  this would be to ascertain, by means of an
instrument  curved  backwards  in the form  of a  blunt hook,  and
brought from  above downwards,  through the fistula, to what point
the intestinal  cul de sac  descends,  and then to penetrate into  the
rectum by  a  puncture from the skin  towards the pelvis, without
dividing the recto-vaginal septum.
  D. In infants  of the male sex we have not  the same resources.
As the meconium only comes out at  the time of discharging  the
urine, it does not, though it shows that the anus is entero-vesical, indi-
cate either the direction  or precise seat of the termination of  the
rectum.  If it escapes from it  at every  moment or at  intervals,
and without any mixture of urine, the  opening is probably in  the
urethra.  Although we cannot always ascertain whether it is at a
short distance from the glans penis, as M. Monod  has seen it, (Bibl.
Med., 1829, t.  IL, p. 447,) or  deeper in, and  near  the perineum, as
it is  found  to be in  most cases, we have nevertheless good grounds
to anticipate some success in such cases, by a methodical perforation
at the usual place of the anus.   In the  first case, as in those  where
nothing outside can enable us to understand the interior condition of
the parts, the operation, as it would, so  to speak, be made at hazard,
would necessarily be attended  with less chances of success.   To in-
cise  the perineum and neck  of the bladder  in the  same way as in
lithotomy, in order to create  a large  common issue both for   the
urine and  stercoral  matters, in  those cases  in which  the  intestine
terminates in the bladder, would be a remedy, if not as dangerous,
at least as revolting as the disease itself.  The  infant in whom Ca-
venne de Laon deemed it advisable to make  trial  of this operation,
died  in the course of  the evening, and  M. Martin of Lyon who  has
recommended it, had doubtless  not  reflected that his  process,  by
leaving the recto-vesical anus  in its congenital state of constriction.
could not have been attended even with the advantage of prolong-
ing the life of the child.  If M. Ferguson,  (Arch.  Gen.  de Med.,
X. XXVIIL, p. 563,) has succeeded by operating in this manner,  the
cases of Zacutus-Luzitanus, and of M. Willaume, are much less cal-
culated to inspire confidence.

                              §11.

  The method of seeking for the intestine through the tissues which
separate it from the cutaneous surface, is the only one up to the pre-
sent  time which presents  any prospect of success in obscure cases.
The infant  is  to be held, with its limbs apart and flexed, upon  the 
IMPERFORATION.
1089
knees of an assistant, or upon a table properly prepared.  The sur-
geon placed in front explores the perineal or inter-gluteal depression
if any exists; if he encounters no indication of anus or intestine, he
endeavors to recognize the point of the coccyx and places the centre
of his incision at about ten lines in front of this bone, and then divides
first the skin to the extent of from ten to fifteen lines, and afterwards
in succession the different layers which present themselves, until he
comes down to the depth of an inch  or two, that is to say, down
to the  intestinal cul de sac. should  any  present, or  until  he  has
lost  all hope  of finding  it.   The left  forefinger,  which constantly
serves as a guide to the instrument, of itself  applied from  time to
time to the bottom of the wound, would enable us to perceive  the
projection and fluctuation of  the distended organ, and to ascertain in
what direction it would be advisable to carry the point ofthe bistoury
or trochar.  In commencing, this dissection should be nearly in  the
axis of the body, that  is to say, almost perpendicularly ; afterwards
we should incline it by degrees towards the sacrum, in order not to
touch the bladder, and  that we might follow the usual track of  the
rectum.   The trochar in this  respect is less certain than the bistoury.
As the bladder in  some degree fills up the pelvis when the intestine
is wanting, it  will almost inevitably  perforate  it.   Moreover,  it  too
readily escapes into the midst of the soft parts, to  allow us here, to
place any great confidence  in it.   Puncture, in whatever way  we
should employ it, could not, without danger, be substituted for dissec-
tion, unless the sac, filled with its matters, was recognizable either to
the finger or eye, or upon the skin, or at the bottom of the wound.
Having once entered into the rectum we enlarge the incision with cau-
tion in different directions, and especially in that where there appears
to be the greatest room.   We then introduce into it a tent of linen or
lint, or even a canula, which terminates the operation.  We have
nothing more  to do than to keep open the new anus, to give it a
sufficient degree of breadth, and to prevent its coarctation or obliter-
ation.  To incise  layer by layer the tissues, sphincter, levator ani,
&c, as M. N. Roux has done, (Arch. Gen. de Med., 2d ser., t.  V.,
p. 475,) is neither better nor  worse than the ordinary method.   To
apply to  the anus in these cases, what M.  Dieffenbach has done  for
the lips, that is to say, to detach the extremity of the rectum in order
to bring down its  mucous membrane and sew it on the skin,  would
at the same time be attended with great danger and  but little efficacy,
and in most cases would be impossible.  M. Amussat, (Gaz. Med.,
1835, p. 753—Arch. Gen. de Med., 2d  ser., t.  IL,  p. 237,) who has
done this in one instance,  does not say whether his  patient remained
cured.   This operation, which we have frequent occasions of prac-
tising,  is  rarely followed  by a complete cure.  Roonhuysen, F. de
Hilden, (Bonet, Corps  de Med., p. 438,) and De LaMotte, who have
been most successful with it, allow that mast of their patients ulti-
mately died at the expiration of a few months, or one or two  years.
B. Bell, who has obtained some successes from it, asserts positively
that it  is  almost impossible to prevent the new  opening from  closing
up again.   The infant operated upon by M. Jodin  soon succumbed.
I  have performed the  operation on  six patients.   Four died: two
after a manifest improvement; the  third  at  the expiration of  six
                               69 
 1090         NEW ELEMENTS OF OPERATIVE  SURGERY.

 weeks, from neglecting the precaution of keeping in the canula ; and
 the fourth from my not being able to  find  the rectum, which was
 continuous, by means  of a filament, with the body of the bladder.
 The two others were cured, one at La Charite in 1837, and the other
 in the practice of M.  Layraud  in 1838.  Failures in cases of this
 kind have nothing in them  to surprise us.  If the  cure obtained by
 Wagler, after having in vain  incised  the  perineum, and  afterwards
 plunged, on the  following day, a lancet into the  rectum, which he
 thought he could distinguish  at the bottom of the wound, remained
 permanent and without any obstruction, this was owing doubtless  to
 his not having been obliged to penetrate very deep, and to the intes-
 tine not having been very distant from the sphincter.   I would make
 the same remark in regard to the little girl  operated upon by the
 surgeon referred to by M. C.  L. Lepine, and  who died three  years
 subsequently of an  entirely different disease,  and also in regard to
 the more fortunate case related  by  M. Miller, (Arch.  Gen. de Med.,
 t. XIX., pp. 591, 595.)   The  cause of this failure is but too readily
 explained: the lost portion of the intestine can never be re-estab-
 lished but  in a very imperfect manner.   It is a fistula which we sub-
 stitute in place of the natural  tube.  The species of mucous  surface
 which ultimately becomes developed,  can  but very feebly represent
 the tunics of the  anus.  Though the system be incapable  of entirely
 closing up stercoral  fistulas, it  has  a  constant tendency to diminish
 them, so that  they soon become nothing more than mere ducts for
 the passage of fluid matters.   The absence  of the sphincter  espe-
 cially, is a  fatal  bar to  success.   When this is the case, it would
 be extremely probable  that the anus, which had  been artificially re-
 established, would be  one  of the most difficult to keep  open.   It
 would be an error however therefore to conclude  with Dumas and
 some others, that an artificial anus on the side ofthe abdomen is always
 to be preferred.  This  also is  nothing more than a fistula devoid of a
 sphincter,  and in all cases  where it could be located in the peri-
neum it certainly would be attended with still less unpleasant conse-
quences.  Among  the  successful cases  above mentioned, we may
moreover add also some others, that of M.  Fristo, for example, (com-
 municated by the author,  1838.) though he was obliged to penetrate
 to the depth of three and a half inches.

              § III.—To establish an Artificial Anus.

  A.  Littre is the  first person who,  in cases of imperforate rectum,
 suggested  the proposition, viz., in 1720, to construct an artificial anus
 in the iliac region, at the expence of the sigmoid flexure  of the co-
 lon.   We  can scarcely understand how Dumas, (Journ. de Med. de
 Sedillot) who, after Toutain,  (Journ. de  Med., 1786, t. LXVL, p. 90,)
 suggested  the same process in 1797, should have given himself out as
 the inventor of it.  A.  Dubois had already, in 1783, performed it on
 an infant  who died on the tenth day.  Duret (Bull, de  la Fac. de
Med., 3d year, p. 112)  also had recourse to it with entire  success on
the 18th October, 1793, while M. Pilhore of Rouen was  no less for-
tunate.  But the infant operated  upon by  Desault, in 1794, survived
only four days.  The case of supra-pubic  abnormal anus mentioned 
IMPERFORATION.
1091
by Voisin of Versailles, also encouraged the anticipations which had
"been entertained from the results obtained by Duret and M. Pilhore,
inasmuch as the infant was enabled  to live by discharging his stools
through  this opening.   Since that epoch, it is true, those hopes have
been  deceived in many cases.   M.  Ouvrard of~Angers,  (Lancette
Franc, t. IL, p. 99,) lost his patient in 1820, as suddenly as Desault
did.   M. Roux was not more fortunate in 1831, in a  similar case;
and the same was the result in the patient of M. Monod, (Bibl. Med.,
1829, t. IL, p.  447.)  Which after all is the operation  which would
never deceive the expectation ofthe surgeon?  M. Serrand, (These,
Montpelier, 1814; Bull, de la  Soc.  Anat., May, 1839, p. 90,) who
saw the  patient operated upon by Duret enjoying good health at the
age of 21, states that he performed a similar  operation successfully
upon  a  little girl in 1813.   The  little  patient being  laid upon  its
back  with its thighs extended, is to be held by one or two assistants.
The  operator being commodiously situated,  makes a little  above
Poupart's ligament, between the antero-superior spinous  process  of
the ilium and  the pubis, an incision of  about  two inches in extent,
then divides layer by layer the skin, fascia superficialis, aponeurosis
ofthe obliquus externus, the lower fibres ofthe obliquus internus, the
fascia transversalis, and the peritoneum, which opening he after-
wards enlarges by using a grooved sound to  conduct the bistoury.
The  intestine, which is distended and  of a livid or greenish color,
spontaneously presents itself behind  the  wound, and  is recognized
moreover by the aspect of its external envelope  and by the arrange-
ment of its fibres.  We now proceed to seize it and bring it to the
outside by the forefinger acting in the manner of a hook, or by using
 the thumb in connection with it.   A noose of  thread which is imme-
 diately passed through  the mesentery, prevents  it from re-entering.
 We open into it in the direction ofthe wound of the belly; the mat-
 ters now escape, and it becomes emptied.  We place a tent or meche
 in the division, if we are fearful of its closing  up too speedily.  Ad-
 hesions soon become established  between the surface of the colon
 and the lips of the wound in the belly.  We withdraw the mesen-
 teric  thread from the third to the fifth day, and the new anus, which
 is then definitively formed, requires  no  further attentions than those
 demanded by anv artificial anus whatever.
   B.  The process of Callisen, which consists in penetrating at  the
 side'in order to reach  the left lumbar colon between the two layers
 of its mesenteric duplicature, and without opening into  the perito-
 neum, has  never been put  in practice on a  living person.   I  am
 wronw; M. Roux has  once made trial of it, and  the little patient died
 two hours after.  It is not worthy of being rescued from the oblivion
 to which the moderns have consigned it.  Incomparably more diffi-
 cult,  and not less dangerous than  the preceding, it would be also
 more inconvenient.   I am informed however  that it has just been
 performed  by a surgeon of Paris upon  a woman affected with  an
 organic contraction of the  intestine, and that  the patient is doing
 well, (10th June, 1839.)                            .
   C  Process of M. Martin.—Nor has  the  proeess imputed by M.
 Paris to A  Dubois, and which  served  as  a text to M. L. A. Martin
 in his thesis, viz., that of conducting through the iliac  opening of the 
1092         NEW ELEMENTS OF  OPERATIVE SURGERY.

intestine, according to the process of Littre, an exploring instrument
from above downwards, so as to ascertain if it would not be possible
to re-establish the natural anus by perforating the perineum, been
up to the present time attempted, except upon the dead body.  We
should be wrong however in proscribing or rejecting it in  an abso-
lute manner.   If by chance we had been deceived, and the rectum
descended sufficiently low down to be made continuous as far as the
skin, without being attended with too much difficulty, we should be
in a  much more favorable condition to  perform the operation.   A
flexible sound, or one that was  properly curved, would in the first
place enable  us to ascertain in what condition the parts were situ-
ated.   I would  not  however  recommend either the  large flexible
canula nor the  enormous trochar of M. Martin, for the purpose of
transfixing the parts in this manner from the interior to the exterior.
It would be better, in my opinion, to look for the point  of the explo-
rator, by penetrating through the perineum, or if it should  be found
possible to introduce through the pelvis a sonde-a-dard, the arrow
of which pushed as far as to the outside of and in the direction ofthe
anus, would  become  the  conductor  of the bistoury  during the re-
mainder of the operation.  However, as it would be somewhat im-
prudent to multiply in this manner the  incisions at the  same  sitting,
and that there would be always time sufficient to do this afterwards,
we might wait before we did so until the  health of the infant had
been restored to its natural  state, and when we could  thus choose
an epoch apparently more suitable.
  D.  If the safety of the method of Littre had  been sufficiently de-
monstrated by experience, new-born infants would not  have been the
only persons to derive some advantage from it.  It might equally be ap-
plied to the sufficiently numerous cases of intestinal obliteration which
show themselves after birth.  Every coarctation of this kind being
fatal, we cannot  see what objection there would be to  the establish-
ment of an artificial anus.   The difficult point evidently would be to
ascertain with certainty, first, that the obliteration exists, and then
that  it has its seat in the rectum, or  in the lower portion of the
iliac sigmoid flexure of the colon, or, at least, in the large intestine, so
that  in placing  the anus in the right iliac fossa, it might be  placed
above  the disease.  We nevertheless still succeed in doing so in quite
a considerable number of cases.   Braillet had no doubt of it in the
patient whose history he has given.   Nor  was M. Martin Solon de-
ceived in the fact cited by M. Paris.  This result was  scarcely less
evident during the disease of Talma.  I could make the same remark
of a woman who died in 1825 at the clinique externe  of the school,
and whose dead  body I  examined.  This process, moreover, would
require no other modification than this ; that in place of always being
performed on the left, it might  become indispensable to direct the
instrument upon the right iliac fossa, if the  coarctation  were situated
in the  transverse or ascending colon.   After  all, this operation does
not exist only in theory ;  I have already said this (see this vol., supra,)
in speaking of gastrotomy, and of practitioners who had had the bold-
ness to perform it On living man, and that M. Martland, (Bull, de Fer.,
t. VIIL, p. 204—t. XIV., p, 255,) who was the first to  make  trial of
it, viz., in 1814, was so fortunate as to cure his patient. 
CONTRACTIONS.
1093
                   Article II.—Contractions.

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

                        § I.—Dilatation.

  The employment of dilatation in contractions of  the lower portion
of the rectum, which was so  much  eulogized by Desault, and since
the time of that author by the majority of surgeons, merits, in fact, a
part of the encomiums which have been bestowed upon it.  All those
indurations which are the consequence of chronic  phlegmasias, and
which occupy only the mucous membrane or subjacent cellular tissue,
and also even certain lardaceous degenerescences,  admit of the trial
of this process.  Dilatation  acts here like compression in the external
engorgements, and  upon the same principles.  The excentric pres-
sure which it makes, compels the effused matters which have become
solidified in the midst of the natural organic tissues, to re-enter into
the general circulation, restores the intestine gradually  to its original
thickness  by enlarging it, and in many  cases breaks up the morbid
process by destroying its germ.   But this result is  not obtained with
equal facility upon all the points of the rectum, nor in  all the differ-
ent kinds of coarctation.  If the disease  consists of prominences
which exist  to a greater extent external to, than in  the interior ofthe
canal, or if it occupies a point which  is too unfavorably situated for
the pressure to be made with accuracy, or  if the apparatus is badly
applied, the  dilatation, in general, will do more harm than good.  It
is executed  by means of meches  of lint spread  with cerate or  medi-
cated pomade, which are daily renewed and gradually increased in
size.  These meches, which may be replaced by any other pliant or
flexible cylindrical body  if necessary, are applicable to affections of
the anus, properly so called, and  those of the upper portions of the
rectum.  Between  the sphincter  and  the concavity of  the sacrum it
is almost always necessary to proceed in another manner.   A small
linen sac, which is introduced  empty in the manner of a purse which
is reversed,  and which is filled with lint in order to make compres-
sion from above downwards  as well  as upon the  contour while we
are withdrawing  it, is then most suitable and ought to be preferred
to bladders distended with air, wrater or liquids of any other description.
  These two methods nevertheless have an inconvenience which is
common to both of them, that of  arresting the course of the matters 
1094          NEW ELEMENTS OF OPERATIVE  SURGERY.

and thereby occasioning a considerable  degree of irritation in  the
greater number of patients.  It would be advisable, therefore, to imi-
tate M. Bermond of Bordeaux, and to substitute the apparatus recom-
mended by this physician  in  place of the meches or purses  which I
have just mentioned.   This apparatus consists of two canulas which
are about six inches long,  one internal, smooth and terminated above
in a cul de sac, the other external, open at its two extremities, and hav-
ing on its outside at different intervals, circular grooves, in order to
attach a chemise to it.  They are introduced, sheathed in this man-
ner, into the organ.  By means of long forceps, we glide lint between
them  and their linen envelope, in such manner as to push back this
latter in  the shape of an  annular border as far as to the top of the
instrument, and  in such manner also as to make a greater degree of
compression in one direction and less in another, according as it may
be found to  be necessary.   The whole apparatus is fastened  outside.
When the patient has need of going to stool, we withdraw the inter-
nal canula and without deranging the other, which may have as much
as six lines in diameter.  The tail-piece, formed by the  chemise
above, almost of necessity encourages the matters to enter  into this
part, which  matters may  be rendered more fluid and diluted, if ne-
cessary, by  means  of  injections or lavements.  We afterwards re-
place the central  canula, which locks by a lateral eperon into  a
notch which is on  the outside canula near its free extremity.  The
fusiform  suppositories contrived by M.  Fardeau,  (Journ. Hebdom.,
1835, t. IV., p.  116,)  whether they  are hollow, solid, or ovoid,  or
terminated  below in  a funnel, or  of silver,  ebony, or gum-elastic,
or those of softened ivory, which I prefer, are  still more commodious.
The meches,  small sacs of linen, bladders, and double canula of M.
Bermond, are no longer applicable,  when the finger cannot reach up
to the diseased point.  M. Costallat (Gaz.  Med., 1834, p. 11) has there-
fore contrived, for these  particular cases, a small apparatus,  which
may be introduced to more than a  foot in depth,  and which in other
circumstances also should not be neglected.  I have already spoken
of it in treating of contractions of the urethra.  This is also  a chem-
ise, but in the form of a cundum, which is preceded by a long blunt-
pointed probe and  conducted by a gum-elastic catheter,  after  which it
is transformed into a meche by means of portions of cotton, which are
pushed up into its interior by a forked stilette.  Its inventor informed
me that he had used it with advantage on a number of persons, among
others upon a female patient whom several  distinguished surgeons
had supposed to be incurable.  But this patient afterwards  came to
La Pitie, where I had an opportunity of examining her, and found
the coarctation of the intestine had returned  to as great an extent as
at first.  It is unfortunate that it is so much complicated as to pre-
vent its  coming into general use, for the idea upon which it is based
is ingenious, and it would be desirable to have it simplified in such
manner as to enable every person to make use  of  it.

                         § II.—Incision.

   Before dilatation had been  proposed, and also even  since it  has
been employed to a very  considerable extent, incision of the coarcta- 
CONTRACTIONS.
1095
tions of the rectum was had recourse to either as an auxiliary means
or as  the  principal remedy.  Wisemann performed this operation
three times on the same  patient,, and  Ford had the good  fortune to
effect a cure in his without a return of the disease.   The same re-
mark applies to M. Copeland, (Dublin Hosp. Rep., p. 150,) who had,
moreover,  to excise various tumors upon the intestine.  The opera-
tion  in other respects is  attended with but little difficulty, unless we
have to go very deep.   The blunt-pointed bistoury, conducted flat-
wise upon the  forefinger,  and then introduced  into the contracted
circle,  is the only instrument we require.  Its cutting edge being turned
towards the walls of the intestine, divides them upon one or on sev-
eral points, and in such manner as not to go deeper than the thickness
of their tissue.   A large sized meche or fusiform dilator is then in-
troduced as far as  \o above  the wound, after which we proceed  in
the same manner as in simple dilatation.  M. Begin (Elem. de Chir.,
2d edit., 1.1., p. 327) has like myself succeeded by adopting this pro-
cess.   The kiotome or bridle-cutter of Desault would be applicable
to cases of this kind, if any particular instrument were deemed ne-
cessary.  We might also use  the  pharyngotome, as  M. Duplat has
done in  one instance with success.  As soon as the finger can no
longer accompany the bistoury, the incision is attended with too much
danger to  be thought of for a moment.   In  conclusion, the  annular
contractions  or those in  form of a bridle, or that are semilunar, are
the only ones that admit  of a trial of this  process; and it is only, in
fact, for the purpose of preparing  or favoring the dilating means to
be made use of, that it can be seriously recommended.

                      §  III.—Cauterization.

  It is a matter of surprise that caustics  have not been applied to
contractions of the rectum  in  the  same way as to those of  the ure-
thra.   There is  every reason to believe, however, that they would
produce the same effects  ; and that the nitrate of silver used topically,
or as an escharotic would add greatly to the success of dilatation, by
destroying the phlegmasic  germ upon the mucous coat of the intes-
tine, in the same manner as it so  frequently does in  the  excretory
canal of the urine.  But I am hardly aware that it has yet been used
in such cases, and therefore cannot, without some other foundation
than theory, or the analogies derived from imperfect trials made by
myself, enter into farther details on this subject.  I find,  however, an
instance of this kind which is quite conclusive, in  the thesis  support-
ed by  M. Duplat.  (See on  the subject of contractions ofthe rectum,
the thesis  of M.  James, Paris,  1838; a memoir of  M. Maslieurat,
Gaz. Med., 1839 ; and the  work of M. Syme,  on diseases  of the rec-
tum, 1838.)
  [Polypi  of the rectum, when found, as they not unfrequently are,
in children, appear under certain modifications distinct from  those in
adults.   M. Gigon of Angouleme,  (see Hervez de Chegoin in Arch.
Gen. de Med., &c, Paris, 4e ser., t. I., pp. 489, 490,) states that they
are, according to his researches, destitute of an epithelium, of moder-
ate size, and have quite a slender pedicle.   They are not apparently
an exciting cause of* prolapsus of the gut, so common in  childhood, 
1096          NEW  ELEMENTS  OF OPERATIVE SURGERY.

inasmuch as this last infirmity is usually found in debilitated consti-
tutions, while the polypi are met with often in robust children. M. Gi-
gon divides these polypi into three classes : mucous, vegetative, and
fleshy.  They are also provided with vessels, and though  M. Gigon
has rarely found any unpleasant hemorrhage from their excision, M.
Roux considers that this may  occur, and should be guarded against
by a precautionary  ligature.   M. Roux, in  applying  a double liga-
ture to the  pedicle of a polypus in a lady, had to observe much cau-
tion, for fear of passing the needle through the arteries which he dis-
tinctly felt pulsating in this connecting  part.
  Tincture of iodine in its strong and  undiluted state, injected into
the track of an anal fistula, completely closed it up  and effected a
radical cure of the disease, in a case in  which it was made trial  of by
Dr. Charles Clay, (London Medico-Chirurgical Review, Oct., 1B13.)
The careful introduction of a meche into the intestine to  a point be-
yond the intestinal opening, enabled him to-ascertain by its color that
the iodine had passed completely through the abnormal canal.  T.]
                        CHAPTER II.

         BODIES TO BE EXTRACTED FROM THE RECTUM.

           Article I.—Foreign  Bodies in the Anus.

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

                              §1-

  The fingers and thumb, the  dressing or lithotomy forceps, or the
entire hand when it can be introduced, are the first means that sug-
gest themselves.  The hand of an expert child, as was done in the
patient who had stuck a cologne-water bottle above his  sphincter,
as mentioned by Nollet, or the hand of an intelligent  midwife  ought
to have the preference, if the  hand of the  surgeon should be  too
large.   A man had introduced a vial into his rectum, and  M. Cuma-
no,  (Gaz. Med., 1838, p. 793,) extracted  it by means of Boer's for-
ceps.  A drill orturrell would be a valuable acquisition, if the foreign
body in question  was a fragment of wood or vegetable,  or animal
substance, and solid  and not flexible, as  is proved by the cases re-
lated  by Saucerotte  and M. Bruchman.  A pig's tail introduced by
its base, and  the hair  of which  previously  shorn  off,  would  rub
against the intestine, should  be  treated as Marchettis  suggested,
(Bonet, Corps de Med., X. III., p. 277,) in  that  courtesan who was
a victim to the students of Gottingen: by means of a thread tied to 
FOREIGN BODIES IN THE  ANUS.
1097
its lower extremity, he succeeded in gliding over  the  foreign body
from below upwards a reed tube, which thus quickly isolated it from
the walls of the intestine, by forming a sheath to it, and immediately
allowed of its extraction, without any difficulty.

                              § II.

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

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

                              § IV.

  Calculi, giving rise to constipation, have been extracted from the
rectum  by Schmucker, by means of  the forceps;  and also by the
ordinary forceps, after having  broken  them up, by Chambon  and M. 
1098         NEW ELEMENTS OF  OPERATIVE SURGERY.

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

                              §  V.

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

             Article II.—Polypi of the Rectum.

   Polypi of the  rectum, though not very rare, are nevertheless not
very common.  At the height of 6 or 8 inches, it is almost impossible
to reach them, and consequently to ascertain their existence.  While
they may be  more easily reached in proportion as they  are lower
down,  they also yield to the same methods  as  for those found in the
sexual organs in woman.  Their excision also is effected with too
much ease to allow any attempt  at arrachement and  cauterization.
The ligature itself is scarcely ever  adapted  to  them  in any case.
Above the sphincters they are secured by means of a  double erigne
or erigne  forceps, which is then handed to  an assistant to hold.  If
the anus presents any difficulty, a jointed speculum is introduced into
it.  The surgeon then, provided with a long pair of scissors curved
flatwise, and protected by  the left forefinger, divides its pedicle.
Lower down the excision is made in the same manner as  for hemor-
rhoids, which will be  mentioned presently; in both cases we put our- 
HEMORRHOIDAL TUMORS.
1099
selves  on our guard against  hemorrhage, by the means which will
also be described farther on.   The excision of a small fungous, pedi-
culated tumor from the anus, was followed by so copious and so sud-
den a hemorrhage, that the patient, who was a young soldier, would
have died if M. Serre (Compte Rendu, 1838, p. 35) had not prompt-
ly had recourse to tamponing of the rectum.  MM. Manec (Journ.
des Conn. Med., January, 1839, p. 107) and Meric, in excising a fun-
gous polypus  from the rectum, after  having ligatured its pedicle,
found a copious hemorrhage ensue at  the  expiration of twenty-four
hours.  The patient was afterwards restored without any accidents.

             Article III.—Hemorrhoidal Tumors.

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

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

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

                             §  II.

  Excision of hemorrhoids in itself is  rarely attended with any great
degree of difficulty.  It  can only in reality be serious in consequence
of the hemorrhage, or inflammation, or purulent infection which may
result from it; from whence it follows that the best process must be
that  which  incurs the least risk  of these accidents, and  which is
most certain to be exempt from them.
  A.  Ordinary process.—The patient being laid upon the edge of
the bed, or a table properly prepared, with the  under thigh extended
and the other flexed, so that the anus may be perfectly exposed, is to
be held by several assistants.  The surgeon placed in front  of the
affected part, ought, according to Boyer, to seize with a good pair of
dissecting forceps or an erigne, all the tumors in succession, proceed-
ing from  those which occupy the most depending point to  those that
are highest up, and then  detach them one-after the other by means of
the bistoury or  a strong pair of scissors.  If they do  not protrude
externally, an effort similar  to that on going to stool compels them
to come out; but as the pain caused by the removal of the first  tu-
mor almost  always  occasions a considerable retraction of the anus,
which draws back the others into the bottom of the rectum, it is im-
portant not to excise any of them until they are all secured,  with a
like number of erignes or forceps, or by traversing or surrounding
each  of them with  a thread.  To dissect  them in the manner of
cysts, in order to remove only the  smallest  portion  possible of their
mucous membrane or skin, as some authors  propose, is altogether
superfluous.  It  is a piece of advice moreover which is much easier
to give than to follow.
  1.  The  loss of substance here has nothing in it alarming.  The
wounds cicatrize very well,  and after  the cure the organ usually re-
gains all its suppleness.  The dressing consists of the introduction of a
meche of some size besmeared with cerate, inserted to the depth of
several inches, and supported outside by coarse lint,  compresses and a
T bandage.  M. PI. Portal,  (Clin. Chir., &c, p. 147,) in extirpating
an erectile tumor which had become implanted in the anus and upon
the neighboring integuments, met with entire success, and his patient
was restored in five weeks.
  II.  Hemorrhage.—Should we  apprehend  ever   so  little  loss of
blood the dressing is to be no longer as simple.   Boyer begins by
introducing to a considerable depth a long tampon of lint nearly cyl-
indrical in shape, and also solid, and embraced by two strong liga-
tures, which are crossed  on its upper extremity, and knotted and
firmly secured upon its lower extremity, and the extremities of which,
collected together in two pairs, remain pendant outside of the anus.
We afterwards push in below this a number of small balls of lint or
additional free tampons  in such manner as to fill up the end of the
rectum with them.  Fastening the whole below by means of a large 
HEMORRHOIDAL TUMORS.
1101
roll of lint placed between the buttocks, over the anal opening, the
surgeon then draws upon  the two ligatures and  knots  them on this
roll with a sufficient degree of force, to make the  lint contained in the
intestine apply itself from above  downwards against the bleeding
surfaces, at the same time that the tampon outside tends to push it
backwards, from  below upwards.  Finally, a large plumasseau and
then compresses and the T bandage complete the dressing.   In this
manner it is almost impossible for  the blood  to make  its escape,
while pure and simple tamponing would only have the effect of pre-
venting its showing itself outside, while it would force the blood to
effuse itself into the intestine, and thus transform the external into an
internal hemorrhage, which would be still more dangerous.  On the
other hand, if the compression is not accurately made, nor with suffi-
cient force, and if the apparatus of Boyer or J. L. Petit is not  pro-
perly prepared, or  is badly applied, the same  accident  might also
happen.   Moreover, it. produces in  some cases  acute suffering, an
almost irresistible desire to go to stool, a sense of weight which it is
difficult to support, colics and even fever, and other symptoms, also,
which render its employment  quite difficult.   Also it is frequently
indispensable that an assistant should  support it during the space of
some hours by means  of his hand, and that we should enjoin  upon
the  patient  not to  make any  effort, but resist with  all his moral
energy the desire which  he  may feel to expel  it, but which rarely
fails to subside after the first few hours.  I have no necessity of add-
ing  that we  should remove all the dressing in order to reapply it
better, if the swelling of the belly, syncopes, paleness, and contracted
pulse should  indicate that the  blood continues to flow; nor is  it
required to say, that the sensation of a weight, or of a foreign body,
which in  certain  cases is acutely felt even in the absence of every
kind of dressing,  would be augmented instead of being moderated by
any of those efforts of defecation which the patient is forced to make
 almost  in spite of himself, and which  he ought to  abstain from at
 every hazard.  If the chemise canula of M. Bermond had been tested
 under such circumstances I would willingly recommend  it, (see dila-
tation of  the anus, above.)  By means of this we  might change,
 modify, and  renew the dressing, and augment  or diminish the com-
 pression without  taking off all  the pieces, and moreover, satisfy our-
 selves,  by removing the central canula, whether  blood  had or had
not become  effused into the intestine, and also  could allow the mat-
 ters to be expelled  as often as the patient felt a desire for it, and do
 this during the space of several days if we judged it advisable.
   B. The process of Dupuytren rejects all precautions of this kind.
 This surgeon immediately applys a red-hot iron  on the bottom of
 each of the wounds he has made, wherever he has reason to appre-
 hend the slightest  hemorrhage.   He does nothing more afterwards
than to place in the anus a meche of but small size, which moreover
up is to be supported and kept as above described.  In proceeding in this
manner we  scarcely ever find any accidents follow.   Nothing dis-
tends  irritates, makes traction upon or compresses either the intes-
tine  'bladder or surrounding  parts.   The congestion  which is  so
powerfully excited by the ordinary dressing, exists but in the slightest
degree and the hemorrhage consequently has very little tendency to 
 1102         NEW ELEMENTS OF OPERATIVE  SURGERY.

 make its appearance.  In this respect the hot iron has the advantage
 of rendering the operation prompt, and is far from producing as much
 pain as the  tamponing.   The inflammation, while it is less disposed
 to extend or to react at a remote distance, is  not so liable  to attack
 the veins which open themselves at the bottom of the wound, nor is
 the development of those purulent collections caused by phlebitis or
 resorption, of  which I saw two patients die  at the hospital  of the
 School  of Medicine,  in 1824 and 1825,  so  much to  be dreaded.  I
 do not know, in fact, if the cautery is in reality indispensable.   The
 arterial vessels which are divided are of such little  importance, that
 the wounding  of them at first  sight would not  appear to  forebode
 much  danger.  The mouths of these vessels if left to themselves
 would probably soon cease to give out blood, and I should not be sur-
 prised if the precautions recommended to prevent hemorrhage were,
 in quite a considerable number of cases, the cause of its occurrence.
 It appears to  me, therefore, that in a majority of cases they might
 be dispensed  with; and  that  it is  from  excess of prudence  that
 they are recommended in cases where  the loss  of  blood at first is
 not abundant.   What, moreover, would  prevent our having  recourse
 to them at  a  later period, in cases where the  hemorrhage  should
 continue to go on to an alarming  extent?   Nothing is  more easy
 when  the wounds  are at  the  exterior.  If  they were deeper  the
 patient, by making some  efforts, could soon expose them to  the view
 of the operator, who could then cauterize them without difficulty.
 Finally, the  tamponing would be a dernier resource, which we could
 always call  to our assistance in  time.  Two patients in whom I pro-
 ceeded  in this manner, in 1831, at La Pitie, had  no  reason to regret
 it.  The same has been  the case  with a great number of  others
 whom I have since operated upon.  I have, however, seen  three
 patients succumb from this operation, one  from purulent infiltration
 into the cellular tissue of the  pelvis, the  second from a phlebitis, and
 the third from  an erysipelas caused by the excision of a small  simple
 pediculated  tumor.
  C. Process  of the Author.—With  the  hope  of  better  avoiding
 hemorrhage, inflammation and purulent infection, I have proposed to
 unite by first intention the wounds made by excision of hemorrhoidal
 tumors and bourrelets.  For this purpose I secure to the outside, and
 by means of an erigne, each tumor which is to be removed,  and then
 traverse their root by a sufficient number  of  threads.  Immediately
 dividing the tissues in front of  them, by means of the bistoury or a
 strong pair of  scissors, I have nothing more to  do  than to  seize, in
 succession, all  the threads, in  order  to knot them, and thus make the
same  number  of points  of simple suture.   Meches  and tamponing
are then  unnecessary, and a complete cure is frequently effected
 from the 10th to the 15th day. 
REDUCTION.
1103
                        CHAPTER  III.

            THE FALL OR PROLAPSUS OF THE ANUS.

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

                    Article I.—Reduction.

  In order to reduce this tumor we proceed in  the  same manner
as in  cases  of  eversion  of  the vagina or womb.   After having
cleansed it with  tepid  water, and then  besmeared it  with  a  mix-
ture  of oil and wine,  the patient being placed  upon his  back, with
his breech more  elevated than the abdomen, and all the muscles
relaxed, we envelope it with a fine line, in order afterwards to  make
gentle  compression  upon it from the circumference  to the centre,
and from  below upwards, by  means of the palms of the hands or
the pulp of all the  fingers, at the same time that the patient is pre-
vented as much as possible from making  use  of any effort.   We
sometimes succeed  better by making pressure  on the centre of  the
mass, by means  of several fingers united together  in  the form  of
a cone, as if for the  purpose of entering into  the  anus,  by  push-
ing before us the compress which covers the  tumor,  and which is
kept  around  it by  the other  hand.  A large sized meche, with or
without a sac, is one of the means frequently employed to keep up
the reduction.   The dilated bladder of Blegny, (Peyrilhe, Hist, de la
Chit., p. 38,)  Morgagni or Levret, (Art des Accouch., 3d edit., p. 38,)
as employed by M. Dieffenbach, (Arch. Gen. de Med., X. XVI., p. 287,) 
1104
NEW ELEMENTS OF OPERATIVE SURGERY.
 the ring of Bassius, the bandage of Cousin, the astringent suppository
 of Turner, a tampon of lint contained in a linen bag, or a  globe  or
 oval body of wood, ivory or gum-elastic, and in  women a pessary in
 the vagina; with astringent injections and hygienic means, are the re-
 medies to be made trial of for preventing the return  of the prolapse
 of the gut.   M. Gervais (Journ. des Conn. Med-Chir., 1839, p. 67,)
 having a  case of extensive prolapsus of the  rectum, which he was
 desirous of keeping up, made use successfully of a ball of cork, which
 he withdrew at the expiration of 30 hours.  Simple reduction equally
 succeeded with M. P. Dalmas, (Journ. des Prog., 2d ser., 1.1., p. 266,)
 though the prolapsus was accompanied with serious accidents.  An-
 other remarkable example  also of the same kind, has just been pub-
 lished, (Gaz. des  Hopit., 1839.)

                   Article  II.—Debridement.

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

  When nothing can prevent the parts from protruding again, or when
 in spite of every effort they  persist in not entering, they knew no
 other means  to oppose to it forty years since, and many authors  at
 the present  day  still know no other, than that  of ablation.   This,
 moreover, is  an excision or exsection which is in itself  quite  an easy
 matter, and which is performed nearly in the  same way as for de-
 generated hemorrhoids, or for a polypus or any other  tumor having a
 considerable  base.  Extirpation, which was  recommended  also by
 Percy,  completely succeeded  in the hands  of Cowper and Pas-
 quier.   It is unnecessary, however, to remove  the tumor as far up  as
 its root.  Should  we destroy only the two lower thirds of it, the re-
 mainder will  invariably re-enter.   Perhaps in this manner the mus-
 cular tissue of the rectum  might be respected, and its mucous tunic
 only divided, without  rendering thereby the success of the  opera-
 tion  less probable.  The dressing and subsequent treatment scarcely
 differ from those mentioned for hemorrhoids.   This remedy, as is per-
 ceived, is  sufficiently severe, and so also is it far from  being always
 successful.   Though M. Phelys (Bull, de la Fac. de Med., 1808) has
 succeeded, a great number of other practitioners have failed,   Fortu-
nate is it that modern surgery may almost always dispense with it
 by substituting for it a process which is less alarming and less pain-
ful, and which  only has the disadvantage of not  being  applicable  to
cases of irreducible prolapsus; and of being restricted in its results
to the retention of the tumor when it has been once returned. 
PROCESS OF HEY AND DUPUYTREN.
1105
        Article IV.—Process  of Hey and Dupuytren.

  This process consists in the excision of the radiating duplicatures
at the margin of the anus, whether they be or be not occupied  by
hemorrhoidal tubercles.   It  appears certain that in the majority of
cases the obstacle to the cure lies in the  dilatation of the sphincter or
a considerable degree of relaxation which has taken place in its mu-
cous membrane and in the skin which is continuous with it  externally.
The cellular tissue which lines them acquires finally so  great a de-
gree of pliancy, that it enables them  to glide with the slightest
effort over  those  layers  to which they are  naturally  adherent,
and  to whose movements only  they  are restricted, when there is
no disease present.   The  ablation  of a  certain  portion of the cuta-
neous tissue has  a surprising effect in  removing this anomaly or  in-
convenience, and becomes in this manner the remedy for the disease
which so frequently results from it.   The idea first suggested itself to
Hey in  1788, in the case  of a Mr. W.,  of Hull, who had been for-
merly treated by Sharp, and in  whom  the anus after the  reduction
continued  constantly to be surrounded by a thin, pendant cutaneous
duplicature (thin pendulous flap) which  was from 8 to 12 lines long,
having on  its inside, near its base, several soft and  bluish-colored
tubercles, similar to those which  are seen in persons who have been
a long time  affected with hemorrhoids. " It appeared  to me,"  he
remarks, " that the prolapsus was owing  to the relaxation of the very
lowest portion of the intestine and  of the cellular membrane which
unites it to the surrounding tissues."  This remark was a ray of light
for the author.   He considered that in order to cure  his patient,  no
other remedy was necessary than that of strengthening the adhesion
of the tissues around the anus,  and  the appropriate action  of the
sphincter itself.  Nothing  appeared to him better calculated to fulfil
this intention than the excision of the tegumentary  flap  and of the
tubercles  which were found appended to  it.  He  hoped  by this
means to  cause an inflammation which would be capable of pro-
ducing a more solid adhesion of the  rectum with the surrounding
parts, and did not  doubt that a  circular wound would  necessarily
bring about a greater degree of constriction of the  sphincter ani.
Hey removed therefore the pendant bourrelets and the bluish tuber-
bles by means of a bistoury.  The operation was performed on the
13th November, and M. W. wrote to him in March, 1789, that the
cure continued perfect.   A second patient  operated upon  in the
same manner, in 1790, was  restored in  three weeks, though the ex-
cision was only made upon one side.  In April, 1791, Hey again had
recourse to his  process, and removed the pendant flap, at the same
time encroaching about a quarter of an inch upon the red membrane
which lines the anus.  The success was  no less complete  than in the
two  first instances.   A lady whom he also treated, in 1799, in such
manner however as to remove,  only after the interval of a certain
lapse of time between the  two  operations, the two soft tubercles
which were situated on the two sides of the anus, recovered equally
well and in as short a period.   Nevertheless the successful  results
that  Hey met with rested, so to speak, in oblivion, even in his own
country.   M. S. Cooper, who mentions them,  speaks of them in too
                               70 
1106         NEW ELEMENTS OF OPERATIVE SURGERY.

obscure a manner to enable practitioners to derive any great benefit
from them, and  but  for Dupuytren, to whom  the  same ideas  sug-
gested  themselves, and who was thereby enabled to construct a me-
thod upon them  and to generalize it, they would probably have at-
tracted no more  attention in France than they had done, in England
up to that period.
  Operative process.—An injection or even a slight purgative should
have been administered on the evening previous.   The patient is  to
be placed in the same way as for the excision of hemorrhoids.  The sur-
geon seizes in succession with a good pair of forceps, each radiating
fold which he wishes  to remove, and excises them with  a sharp
edged pair  of scissors  from below upwards, commencing upon the
margin of the anus at about an inch from the sphincter, and termina-
ting at some lines above it.   Dupuytren says that the removal of four
of them is sufficient, one in front, another behind, and  one on each
side.  I deemed it necessary in one case to excise six, and in another
eight, because of the extreme relaxation of the parts, and  the  great
dilatation of the anal opening.  It  is unnecessary to  say that we
should  give a greater or less degree of breadth to each strip that we
excise.  We commence the division more or less below, and termi-
nate it more or less above, according to  the condition  in which the
parts are found.   One of Hey's patients had a hemorrhage, but I am
not aware that Dupuytren met with this accident.  As the English
surgeon has not given any detail, either in relation  to his process  or
the dressing, we  are not enabled to say whether the loss of blood he
mentions, is to be imputed to the operation itself, or  to the manner  in
which it was  performed.  The professor of the  Hotel Dieu limits
himself to  covering  the wounds with a  plumasseau,  imbued  with
cerate, and places no meche, or but a very small one in the anus.
In two instances I have  adopted an opposite course.   The meche,
which I introduced to quite a considerable  depth  into the rectum,
was of the  size of the  finger.  I detached  several parcels from  it,
and lodged them in  each wound, where I kept them separate by
means  of coarse lint, and afterwards by a large  plumasseau  with
compresses and a T bandage.  My intention was to prevent the im-
mediate reunion  of the small wounds, and to oblige them to suppu-
rate, in order to  obtain an  inodular cicatrix, which would be  more
elastic and firmer, and adhesions which would be more solid, than those
resulting from primitive  cicatrizations.  I have had no reason to  be
dissatisfied  with  my course.   The cure was  complete ; but I ought
to acknowledge that  the more simple  dressing preferred by Dupuy-
tren, cannot be much less advantageous, since the patients who were
submitted to this treatment were also restored without any return  of
their disease.   To those who are familiar with  the  difficulty attend-
ing the cure of prolapsus ani, and with the inconveniences which it  in-
volves, the  operation which I have just described will  prove an  in-
valuable acquisition.   One of the  cases which most excited my  at-
tention when I arrived in Paris in  1820 was a successful  result  of
this kind.   A woman who had been delivered in the surgical wards
of the  Hotel Dieu, and who for 14 years  had never gone to stool
without her anus falling down in the form of a red livid  tumor  as
large as the two fists, was almost instantaneously cured by the ab- 
CAUTERIZATION.
1107
lation of some of the folds of its skin.  M. Paillard asserts that this
operation, which was frequently performed by Dupuytren after the
year 1815, never failed but in one instance ; and also that this single
failure was to  be attributed possibly to  the process adopted.   On
my own part I  have performed it on five  patients  at the Hospital of
St. Antoine, La Pitie, and La Charite—two were women and  three
men, and its immediate  results  were no less conclusive.  The  same
has been the case with the operation as performed by MM. Mauge-
nest, (Gaz. Med., 1832, p. 857,) Giorgi, (Journ. des Conn. Med., X. I.,
p. 349,) Lutens, de Cock, (Bull. Med. de Gand., X. I., p. 37,) Ammon,
(Bull, de Fer.,  X. XIX., p.  64,) and  Dieffenbach, (Gaz.  Med.,  1831,
No. 2.)   M. Heustis also was successful,  (Ibid., 1834, p. 777,) by ex-
cising a circular fold around the  anus.   The radiating cauteriza-
tions which were formerly used by Moreau, (Saviard, Obs. XIV., p.
55,) in the direction of the duplicatures of the anus, in order  to  con-
tract this opening, might moreover have  suggested the idea of the
method  of Dupuytren.  I should remark, however, that the  cure  is
not always permanent.   In one of my patients there was a return of
the disease at  the  expiration of a  year.   In  May, 1839, I saw an
Englishman who had been  formerly operated upon  by Dupuytren,
and in whom the prolapsus had also been reproduced.  If the  pro-
lapsus still shows itself at the first stools which  succeed to the exci-
sion, it is rarely as marked as it was before, and  returns of itself or
with less difficulty, and soon disappears entirely.  The freedom ofthe
belly favors the success  of the  operation  by exempting the  patient
from making as  much effort during his stools, and must in consequence
be  attended to  by  means of injections, or laxative drinks, or  mild
purgatives.  Finally, the excision of the radiating folds  of the   anus
seems calculated to answer for  cases of prolapsus, which are owing
to  a  state of  relaxation of  the  mucous  membrane, integuments,
sphincters, and  external  tissues; for all those cases in  a word which
are not  caused by an  organic lesion, or disorganization of some of
the parts contained  in the pelvis or  hypogastrium ; so  that the am-
putation of the  tumor should be reserved for those cases of prolap-
sus which are absolutely irreducible.

                  Article  V.—Cauterization.

  A means which acts nearly in the same way as  the preceding ope-
ration is that of cauterization.  Cauterization with the red hot  iron,
which was employed with success by Ansiaux, (Clin. Chir., 2e edit.,
p. 174,)  in  several  patients, and  by M.  Philips,  (Rev.  Med.,  1833,
t. III., p. 452,) -and M.  Kluyskens,  (Gaz.  Med.,  1834, p. 777,) has
been again eulogized by M. Burgraave,  (Bull. Med. de Gand., X. I.,
p. 37,)  as one  of the most  certain and  easy modes  of remedying
prolapsus ani.   First proposed by Leonidas, it had also been extolled
by Marchettis and Psyter; but  I can scarcely conceive what advan-
tages it  can have. 
1108         NEW ELEMENTS OF  OPERATIVE SURGERY.
  Article VI.—The Intestine protruded through  the Anus.

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

                    Article VII.—Fissures.

  The fissure  or crevasse of the anus  is a  small  narrow elongated
ulcer  which developes itself between the radiating folds ofthe funda-
ment, and  causes  in the majority of patients the most acute pain.
The most ancient  authors  speak of it  in such vague terms, that no
person, before  the researches  of Boyer, thought of separating it from
the other anal ulcerations.  Aetius, in  mentioning it,  appears how-
ever to have already had  reference  to constriction of the  sphincter.
Avicenna enumerates the causes of it,  without having  had any very
distinct conception of its character.   Albucasis, who  points out its
treatment in detail, imputes it to constipation of the belly  and to the
desiccated  state  of the stercoral  matters, and Grueling does not  dis-
tinguish it  from  the ordinary rhagades, though he had already as-
similated it to the crevices seen on the hands of servants during
winter.   Lemonnier, the first writer who has distinctly described it,
compares  it, like Grueling, to the cracks upon the hands or lips,  and
accurately  defines  its seat, but does not establish its mode of treat-
ment.  Sabatier makes only  a slight allusion to  it in  his Medecine
Operatoire, while all the other authors of repute, both abroad and in
France, dowm to the present  times,  have given no description of it.
It was not however because  it is a rare disease, for Boyer, in 1825,
announced that he himself had already met with 100 examples of it.
I myself have  noticed more than 30 cases of it.  But up to that time
its origin  had  been imputed  to  affections altogether different, to the
venereal disease, hemorrhoids, disease of the bladder, to a blind or
a complete and  concealed fistula, a preternatural incurvation of the
coccyx, and even  to the existence of a cancer, either  of  the uterus,
prostate or rectum. The description which E. Home gives of the acci-
dents caused by the engorgement of the lateral lobes of the prostate
might also well be classed under this head.   " There is," says this au-
thor, "a great,difficulty in going to stool, and a tenesmus, accompa-
nied with violent pain, which is increased by the efforts  which the pa-
tient makes to relieve the intestine."  The  table which M. Copeland
has given, of what he calls spasmodic contraction of the sphincter,  also
appears to  me, at least in great part, to have reference to this disease.
It has frequently  been  confounded with  the rhagades  and other 
FISSURES.
1109
superficial exulcerations of the anus.  The remarks of Guy de Chau-
liac and Dionis in reference to  it leave no doubt on this subject.
Thus fissure at the anus was not in reality known as a distinct dis-
ease until after the year 1822.  M. Blandin believes with M. Hervez
de Chegoin that the fissures situated below or above  the sphincter,
constitute a disease of little importance, and one which is cured by
simple means or disappears spontaneously, while the others only  pre-
sent all the series  of inconveniences presented by Boyer.  But  this
distinction is purely theoretical.   Among the patients whom  I have
seen there were many in whom the crevasse had given rise to exceed-
ingly violent pains, though it was  entirely disconnected  with the mus-
cular ring  which surrounds the termination of the rectum.  The con-
striction of this muscle is a point which requires special elucidation. Is
it the cause or is it the effect ?  Boyer, upon the strength of the  fact
that he has several times encountered the constriction without fissure,
that he has never seen the fissure without constriction, and that the  sec-
tion of the sphincter, even without touching the fissure immediately,
causes the accidents to subside, adopts and defends the first opinion.
Others, basing their opinions  on the ground that the ulceration may
exist without its being  possible to perceive it,  pronounce themselves
in favor of the second opinion.  It cannot be denied, in fact, that the
fissure may sometimes take place without constriction, though it may
be  at the same time accompanied by its other symptoms, four or  five
examples  of which have fallen under my own observation.   Again,
who could assert that the fissure was wanting, merely from the  fact
that it has not been found ?   The case related  by M. Louvet is in
reality of no weight, since the patient was not even explored.  The
confidence which is due to the experience of  Boyer,  is in fact, the
source of all the value attached to the observations he adduces in
support of his opinion, for the truth of his assertions has never been
verified in  the examinations of the dead body.  The  practitioner,
when he reflects that a crevice irritated by the passage of alimentary
matters, may cause a spasmodic contraction of the subjacent muscu-
lar fibres,  and that it is inconceivable how a muscular constriction
can produce a fissure, will, as it appears to me, accord his adherence
by preference to the second opinion.

                          § I.—Signs.

  The accidents which denote a fissure are of two orders,  viz., those
which  have reference to the  disturbance  of the  functions, and those
that relate  to the appearance  of the parts themselves.   This disease,
when it exists in an  extreme degree, is accompanied with excrucia-
ting torments.  At the moment of going to stool, the patients compare
their pains to those which would be produced by the introduction of
a red hot knife into the anus.   This sensation of burning exists some-
times to such degree, that it produces the most inconceivable anguish,
with symptoms of  convulsions, and accompanied  with syncopes.  To
others  it appears as if some person was tearing out the fundament.
During the interval between the  stools, they sometimes experience
only a burning  sensation,  lancinating pains that are  more or  less
acute, a sense of weight, and some symptoms of colic.   As the stools 
1110         NEW ELEMENTS OF OPERATIVE SURGERY.
approach, however,  the pains sensibly augment, and do not reach
their extreme  point of violence, except at the moment of the  expul-
sion  of the matters, after which  they continue  to diminish  during
the space of some hours.   The constipation  becomes  so obstinate,
that  the alvine  evacuations would only take  place  at intervals of
8,  10, or 12 days, unless they were solicited.  The patients  dread-
ing them beyond any thing that can be imagined, recoil  from them
at  the moment they are to take place  as much as possible.  Never-
theless, they are aware that their  infrequency renders them so much
the more painful.  One, two, three,  or  four  injections,  which are
sometimes required to procure a single evacuation, at other times are
wholly  insufficient.  Purgatives alone, administered  by the mouth,
succeed in opening the belly.   Hence there are certain  patients  who
feel themselves under the necessity of taking a cathartic every other
day.  A lady  who was treated by Boyer, had  come to  the  determi-
nation  of keeping a canula fixed in her anus.  A patient at the Hotel
Dieu, stated that he would  much  rather die than go to stool  again.
The  liquid state  itself of the matters does not in  all patients exempt
them from suffering, as is proved by a case related by Boyer.  Though
some may walk, or seat themselves, or attend to their occupations
for several hours in the interval between their paroxysms, others are
obliged to keep their bed, though it becomes a source of distressing
irritation and fatigue to them.  The lancinating pains extend towards
the bladder or the uterus, according to the sex, and even  reach in
certain cases the highest part of the hypogastrium ; the products of
digestion become altered ; the patient eating but little, from apprehen-
sion  of having stools, loses his natural color; and his features soon
express the  sufferings he endures,  in so marked a  degree,  that it
would  be supposed he was laboring under a profound organic  lesion.
In respect to the anus, the introduction of a  syringe, meches, canulas,
or a  foreign body of the  smallest size, reawakens the apprehension
ofthe alvine evacuations.   The pain occupies  quite a circumscribed
space of the contour of this opening, and is frequently accompanied
with pulsations  similar  to  those  which would  be produced by a
phlegmon.  The finger encounters here  a  constriction which  can-
not be overcome without producing the most severe exacerbation.
When  we press  on any  given point  of the interior of the sphincter,
the pain immediately acquires such a degree of acuteness,  that it
draws  forth piercing cries from the patient.   If we separate its folds
apart, the eye  finally perceives at the  bottom  of one of the grooves
which  lies between them, a small  ulcerated fissure, one to two lines
broad,  and from four to eight or ten lines long.  Its borders are usu-
ally neither callous nor tumefied ; and its surface in quite a number
of cases is of a very bright red  color. In this  respect  we  cannot
convey a more  exact idea of it  than by comparing it to the chaps
which  are seen on the hands and  feet, in country people during  win-
ter, much more than to  those  on  the lips.   Different from  rhagades
and  other exulcerations,  it gives out scarcely any exudations, and
rarely  stains  the  linen.   The contrary of this however sometimes
takes place; in a small  number of  cases there sometimes  exudes
even streaks of blood with the faeces, but these occur only as exceptions.
Fissures ofthe anus, from being concealed between the tegumentary 
FISSURES.
1111
duplicatures, are not always readily discovered.   We can  only de-
tect them in certain cases by means of the  closest examination, and
by spreading out the skin of the  fundament with  the greatest  care,
and by making the patient protrude the anus  a  little, as if for the
purpose of going to stool; in most of the cases the anus is retracted to
a great depth.   The situation of the fissure, moreover, has no fixed lo-
cality.  Though ordinarily on the side and to the right or left, it is also
sometimes seen behind or in  front.  In some cases it is so low down
as scarcely to  reach the beginning of the mucous  membrane above,
or it may be placed so high up above the sphincter as not to reach
the skin below.  It is not unfrequent to find a hemorrhoidal  tubercle
forming, as it were, its root, and receiving, so to speak, its tail.  Most
commonly, however, it is situated in such manner that its commence-
ment is located upon the entrance of the anus  itself, while its  other
extremity reaches  to a greater or lesser extent towards the intestine.
When not distinguishable by the eye, the finger passed around upon
the different points of the  anal  circle above  and below,  may be
more fortunate. If there is  a fissure, the pain becomes poignant as
soon as it is touched.   A  hardness, the appearance of a tense cord,
and rugosities  that are more  acutely sensible than the remainder of
the intestinal opening, indicate  its presence.  But this mode of ex-
ploration  is not in reality indispensable,  except  the crevice is too
high up to allow us to draw it down so as to expose its location to
view.   We shall not  moreover  confound an alteration  of this kind
with organic coarctations of the rectum, if we take  care  to notice
that  the suppleness of the tissues is preserved, and that we experience
a sharp, sudden contraction, instead  of a  permanent  constriction
with  degenerescence  of the parts.   It is too  easy to distinguish it
from internal or external hemorrhoids writh  or  without excoriations,
also  from chancres and other ulcers, and from  fistulas and affections
of the prostate or of the bladder, or sexual organs in women, to  make
it necessary for us to dilate  upon its differential  diagnosis.  Three
essential symptoms therefore characterize fissure at the anus: 1st,
burning pains  at the moment of passing the stools; 2d, a superficial,
narrow, long ulcer, or sort of crevice, at  the entrance  of the  intes-
tine ; 3d,  a violent and painful constriction of the  sphincter, without
any  appearance of organic lesion.  Moreover,  it is not accompanied
in all cases indiscriminately with the long  catalogue of phenomena
which we have just described.

                        § II.—Treatment.

   Fissure at the anus, if left to the resources of the  system, may
endure to an indefinite length of time.  Since  it  has been examined
with care, it has not yet  been possible to ascertain  in  an authentic
manner that it has ever  been cured without  the aid of art.   The
patients  exhausted by  their sufferings, fall  into  a state of wasting
decay and thus succumb, or ultimately become attacked with some
incurable organic  disease.   An English lady who had rendered her
life supportable for several years, says Dupuytren, by the use of calo-
mel, did not effect a cure.   Baths,  leeches,  bleeding, calmants, anti-
spasmodics, purgatives, lavements, and injections of every description 
1112          NEW  ELEMENTS  OF OPERATIVE SURGERY.

furnish no better sources of relief.  Nothing will succeed, according
to Boyer, but the incision of the sphincter.  On this subject we must
understand ourselves: simple fissures  unaccompanied with constric-
tion, whether they be syphilitic, hemorrhoidal or dartous. or  of any
other nature, evidently yield to  milder means.   The ancients, who
confounded all of them under  one designation, could not have been
always  deceived  in  speaking  of their pomades  and  other medica-
ments.  Before laying it down as a fact that this or that medication
has cured the patient, it becomes necessary, if we would not repro-
duce the confusion which, in this respect, has so long  existed in sci-
ence, to give positive demonstration  that the fissure was actually
accompanied with a constriction of the sphincter.  But  this unfortu-
nately has not been done in the majority of cases  published up to the
present  time.  M. Blandin, for example, in saying that the fissure
has callous borders  and a grayish bottom, and in distinguishing it
only by its seat in place of endeavoring to discover its nature, would
reproduce, doubtless unintentionally, the obscurity which was  so hap-
pily dissipated by Boyer.  For myself, I wish to be  understood  as
speaking here only of a true fissure or  painful crevice at the anus.
  A.  Various Medications.—I cannot understand why Albucasis,
who recommends that we should abrade the fissures with an instru-
ment or the  nail until they are  made to bleed  or tumefy, or wh)
Guy de  Chauliac and Dionis, who cauterized or scarified them, may
not have also succeeded  in curing them in some  eases, if it  be true,
that  in  our days Guerin has eradicated  them with the red-hot iron,
and that the nitrate of silver has frequently succeeded ; nor can I share
with the moderns in  their aversion to  such remedies.   A species of
balsam  which usually soothes, but with which Boyer obtained suc-
cess in  one instance  only, which, however, was only a case of mild
constriction, is made  of the following materials ; hog's lard, syrup of
rhubarb, syrup of nightshade, and oil of sweet almonds each, 5 ounces.
Some spoonsful of this  are  injected  into the rectum  with a small
syringe  two  or three times a day.  It  is probable that the blanc-
rhasis, and most of the pomades  recommended by the ancients, pos-
sessed the same qualities.   Dupuytren appears  to have made  use
with advantage of a mixture  of extract of belladonna two ounces,
water sweetened with honey two ounces, and  hog's lard two  ounces,
which was introduced into the anus upon a meche besmeared with
it.  M.  Descude says that we may cure the fissure by administering
oil of hyoscyamus in large doses  by the mouth, at the same time that
we employ  mercurial ointment  as a  topical  application.   M. La-
moureux (Soc Med. de  la Seine-Infer., t. IX., p. 78,) states  that  he
has succeeded by employing  belladonna, or repeated lotions, as is
recommended by Mothe, (Arch. Gen. de Med., t. XVIL, p. 648.)
Douches of cold water and decoctions of chervil or of poppy heads,
have  also been extolled.   I have succeeded in  two or three  in-
stances  in causing the fissure to be besmeared morning and evening
with a pomade of white precipitate one drachm, and hog's lard  one
ounce.  But  the three remedies which have been most zealously  re-
commended for some time past have, nevertheless, been cauterization
with the lapis infeinalis, dilatation and the  section of the sphincter.
  B.  Cauterization.—By attacking the whole extent of the fissure 
FISSURES.
1113
with a crayon of nitrate of silver, we may hope, by changing the
condition of the surfaces, as  was done by rasping, excision, or the
actual cautery, to  transform  it into a simple wound.  Beclard, who
stated that he had employed this method with a success almost un-
varying, was, however, opposed before the Academy by M. Richer-
and, who affirms that he never derived  any benefit from it at the
hospital of St. Louis.   Three of the patients, also, in whom  I made
use of it not having obtained the slightest relief from it, I was induced
to believe that Beclard had only had recourse to the nitrate of silver
in fissures  without  constriction, or that his successes were to be at-
tributed to the dilating meches which he used at the same time; but
the cures which I  have  since obtained by the aid of this means in
decidedly marked cases of fissure, oblige me to change my opinion.
  C. Dilatation.—The employment of meches of lint gradually in-
creased in size, until they overcome  the resistance of the sphincter,
appear to  have had more  efficacy.   Beclard himself states that he
had reason to  be well  satisfied with  them.   M. Marjolin and MM.
Nacquart and Gendrin, also appear  to  have obtained unquestionable
cures  from this remedy.   The great point is not to dimmish after the
first, but to increase them rapidly to the largest size  possible, what-
ever may be the resistance of the  sphincter i, the pain, which is ex-
cessively acute  during the first hours, afterwards subsides by degrees,
and disappears  in a great part before we have reached to the fourth
or to the fifth meche.  There  is no objection, moreover, to the dilating
body being besmeared with one of the pomades above indicated.  I
cannot, meanwhile, withhold the comparative experience that I have
had in this treatment, though I have yet made but three trials  with it.
Ordinal meches besmeared with Boyer's mixture, have effected nei-
ther more  nor less  than the pomade  of Dupuytren, or that with bella-
donna and opium without acetate of lead, or that of mercurial ointment,
either simple or in combination with opium. Having obtained no ame-
lioration from the employment alone of the populeum ointment, blanc-
rhasis, pomade of precipitate, and  cauterization with nitrate of sil-
ver, I put  the dilating meches to  the test, sometimes besmearing
them with cerate only, and at other times w7ith the medicated po-
mades, when the result proved to  be decidedly  the  same in both
cases.  Copeland had already employed dilatation in spasmodic con-
striction of the anus, and I am of opinion that  those physicians who
would have sufficient resolution to engage their patients not  to give
way before the first suffering, might obtain decided  benefit from it.
The three cases which have been published by M. Mondiere, (L'Ex-
per., X. III., p.  264,) come in support of the opinion which I formerly
expressed  on this subject.
  D. Incision  of the sphincter, as proposed by  Boyer, and  since
adopted by almost all surgeons, is the means which, up to  the  pre-
sent time, has  procured  the  greatest number of cures ; so much so
that its inventor considers its  success almost  infallible.  Beclard and
MM. Richerand, Roux, and Lagneau, however, have cited  cases in
which it had failed in their hands.  Consisting  of  a  deep incision on
one or both  sides of the anus, necessarily  makes it a resource wThich
must be of an extreme character, and one which  patients do not al-
ways  assent to without  much opposition.  We ought not therefore 
1114          NEW ELEMENTS OF OPERATIVE SURGERY.
to propose it, except as  a dernier resort, and  after having unavail-
ingly made use of the other  operative methods.   The  preparatives
which are then similar to those of the operation for fistula, still more
imperatively  demand that we should cleanse out  the  large  intestine
on the evening before, and two or three days in advance, by the aid
of injections and mild purgatives.  The articles, which are composed
of a straight, blunt-pointed bistoury, and  an ordinary  straight bistou-
ry, a large meche, a  T bandage and all  the  essential  accompani-
ments, being  arranged in order,  and  the  patient  laid upon the
edge of a bed, with his head depressed, the  under thigh stretched out
and the other bent, and his two buttocks  stretched wide apart by the
assistants, the surgeon then introduces the  forefinger  of his left hand
as far in as beyond the sphincter, and using it as a guide to  glide in
flatwise  the  blunt-pointed bistoury to  such depth  as is required,
immediately  proceeds to  make the incision.  Though  the fissure
ought in some respects to  be  the locality  of  the wound, it must how-
ever, in consequence of the urethra or vagina, be left intact, should
it be situated on the median line  in front.   Boyer considers that  it
will always  be found sufficient to divide the muscle on one of its
sides without paying  attention  to  the fissure; but prudence, if not
necessity, as  it appears, to me, makes it preferable  that the  bistoury
should make the incision in  the fissure  when  the  latter can be dis-
covered.  We then prolong the incision upwards and downwards
with the straight bistoury, for an inch  or two  upon the skin, and in
such manner  that the entire thickness of the sphincter may be di-
vided.  Unless there should  exist several  fissures, or that  the con-
striction extends to too great  a  distance,  a single incision will be
found sufficient.  Otherwise we make one on each side, and accord-
ing  to the same rules.  Tf the  borders  of the cleft  are callous or
rounded, we seize  them successively with the forceps, and excise
them with a single stroke of the bistoury or scissors.  After this
there is nothing to attend to but the dressing, for hemorrhage under
such circumstances is almost  impossible.  The  operator immediately
introduces the meche and causes it to enter to  an inch at least be-
yond the superior angle of the incision. After having detached some
portions  of it, and  placed them in the wound, he  fills  up the inter-
gluteal  groove  with  coarse lint or with  gateaux;  places a  few
long compresses over this; then supports the whole by a T bandage,
and causes the patient to  be  carried back  to his bed if he had been
removed from it.  The  subsequent treatment and other dressings
are the same as in fistula.
   Relative value of the different methods.—In fine, fissure ofthe anus
appears to be susceptible of a cure in various ways.  Its lips by being
kept either in perfect contact or completely separated apart during
a certain length of time, allow of cicatrization  by the first intention,
or  admit of the thorough cleansing of the wound.  The pucker-
ing of  the  anus, or  the constriction of its sphincter,  by  spread-
ing open or approximating its walls on  the slightest movement, de-
stroy in this  manner at every moment the  conditions that are indis-
pensable for  its consolidation.   Caustics and excision,  by imparting
to it the characters of a recent wound, ought to favor its agglutina-
tion and thereby possibly effect a cure in a certain number  of cases, 
FISSURES.
1115
 though they may not therefore be a radical remedy for it.  Unguents,
 pomades, &c, being capable only of modifying its nature or surface,
 must on that account alone succeed still le'ss frequently.  Dilatation
 by forcing the dupb'catures  of the fissure to spread out, obviates its
 constant laceration, prevents the irritating matters from becoming ar-
 rested and stagnating between its lips, and enables it to close in the
 same manner as a  simple excoriation.  If the incision acts directly
 upon the fissure  it is immediately merged  in the remainder of the
 wound and no longer presents any peculiar feature.  When the sphinc-
 ter has not  been  divided by the instrument, its fibres in  retracting
 approximate the  walls  of the wound, and thus  obliterate it in such
 manner that no particle of matter can glide in between them, so that
 time is given them  to become solidly agglutinated  before  the  anus
 has resumed its usual functions.  Thus  in theory as in practice, in-
 cision is the method which presents the best chances of success; but
 this operation is not exempt from every danger, though in general it
 is easy and may consist of nothing more than a simple debridement.
 If Boyer has never been disappointed in  his expectations, there are
 others who have been less fortunate.  In  my knowledge two patients
 have  died from this operation.  One who was a young woman of
 strong and robust constitution did not succumb  until after the lapse
 of several months.   Adhesions had become established among the
 organs of the pelvic cavity,  and the cellular tissue in the  neighbor-
 hood  of the intestine contained pus in a state  of infiltration.   The
 other, wrho was a man 35 to 40 years of age, was seized on the 12th
 day with a violent entero-peritonitis, and died  in my department at
 La Pitie, in  the month of November, 1831.  A considerable number
 of purulent collections  were  found  under  the peritoneum of the
 pelvis.   The incision of the  sphincter, however, had been  attended
 with no peculiar circumstance.  If the idea of a large sized meche
 alarms the most of  those to whom it is proposed, the introduction of
 the finger, which must precede the incision, is scarcely less repugnant
 to them.  Perceiving in the first case that their sufferings diminish
 instead of augmenting, they soon recover from  their terror;  while
 in the second case they have to dread, in addition, the consequences
 of a bloody operation.   Prudence,  therefore, would seem to dictate
 that we ought to make  trial, in succession, of some of the  principal
 topical applications  recommended, and even the nitrate of silver and
 the dilating meches before we proceed to the incision.
  E.  Excision.—With  the  view of avoiding  the division  of the
 sphincter, I deemed it advisable to suggest the excision of the fissure
 itself.  This method, which was extolled by Mothe and Guerin, and
 which I had already indicated in 1832, has now been frequently per-
 formed.  Some of the essays which  I made were published in the
 year 1836, (Demonge, France Med., t.L,p. 46.)  Everything  being
 arranged as above described, I seize the fissure with an erigne, then
isolate it on the right and left with a cut of the bistoury, or simply
extirpate it entire with a good  pair of scissors.   By this means the
muscular tissue is respected, the operation but little  painful, and the
wound cicatrizes  promptly,  while  the dressing is the same as  after
the incision.  I ought to add, however, that two of the six patients 
1116         NEW ELEMENTS OF  OPERATIVE SURGERY.

whom I treated by excision had the fissure reappear and have never
been completely cured.

                   Article VIIL—Fistulas.

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

                        § I.—Varieties.

  Though the existence of complete fistulas has  never been ques-
tioned, it is not the same with the others.
  A.  Foubert, and afterwards Sabatier, who were disposed to be-
lieve that there were no external blind fistulas, asserted that  the ab-
sence of an internal opening was explained by the examination hav-
ing been in such cases badly conducted.   To this remark it  may be
replied, that one means  of always  detecting it, as some practitioners
flatter themselves, is to  make one complete with the sound or explo-
ring probe, when there  is none in  reality.  Their  doctrine, founded
upon the principle that fetid abscesses of the anus are always caused
by a perforation ofthe rectum, has  no longer need of being combated
at the present day.   The more the  rectum has been attenuated, what-
ever may  be the extent of the abscess, and  the slower has been the
destruction of the cellular  tissue, and the more  extensively it has
spread in  the  ischio-rectal depression,  or the more impaired the pa-
tient's constitution is, or the more it is implicated  in  those affections
which modify the entire organism, the  more is this kind of fistula  to
be apprehended  after abscesses of  the  fundament; so that external
blind  fistulas far from  being impossible, are, on the contrary, ex-
tremely frequent.
  B.  Internal blind fistulas  have also been rejected by a certain
number of authors.  It  would seem,  in fact, that it is not  allowable
to admit of them but as a point of departure for complete fistulas.
In the theory of Foubert for example, it would be difficult to conceive
that when the intestine is opened into, there would not be formed  an
abscess which would soon become apparent externally, or that the col-
lection could pour out its pus into the interior, over a certain number of
days, without also making an external opening.  Experience at the pre-
sent time has produced  a perfect  unanimity on this point.   My own
observations are even calculated to make me consider internal blind
fistulas quite a common disease.   They are reduced, it is true, to a
cavernous ulcer, whose pus is poured out into the  rectum in conse-
quence  of the pressure of the surrounding parts, but which may per- 
FISTULAS.
1117
sist for months without making any manifest progress towards the
skin.  I have now seen at least a dozen  examples  of them.   If the
orifice is not very large, and situated below the dilated portion of the
rectum, this in itself may be but very slightly irritated by the faeces,
for the stools tend rather to  close it up than to enter into it as they go
out.   We thus perceive that all discussion on  a  subject of this kind
will be henceforwards confined to a dispute about words.
   C.  A complete fistula is not  always simple ; quite frequently there
will  be found one on each side.  In other cases also it may have a
greater number  of openings externally, though there may be but one
only in the interior.   In certain cases it  is pierced, as has been re-
marked, in the  manner of the spout of a  watering pot.   Its intestinal
opening, which in most cases consists of  one  only, has scarcely ever
more than this when there  is  but one opening only externally.  In-
stead of following a uniform direction, its track is frequently sinuous.
The one on the left side for  example may pass to the right.  Its pre-
sence in front does not prevent it from having its origin behind, and
vice versa.  After  having proceeded  in one direction, it may hap-
pen that it will take  another route, and  form various angles before
terminating at the skin.  If  a  simple opening externally may some-
times receive various branches, it is  still less rare when a patient
has several passages, to find them all converge with more or less uni-
formity towards the  perforated intestine.  In place of one sinuous
track, there may be  sometimes found between  its two extremities,
passages of greater or less calibre, which  are prolonged sometimes to-
wards the ischium ;  sometimes above the coccyx and  glutei mus-
cles, and towards the sacrum, and into the pelvis;  or at other times
also they may surround the whole contour of the termination of the
rectum, which latter is then suspended, as it were, in the centre of a
vast purulent cavity.
                              § II-

   The precise situation of the internal orifice  of  complete  fistulas
has become during  the last half century the  subject of a very  spe-
cial investigation.  The ancient authors,  the entire Academy of Sur-
gery, and Desault himself and most of his  pupils, without appearing
to suspect that such a principle could be contested, had maintained that
we would  find  the  rectal orifice of the fistula  sometimes in close
proximity to, and at other times at quite a considerable distance from
the anus.   M. Ribes, on the contrary, maintains that it  is always or
almost always situated above  the external sphincter.  This doctrine,
advocated  by M. Larrey, who like M. Ribes ascribes it to Sabatier,
belongs entirely, if M. Pleindoux is to be believed,  to Brunei, a phy-
sician of Avignon, who  defended it  in  the  year 1783 in a special
treatise on  the  subject of fistula.  In respect to  Sabatier himself,
there is reason to be astonished at the silence which he observes on
this subject.  It was in fact to be expected, after the language which
M. Ribes imputes to him, that we should find him develope his opinion
in detail in his Medicine Operatoire, in  which work he says not a
word of it.  However this  may be, the  assertions of M.  Ribes, from
beinrr supported upon numerous facts and careful  dissections, could
not fail to attract the attention of investigators.  M. Roux and Boyer 
1118         NEW ELEMENTS OF OPERATIVE SURGERY.

still contend that there may be fistulas situated very  high up, while
M. Richerand has completely ranged himself under the new opinions.
After the examples of those masters in the scienee, I desired  t<> as-
certain myself what was  the truth in this matter.  Out of thirty-
five cases of fistulas which I was enabled to  examine  for this pur-
pose,  in  the year 1833, either upon the  dead body  or during life,
I found four in  which the ulcer in the rectum was as high up  as
an inch and a half, or two or two and a half inches, and consequently
a little above the external  sphincter.  A fifth  example among these
fistulas, even reached as  high as  over  three inches,  for  it could
scarcely be reached  by means of  the finger, but  this was after it
had made a long track between the mucous membrane and the other
tunics  of  the rectum.   The others opened at the entrance of the
anus or at a few lines within it,  in conformity to the opinion of
M.  Ribes.  Three  of them even had their  orifice outside of the
villous membrane of the  anus,  and two only were found a little
nearer to the valve of the sphincter than  they were  to the integu-
ments.  I could at the present day  enumerate  as many as a hundred
cases of this description, and in which the  same distances were al-
ways observed.   Thus experience, which concurs with the  anatom-
ical explanation which I have elsewhere given in relation to this mat-
ter, (Diet, de Med., 2nd edit., art. Abces de FAnus) authorizes us in
asserting that certain fistulas may  open  upon the skin  itself at the
entrance ofthe anus ; that most of them  have their orifice  between
the sphincters, and that it is also not very uncommon to meet with
them at a short distance above.   In remarking the distance to which
the intestine is occasionally separated above, we  find moreover an
explanation  of the reason why so  great a  number of practitioners
have not thought of searching so low down for  these openings.  In
fact, the  probe  separated  from the forefinger only by the mucous
membrane itself, will ascend sometimes without the slightest  effort,
in the same way as  it would between two sheets of paper, as high
in a great number of cases as to  the distance  of two or three inches
in the direction towards the pelvis,  though the  fistula may be situated
at some lines only from the anus.   This circumstance arises from
two causes : 1st, because the  inner membrane of the rectum being
denuded of  its cellular tissue, easily allows itself to be separated by
the instrument  which glides  between it,  in such cases,  and the
muscular coat, in the same way as it would between two  pieces of
wet linen ; 2nd, because the pus of the fistula or the humidities of
the intestine, intercepted by the internal sphincter  below, and by the
external  sphincter  outside, find  more  facility in taking  a reflux
course upwards, between the coats of the  intestinal tube itself.

                       § III.—Diagnosis.

  The recognition of fistulas in the anus is rarely  attended  with any
difficulty; their differential diagnosis only sometimes presents some
degree of embarrassment.   Whether they be complete or incomplete,
there always exists, provided they have an external opening, an ulcer
at the margin ofthe anus.  This ulcer has been preceded by an abscess
or by hemorrhoids in a state of inflammation  in the greater number 
FISTULAS.
1119
of  the  patients,  and has  already  existed for a  period of  several
months.   Some  persons  however  are unconscious  of its origin,
and have been affected  with it for a long time without having been
aware of it, considering  themselves  to be laboring only under fluent
hemorrhoids, either internal or  external.  A small  projection  or
tubercle of variable size, quite frequently conceals its  orifice, which
latter, in other cases, is  hidden at the bottom of a  kind of  lacuna.
Pressure usually causes  a small  quantity of pus  to  escape from it.
The matter which  comes out from  it, and which stains the shirt of
the patient, is sometimes  of a reddish color, and, as it were, sanguino-
lent, sometimes ruddy and exceedingly limpid, while at other times
it resembles greyish and serous  pus.   This ensemble of characters
however, also belongs equally to  a fistulous ulcer  and to an external
blind, as well as  to a complete fistula.  The faecal odor emitted  by
the matter, or the linen which is imbued with it, is perceived alike in
both  cases.   The escape of gas  would be a  more conclusive  sign,
were not the air, which  is introduced into the fistula while the rec-
tum is  empty,  and when  pressure  from without inwards or  from
within outwards  can cause it to  be expelled, of a nature frequently
to deceive on this point.   In order to demonstrate with certainty that
there is actually a fistula, it is necessary that certain particles of the
substances which pass through the digestive tube should have made
their escape  from  the ulcer; that  we  should have seen worms or
other foreign bodies, or stercoral  matters, or a portion of the liquids
thrown up in the injections, make their exit  from it; and that the
patient, at the time of going to stool, should have perceived that
wind or humid matters were passing through as  they entered  from
the  rectum.  Such  signs, it is  true,  are  sufficient  to  remove  all
doubts;  but  as  fistulas  are not  all accompanied by  them,  and as
they  are moreover purely rational,  the surgeon  is obliged to  have
recourse besides  to those  furnished  by the probe  and  by  phy-
sical indications.  The  exploration then requires that the  patient
should be laid down in the same way as for receiving an  injection.
The  left forefinger introduced into the anus, proceeds at  first in
search of the internal ulcer, which  is recognized without  difficulty
if it is large, and which, if it is narrow, is quite frequently  indicated
by  a pain somewhat more acute, or by a small protuberance like a
pullet's  rump, but not  always, as Pelletan  thinks.  The right  hand
then introduces  the probe, which ought  to be smooth and blunt-
pointed,  and  small and  flexible,  unless the entrance  of the fistula
should be so large as to  require but little  precaution.  The  void
which it meets with shows in which  direction we  should push it.  If
the exploring finger has found the internal opening, the remainder of
the search is not difficult.  In the contrary case the operator, always
acting without any effort,  leaves the instrument to penetrate,  so to
speak, of itself, makes it  pass around the whole extent of the  morbid
cavity, and brings  its point towards the anus and between the two
sphincters, if it has not already been directed to  that  region in the
beginning ; then  follows  its various movements on the contour of the
intestine by means of the finger which he has introduced into the
anus, and does not withdraw it until after he has in vain  searched
in*o the different recesses and all  the deviations, sinuses and passages 
1120          NEW  ELEMENTS  OF OPERATIVE SURGERY.

of the fistula; or until he has positively ascertained  in some way
or another the situation of the  internal orifice of the fistula.   His not
being able to find anything in  such cases is no proof that the fistula
is  incomplete; a bridle or sinuosities, or valvular folds, constitute so
many obstacles which are to be taken  into the account.  In certain
cases the  finger does more harm than good, and is not to  be  intro-
duced into the anus until afterwards.  Injections of tepid water may
be  made  trial of for the  purpose  of  having more freedom in the
passages.   As they  sometimes  come  back through  the anus, it
has also  been recommended to make  use, for these injections, of a
colored liquid, or milk, or ink, or water, for example, tinged  with
saffron or sunflower, in  order that its presence may not be mistaken.
For the same  reason such matters, if they were injected through the
rectum, are of a nature  to come out through the fistula.  .
   The putting in of a  thread, as M.  Ruspoli recommends,  (Gaz.
Mid., 1835, p. 505,)  would make the simple injection still less instruc-
tive than  the  colored.  We might,  moreover, if it were necessarv,
freely enlarge its whole track by introducing into it  tents of pre-
pared sponge, or gentian  root, or  anything similar.   When these
various essays have  been followed by no  results, we may  con-
sider that the case in question  is one of external blind fistula. What-
ever Foubert  may say of it, the contrary cannot  be admitted  save
in the character of an  exception.   The signs of an internal  blind
fistula are not so  numerous, but are less variable.  After pains or
symptoms of a deep-seated phlegmon, a certain quantity of purulent
matters will be observed to escape from the anus.  From  that time
the stools  in coming out are found to be  besmeared with them to a
certain extent, while during the interval the shirt becomes stained
with them.  Sometimes also the ulcer precedes the abscess or deep-
seated inflammation at  the margin of the anus.   Then  the acci-
dents develop themselves with more moderation at first and do not
increase  in intensity until  afterwards.   The finger meets with the
same  peculiarities in the intestine as if there existed a complete fistula.
At the exterior we sometimes distinguish a simple painful induration,
and sometimes a violet or reddish colored spot with or without atten-
uation of the  skin.  In pressing upon this point at the contour of the
anus,  we  empty the pouch of which  it  forms the bottom, and pus is
immediately effused into rectum.  Moreover we  are  rarely called
upon to ascertain the existence of an  internal  blind fistula, until it
has reached to a very advanced stage ;  for up to that  time patients
pay no attention to  them scarcely, and refer their difficulties to blind
piles,  for which they do not ask for any relief.   Urinary fistulas,
which show themselves in the  neighborhood of the anus, are distin-
guished from the preceding, by the rose or particolored tubercle de-
pressed in the form  of a pullet's rump, which almost constantly con-
ceals its orifice ; also by the species of fibrous cord which is prolonged
in the direction towards the bladder or urethra, and by the fluidity,
color and  urinous odor which exudes from them ; also by the fact that
fluids do not usually escape from them except at the moment when
there is a  desire to empty the  bladder;  likewise by the absence of
surrounding cavities,  and the  direction the probe  takes,  and espe-
cially by the fact that this instrument cannot penetrate into the rectum. 
FISTULAS.
1121
                       § IV.—Prognosis.

  Fistulas at the anus in themselves are not dangerous.  Those which
have  but  one orifice, whether internal  or  external,  blind fistulas in
fact, frequently terminate of themselves in  a1 fortunate result, though
Boyer maintains the contrary ;  it is even certain  that complete, that
is, the true  stercoral  fistulas, sometimes  disappear spontaneously.
I saw a remarkable example of this in an old soldier, who had been
a long time  a patient at the Hospital of Tours.  Another time, in a
woman, I ascertained without the least  difficulty, by introducing a
probe, the presence of an anal  fistula, at the beginning  of the year
1831.  Apprehending the attack of some pulmonary affection, I sent
the patient into the country.   She came back two months afterwards
perfectly cured, and has  continued  to  remain so ever  since.   M.
Ribes relates two cases wmich are not  less conclusive.  Who does
not know, moreover, that these  fistulas  will  frequently  close up
during the space of a month or  year, then reopen afterwards, and
finally get perfectly well; and  that a  certain number  of patients
have  them without caring to  pay  any attention to them, and  finally
find  that they  cicatrize  without an  operation?    Such  a  result,
however, is  one that is entirely exceptional.   In the immense  ma-
 jority of cases fistula in ano will not  yield without the aid of art.
Whatever may be  the number of sinuses,  we  may obliterate them,
provided they have  not extended beyond  the perineal  aponeuroses
above, and that they are not kept up by some local disease.   If the fis-
tula has existed for a long period of years, and is accompanied by vast
cavities and by passages which  extend beyond the coccyx, sacrum
and glutaei muscles, laying bare  the latter,  as I have seen in several
instances; or if the levator ani has been attacked and the intestine is
extensively  dissected beyond the reach of the  finger, it is  rare  that
we succeed.   The  most prudent course then, is to confine  ourselves
to cleansing means and palliative treatment.  Like all wounds which
suppurate, a fistula at the  anus may give rise to the accidents of re-
sorption.  If fistula  in ano ought to  be  respected in pulmonary  pa-
tients, it is less because its cure aggravates  the principal disease, than
from  the impossibility of effecting its cicatrization  after having  ope-
rated upon it.   The contrary undoubtedly may happen, but it is  only
by exception.   J. L. Petit, who  was one of the first to investigate
this subject profoundly, leaves no room  for reply.  M. Morere, with
a view to subvert the principle which has been universally established
in our days, by relating the case of a patient, who, after being ope-
rated upon  for a  complete  fistula, afterwards recovered  from his
phthisis, forgets that this patient was not all phthisical.

                        § V.—Treatment.

   All the  means employed in ulcers accompanied with separations of
the integuments, or in  sub-cutaneous  fistulous  ulcers, have been
recommended for anal fistula.   We may find in Avicenna the waters,
unguents and balsams, recommended for this purpose by the ancients.
The patients who were sent to the waters of Barrege and Bourbonne,
and the liqueurs and pomades  prescribed  to Louis XIV.,  who him- 
1122          NEW  ELEMENTS  OF OPERATIVE SURGERY.

self was affected with a fistula in ano, prove that at the time of Dionis
they were full as rich in resources in such cases as at the epoch of
Galen and the Arabs.   Purmann succeeded with lime-water, calomel,
alum and orpiment.  Bourdonnets of lint, good diet and detergent
injections were found sufficient by Pallas.   Injections of gum-ammo-
niac were not less efficacious  in the hands of Evers, and it required
all the experiments undertaken in the case of Louis XIV., to  reduce
such pretensions to their just value.  Inasmuch as this disease some-
times gets  well without the slightest  assistance, it would not, after
all, be  surprising if such remedies had obtained a certain number of
cures,  unquestionable examples of which are to be found in the col-
lection of Bonet; but, as art possesses methods which are incompar-
ably more advantageous, they have been for a long time abandoned.
  A.  Caustics.—Caustics,  employed  at  the remotest period  of an-
tiquity, since they are already mentioned by Hippocrates,  and that
most of the Greek  and Latin  authors  also describe them, and which
have been  eulogized  so much by De Vigo, who especially  praises
vermilion, by means of which remedies  Lemoyne had, Dionis says,
acquired a considerable fortune, and  which, according to Sabatier,
other  charlatans still made use of at Paris, even with full as much
profit in the last century,  are, however, at the  present  day  totally
proscribed.   This does not arise from their being always ineffica-
cious.   Tents impregnated with sublimate, litharge, segyptiac, lapis
infernalis, filings of copper, arsenic,  or  precipitate and  the  actual
cautery, which substances are still made use of by MM. Dieffenbach
(Kleinert's  ReperL, Sept., 1831, p. 81,) and Fingerhuth, (Encycl. des
Sc Med., 1836, p.  205,) together with discs of minium and a thou-
sand other  similar substances, are, on the contrary, of a nature calcu-
lated to cure a certain number of fistulas, whether by modifying the
surface of  the  ulcerous passage, or by destroying the entire bridle
which  separates its two extremities  ; but the uncertainty of their
action  and the disadvantage  of destroying sound parts we  would
wish to preserve, do not allow of our having recourse to them  except
where better methods are impracticable.   Simple fistulas, or such  as
have but little depth, or where  there is great timidity and  an ex-
treme  repugnance  to anything  having  the name of an operation,
could alone, at the  present day, justify their employment in  certain
cases.   The method of Sabatier, which consisted in introducing the
roll or tent impregnated with the caustics only in the direction ofthe
bridle  to be destroyed, that is, to the intestine, would then deserve
the preference if our object was to effect a destruction of parts, and
not to)limit ourselves to a modification of the entire  morbid surface
by means of chemical cauterization.
  B. Ligature.—The same remark nearly applies to the ligature,
which, according to one of the books attributed to Hippocrates, was
formerly constructed of five strands of thread surrounded  with horse-
hair, and which was passed  from the  fistula info  the intestine  by
means of a probe, in  the same way as with caustics  and injections.
At the present day it is  but rarely made use of.   At the time  of
Celsus they used a kind of packthread  besmeared with some escha-
rotic substance.  Avicenna preferred twisted hairs or hog's bristles.
G. de Salicet recommends, according to Sprengel,  that we  should 
FISTULAS.                        1123
employ a small cord having knots upon it, for the purpose of cutting
through  the parts ;  while Guillemeau, who was an imitator of Pare,
passed it into the rectum by the fistula and through a canula with a
needle having a  double cutting  edge.   Notwithstanding the argu-
ments of Foubert, who  substituted  a  leaden wire for the ordinary
thread, and who,  for the purpose of introducing it, contrived a probe
in the form of a larding  pin ;  of Kamper who returned to the liga-
tures of linen or silk thread; of J. F. Borsquet, who recommends
that the  leaden wire should be surrounded with lint and introduced
by means of a needle; of Desault, who employed a directing sound,
and afterwards a  canula, like Pare, and then a leaden wire which he
seized in the intestine with  his finger or with his gorget forceps, in
order to  bring its extremity through the anus  and to fasten it by
means of a knot-tightener ;  of Flajani,  who makes  use only of a
waxed hempen thread;  and of the greater part of timid surgeons,—
the apolonosis counts scarcely any more  partisans  among the prac-
titioners  of the present day.   The advantages which are ascribed to
it by its defenders, and which are more apparent than real, are coun-
terbalanced by numerous inconveniences.  Its action is extremely
slow.  The strangulation which it exercises causes sometimes a good
deal of pain and nervous contractions, which  are necessarily alarm-
ing.  Complicated, multiple, and deep-seated fistulas would yield
to it  but rarely, while in the most simple cases it  is far  from  being
always found to answer.   However, if any one should still be disposed
to make  trial of it, it would  be a matter almost of  indifference whe-
ther we  made use of a strong cord of waxed  thread or of silk, or a
leaden wire, or one of fine  silver, which, in  the first case, is to  be
passed through the fistula by means of a flexible probe ;  and in the
second case, along a grooved sound,  or through the interior of a
canula, and then  brought to the  outside by means of the left fore-
finger, which proceeds  to search for it in the intestine in order to
form a noose with it.  The extremities are afterwards to  be enclosed
in the bullet knot-tightener of Riolan, that of Girauld,  or what is
better, M. Mayor's, or in the instrument of Desault, or twisted upon
themselves if they are of a metallic nature.   By taking the precau-
tion to tighten them in proportion as the tissues yield, that  is to say,
every day or every two  or three days, according as a greater or less
degree of constriction is produced, we succeed in cutting through
the entire bridle in the space of from twenty to thirty or  forty days;
so that at the moment when the ligature falls the fistula is usually
found cicatrized.  But how often are we obliged to remove it before
it is time, in consequence of the pains which it causes, the tardiness
of its operation, and the utter inability of the patients to endure it!
In 1824 M. Bougon made trial of it  at the hospital of Perfectionne-
ment on a courageous  adult of excellent  constitution.  The patient
kept it in for three weeks, complaining of more and  more acute suf-
fering every time it became necessary to increase the constriction.
At this period the bridle, though it was of small length, was not half
cut throuo-h, and as the pains went on increasing, it was deemed ad-
visable to proceed to excision, which was attended with prompt suc-
cess.  When properly considered, the ligature, from its being appli-
cable only to  superficial and simple fistulas, ought  to be laid aside. 
1124          NEW ELEMENTS  OF OPERATIVE SURGERY.

and with so much the less regret because the methods which we then
have as a substitute for it are generally attended with but little pain,
and are applied with as much facility as certainty.
  C. Excentric compression.—Surgeons, however, have  not all yet
abandoned the idea of curing anal fistula without a bloody operation.
In these latter times there has been suggested a remedy which has the
appearance of being even very ingenious, and the object of which is
to dry up the ulcer by closing its internal orifice.  The suggestion,
which belongs I believe to M. Bermond, also occurred to M. Colombe.
The first considers  that his  double canula with sheaths, applied in
the manner described farther  back, (see hemorrhoids,) would per-
fectly carry out the indication, and  the second alleges  that  he  has
succeeded in keeping up in the anus a hollow ebony cylinder, re-
tained outside by means of ribbons.   It  is a method which may be
made trial of, but which experience  has not yet sanctioned, and from
which we must not anticipate too great a degree of benefit.  In a pa-
tient in whom M. Colombe himself employed it, the mucous membrane
of the rectum was invaginated  into the upper opening of the com-
pressing body, and occasioned acute pains.  M. Piedagnel  alleges
that he has attained the success  desired by fixing into the rectum  a
small sac filled with lint, in the same way as for the purpose of ar-
resting a hemorrhage  there.  M. Montain, (Therap.  Med.  Chir.,
p. 85,) even asserts that he has cured a number of fistulas at the anus
by means of a compressing instrument, which had its point d'appui on
the hip, and which was aided by cauterization.  But all these modes
appear to me of very doubtful efficacy.  There is nothing, there-
fore, after strict analysis, but the cutting instrument, which can tri-
umph with certainty over fistula  in ano, and cure every form of it.
  D. Incision.—The ancients, notwithstanding their predilection for
caustics and the ligature,  knew also however, that the best remedy
for fistula in ano was incision.  Hippocrates mentions this in express
terms, and the syringotome, a kind of sickle-shaped  bistoury, em-
ployed in the time of Galen, proves this satisfactorily.   Leonidas,
(Peyrilhe, Hist, de la Chir., p. 442,) performed this operation with
an instrument which terminated  in  a long flexible probe, and  which
was introduced through the fistula, and brought out through the intes-
tine, in such  manner as  to  divide  the bridle with one cut.   In the
medieval epoch H. de Lucques first introduced a ligature, and then
made  use of it as a sound or  probe to stretch the parts  before in-
cising them.  Guy de  Chauliac, who was always  alarmed at the
idea of hemorrhage, preferred  a  grooved sound on which he guided
a bistoury heated to a white heat.   F. ab Aquapendente, after hav-
ing dilated the fistula with  his  speculum, merely used for making
the incision, a blunt-pointed  bistoury slightly concave, together with
a sound.  Others,  as Spigel for example, proposed to  sheath the
syringotome  in a  silver,  curved, blunt-pointed canula,  which pen-
etrating the first into the  rectum was to be withdrawn from it  by
the finger, leaving  a thread at the extremity of the bistoury in order
to draw that  at the same  time by its point and  handle, and to divide
the fistula with one cut.   It was  Marchettis who suggested the idea
of introducing a gorget into  the anus, for receiving the point  of the
cutting instrument or of the sounds.  Wisemann got along very well 
FISTULAS.
1125
without them, and made use of a scissors in place of the syringotome,
which, however, did not prevent Felix from reviving the bistoury of
Leonidas, which he modified by covering it with a coating in order to
render its introduction less painful, and which instrument subsequently
received the title  of royal from the operation which was performed
with it upon Louis XIV.   J. L. Petit showed, that an ordinary bistou-
ry slightly concave, and guided upon a grooved sound, was full as good
as the instruments which had been extolled up  to that period; and
Runge gave as much  security as possible to this process, by advising,
like Marchettis, the use of a gorget, a gorget which Percy (Mem. de
FAcad. Roy.  de Med., X. IL, p. 1,) prefers should be of wood,  rather
than metal, and by using also a grooved sound, which two instruments
were introduced, one  into the intestine and one through the fistula, in
such manner, that  by  means of a straight long bistoury with a thick
point, destined to  glide upon the sound, we could cut through all the
parts comprised  between  them.    Z.  Platner considered  that  he
could make an improvement in the mode of incision, by recommend-
ing that  we  should  accomplish it  by means  of a  concealed bis-
toury, which  others commonly  employed  with the  gorget.   Pott,
with  a view  of simplifying it  still further, required  nothing  more
than his curved blunt-pointed bistoury, wThich B. Bell  replaced by a
narrow bistoury terminated like the beak  of a sound.   The instru-
ment of  Pott  was almost immediately modified  by  Savigny, who
fixed upon one of its sides a pointed blade, which could be thrust out
or drawn in at pleasure, and by T.  Whately, who  made its cutting
edge  movable, and  arranged it in such  manner as  not to with-
draw it  until  after having introduced  the probe point of its blade
into  the  rectum.   In our  times  some persons,  however, have  re-
vived this  bistoury,  the point of which  Dorsey  elongates into a
cone, while A. Dubois makes the instrument advance  upon a flexible
grooved  sound, which has been previously brought out of the anus
through the  intestine  by means of  the finger.   The  ancient  probe
bistoury  of Leonidas revived by H. Bass, and afterwards by Brunei,
is the instrument adopted by M. Larrey.  In the way this last surgeon
has modified it, it is no other than an ordinary  straight bistoury, ter-
minated by a long flexible blunt probe,  which is pushed through the
fistula and brought out by the anus,  and which, requiring no director,
divides with a single  stroke the whole thickness of the bridle.  Fi-
nally, M. Charriere has constructed  one, the back of which is grooved
in such manner, that it glides as well on a cylindrical stem  as upon
a grooved sound,  so  that the  exploring probe  which  is ordinarily
used becomes its  conductor, and  has no need  of being replaced  by
the sound.  Without denying the  successful results ascribed to each
of their numerous processes, we may at least maintain that there is
nothin"- of any real utility to be preserved out of all  this arsenal of
instruments, but the  wooden gorget of Percy, the grooved sound,
the straight bistoury, and the bistoury of Pott,  or that of M. Larrey,
as in fact has been done by the moderns.
  E.  Excision.—Nor has the  mode of performing excision always
been the  same.  According to Celsus, we are to make an incision on
each side of the  fistula, he says, and then to remove all the parts
which are thus circumscribed.  Paul of Egina had recourss to the 
1126          NEW  ELEMENTS OF OPERATIVE  SURGERY.

ordinary syringotome, forceps, and bistoury.   Some excised only all
the movable wall of the fistula, aftei having embraced it in a noose
of thread or raised  it up with a forceps or sound, and to make the
excision made use of either the straight or concave bistoury, or curv-
ed scissors, as was still preferred by G. Heuermann.   Others were not
satisfied until after having excised  the whole fistula, either with one
cut or by excising its two walls in succession. There are those who,
after the wall of the fistula was destroyed,  confined themselves to
pure and simple scarifications of the  callosities.  At the present day,
those who, like Boyer, adopt excision, begin  by incising the fistula,
and afterwards confine themselves  to  the removal  of  the divided
flaps, (des teguments decolles,) which  they seize with  the forceps
and excise with the bistoury.
  F. The manual of the operations for fistula.—A purgative ad-
ministered  the evening before, if the state of the  digestive  organs
allows of it, is required in order to prevent the necessity of too soon
going to stool.  " An injection," says Dionis, " ought in fact to  be
given two hours before, in order that during the operation the sur-
geon may not incur the  risk of having his face besmeared with ster-
coral matters."
  I. The articles required consist of the particular kind of bistoury
which is  preferred, several ordinary  bistouries, a pair of strong dis-
secting forceps, a grooved silver sound, and one of steel, without a
cul de sac, a gorget of ebony or box-wood, straight scissors, and those
that are curved flatwise, a number of cauteries, needles, and ligature
threads, a long meche and meche-holder, tampons, and the hemosta-
tic means elsewhere mentioned, (see  Excision of Hemorrhoids.) small
balls of lint, three or four plumasseaux, long compresses, square com-
presses doubled twice or four times,  and a T bandage doubled.
  II. The patient is  laid upon the right side, when the  fistula is on
the right, and on the contrary, on his left side when  it is on the left,
in front,  or behind, and doubles himself up, with his head lowered
and his belly supported upon a transverse piece, while he stretches
out the limb which is below, and flexes the other.  An assistant situ-
ated in front  of him prevents him  from  raising  up his head, and
watches his arms.   The pelvis  and  the  flexed leg are kept immova-
ble by a second assistant.   A third  placed behind him, is charged
with separating the  buttocks, and of holding the gorget at the proper
moment.  Finally, there will be required  a fourth, and even a fifth,
to hold the other leg, to stretch the  tissues,  and to hand the instru-
ments or cleanse the wound.
  III. Before proceeding  farther, we search for the two openings of
the fistula.  The discovery of the one  outside cannot be attended
with any great difficulty.   The stercoral  humidities,  or  the pus
which  escape from it, suffice, in the absence of a wound, to point
out its seat, even though it should be at  the centre of a hemorrhoidal
tubercle, or in the bottom of some tegumentary duplicatures.  It is
not always the same with the internal opening.  This  last  presents
itself quite frequently at the  middle  of  a small induration or pullet's
rump, very readily  distinguishable by the finger introduced into  the
rectum, or it appears under the form of quite a large ulcer, which may
be recognized with still greater  facility.  Frequently it is not found 
FISTULAS.
1127
because we look for it too high up.   It is sometimes so near  the
skin externally, that it requires attention, in order that we may not
be deceived.  It is only after having carefully explored all the stran-
gulated or straight portion  ofthe intestine, that we should proceed to
examine if it is not situated higher up.  A flexible probe, moreover,
will remove every doubt.  We  introduce  it  with the right hand
through the cutaneous orifice, and with caution, in the direction of
the fistula, and allow  it  to follow without  effort  the  various tortu-
osities, so that its head will soon present itself to the finger ofthe left
hand, which is waiting for it in the rectum.  When there  is but one
external opening, this probe in general penetrates with a sufficient
degree of facility, unless the fistula should  turn round at  too sharp
angles in the course of its progress.   When there are several passa-
ges, on the contrary, or numerous openings  around the anus, the
search sometimes is attended with a great deal  of difficulty.   We
then introduce the probe into each of  them in succession, proceeding
in the manner just described.   The failure of such explorations  does
not authorize us to conclude that there is no opening in the intestine.
There are too many  circumstances which may conceal it from the
view of the operator.  If some milk were retained above the anus,
it would prove, if it  issued through the outer orifice, that an inner
one existed in the same way that if pushed through the outer the
milk should be seen  to return through the anus.  Any other  mild
fluid of a strong color would serve the same purpose.  It happens in
other cases that the exploring instrument is found no longer separated
from the forefinger except by a thin pellicle, like a sheet of paper, and
yet notwithstanding it cannot be made to present itself naked in the
intestine.   It will glide with freedom  in every direction without the
slightest trouble.  We perceive that the mucous membrane is atten-
uated and separated, and nevertheless still recognize that the end of
the probe   is  outside the   gut.   Does an  opening exist  on some
other point ? or is it not rather an  external blind fistula 1  it is impos-
sible to say.   A decisive step  however must- be  taken.  This  state
of things, which formerly was found  very embarrassing, and which
is  still one  of  the most disagreeable  for those surgeons who do not
consider it  proper to operate until  after having explored the fistulous
passage through both openings, does not, in  the opinion of M. Roux,
require so many precautions.   This surgeon, in fact, affirms that the
internal orifice of the fistula to be  divided, is far from deserving the
importance  which is  generally attached to it.  Whether it exists or
not, the remedy is the same.  The decollement of the rectum is suf-
ficient to justify the operation.  Those minute  researches, which oc-
cupied so much of the attention of the members of the Academy of
Surgery? appear  to  him to be almost superfluous.  As  for  myself,
who,  like M.  Jacquier, (communicated by  the author, 1839,)  have
seen the disease persist in  patients operated upon after the precepts
of M. Roux, and who, on the other hand, am aware of the successes
obtained from this method  by M. Begin, I am of opinion, that without
neglecting those means required to ascertain if the ulcer  opens into
the intestine, we  should  nevertheless operate,  when we  do not find
it  if  the disease should continue to persist for  some months,  and
that the rectum bas undergone decollement to a certain extent.  If 
1128          NEW  ELEMENTS  OF OPERATIVE SURGERY.

however the opening shall have  been found, and is not situated very
high up, the silver sound is immediately to be substituted for the probe.
We proceed with the forefinger  to search for it in the rectum, seize
its point, and, after depressing and curving it a  little, bring it out by
the anus, while at the same time the surgeon continues to urge it along
the fistula with his right hand.   A simple strait  bistoury, such as that
employed by M. Richerand, M. Ribes, and Sabatier, and as is recom-
mended by Dupuytren, and which I have  several times myself made
use of, or Pott's curved bistoury, or Dorsey's, with a conical point, or
the slightly concave bistoury of J. L. Petit, being then guided upon the
groove of a sound, the extremity of which  is  steadied by an assistant.
divides through the whole bridle  with a single cut, making  the opera-
tion one of extreme simplicity.
   IV. When the fistula is higher up, or the decollement has extended
very far, it is  better to  imitate Boyer and M. Roux, by making use
of a  steel director with an extremity somewhat pointed.   It is intro-
duced as high as to the  upper  part of the  fistula.   A gorget is  then
to be substituted for the finger, which last in the rectum had followed
all the movements ofthe sound,  and now  presents to it the gutter of
the gorget.  The director is to be pushed against the gorget in  such
manner as to pierce  through the intestine.  By moving them back-
wards  and forwards  so that they rub against each other,  we satisfy
ourselves that they are in actual contact.  At this  stage the assistant
seizes the handle ofthe gorget, fixes it, and reverses it a little to the out-
side, as if for the purpose of vibrating it.   The  surgeon, with his left
hand, acts in the same manner on the plate of the director; seizes a bis-
toury with a strong point with his right  hand; fixes its point into the
conducting groove ; pushes it quickly up to the gorget; and  withdraws
it  by elevating  his wrist ana without  allowing  it to abandon the
point d'appui which he  has given to it.   For fear the whole of the
bridle may not have been divided, the bistoury is to be reintroduced
a second  and  even  a third time upon the director;  after which, in
order to  be certain that we have  left nothing,  we withdraw the
two auxiliary instruments as  if  they were a single  instrument, and
without separating them.  Should there remain a cul de  sac above,
we should immediately  proceed  to lay it open by dividing, by means
of the scissors guided  upon the finger, the abnormal valve which
forms it.   The  cutting edge  of the bistoury turned to the outside,
is then to be directed upon  the bottom of  the wound, which latter it
incises or scarifies to a moderate extent throughout its whole length,
and afterwards prolongs it, at  the expense ofthe skin, to the distance
of about half an inch or an inch upon the buttock.  However little
decollement or attenuation  ofthe integuments may have taken place,
they are to be incised by a crucial incision or a T incision reversed,
after which each of the flaps  is  to  be seized with a forceps and cut
off at their base from their  free surface to the wound, by means of a
bistoury.   Without this precaution the suppuration would  be intermi-
nable and a cure rendered  very  uncertain.  The pain that it causes
and the time that it requires, are nothing  in  proportion to the advan-
tages that result from it.  Prudence does  not permit us  to dispense
with it except in the cases of  those fistulas which are wholly of a
simple character.   What we have done on the first fistula we repeat 
FISTULAS.
1129
on the others, in order that we may reunite them at the wound of the
rectum.  All the  tegumentary flaps which are thus formed are also
to be excised,  however little they may be  altered or attenuated.
The same bistoury, or the probe-pointed one,  and always to be con-
ducted upon the finger, is to be made to act in the last place upon
the different bridles and valves which are met with at the bottom of
the openings or of the wound, in order, before we terminate, that we
may regularize, as  perfectly as  possible, the whole interior  of the
bleeding surface, after which the operation is finished.
  G. The dressing is the same as for fissure at the  anus, except that
the meche should be larger.  It is  important, after having intro-
duced it, to separate a bundle of fibres from it to place between the
lips of the  wound,  beyond which  latter  it  should pass up  to the
distance of an inch or two.   A sufficient quantity of coarse lint and
plumasseaux laid over this fill up the margin of the anus.  The whole
is then to be covered over with two or three square compresses and
afterwards by as many long compresses, which are to have some
degree of width.  The two heads of the T bandage previously fixed
around the belly, then brought down over these different portions of
dressing, passed between the thighs, and then crossed and brought in
front, one to the right and the  other to the left, and afterwards
knotted or fastened with pins upon the hypogastric circular, complete
the dressing.
  H. Accidents.—Hemorrhage, should it occur, is  to be treated in
the same  way as after  excision of hemorrhoidal  tumors.   If the
artery which bleeds can be seen, it is to be surrounded with a thread,
unless we should  prefer torsion.   In the contrary case we introduce
the pulp ofthe finger into the bottom ofthe wound, in order to com-
press  in succession  all  the  differents  points  of it.   As  soon  as we
arrive by chance  upon the vessel, the blood ceases  to flow.  This  is
the point consequently upon which we must apply the small balls of
lint, charged or not with hemostatic powders or liquids.   The  meche
and other  portions of dressing  are  afterwards adjusted  as  above
described.   Should  we not  succeed, and that the tamponing also of
the whole bleeding  surface does not prove  sufficient, we have no
other resource than  to choose between the actual  cautery, Levret's
bladder, Blegny's gizzard, the tampons of J. L.  Petit, adopted by
Boyer, or the apparatus of M. Bermond; but it rarely happens that
we are reduced to this necessity, and so much  the less so inasmuch
as the hemorrhage, which sometimes follows the operation for  fistula,
is useful rather than injurious, and that in almost in  all cases it  ceases
spontaneously before it has become alarming.
  I. Remarks.—The exclusive partisans of incision do not  always
proceed precisely in the  manner which  has  been described.  The
decollement (denudation) of the rectum is not, in  their opinion, a
reason  for prolonging its incision above the fistula.   They maintain
that after the operation  the intestinal wall will attach itself and soon
become agglutinated on its outside to the suppurating surface; that
so also  its  cutaneous flaps and indurations do not fail to re-agglutinate
or disappear, as soon as  the  bottom  of the fistula  has become con-
tinuous with the anus, without any interposing impediment, and con-
sists of nothing more than a mere notch or  gutter in the intestine; 
1 130         NEW ELEMENTS OF  OPERATIVE SURGERY.

that we in this manner abridge the length of the operation, and much
of the sufferings of the patient, and also the continuance of the sup-
puration and the period of the cure: that  we have less reason to
apprehend  hemorrhage and  fever, and that less  deformity  results
from the operation; finally, that the important  point  is to interrupt
the continuity of the sphincter, which, by retaining  the faecal matters,
obliges them to penetrate in  part into the fistulous  passages.  The
objections to be made against this reasoning are, that if the denuded
and attenuated parts may, in fact, ultimately become re-agglutinated
after a simple incision, in a considerable number of patients, so is it
not uncommon to find the contrary take place.   Moreover, how
could it be otherwise 1  We see here nothing more than is remarked
every day, on every other region of the body.   There  is nobody at
the present time  who has  any doubt, that the excision of the livid
and attenuated flaps which cover the bottom of a great number of
interminable cutaneous ulcers is the best remedy that can be opposed
to them.  The section of the sphincter does not always take place;
moreover, it is not this muscle, but in fact, the fibro-muscular circle
situated above it which forms the most contracted part of the anus.
After all, what have we to  fear?  A loss of substance in the midst of
such soft parts is soon repaired.   The pain is less acute than is gene-
rally supposed.   By the very fact itself that the tissues are  attenu-
ated and, as it were,  dissected, they cannot contain vessels of large
calibre. Difficulties therte are none, for those who know how to handle
the bistoury.  In  a few seconds  all the flaps have been seized and
extirpated.  The patient, resigned to the operation, prefers suffering
a little more, in order to have all the chances possible of being cured
with certainty and rapidity.  On  the other hand, we do not perform
this excision except   in fistulas that are accompanied with  a very
marked degree  of decollement.   The division, in  fine, scarcely falls
upon anything else than the skin, and the whole is limited  to a pure
and simple incision when the passage to be destroyed is not surrounded
by any disorganization.  In a word, the indication to be fulfilled in
these cases presents itself under two points of view:  first, to dry up
the source of the fistula by incising the rectum ; and secondly, to place
the wound  afterwards under such conditions that its cicatrization may
be accomplished with facility.
  I. Those fistulas which open upon the anterior wall of the intestine,
exact somewhat  more precaution than the others.   Their excision
should not be attempted without some very evident necessity. The bis-
toury introduced  into the bottom  of these for the purpose of scarify-
ing them, could reach too quickly into the bladder  and peritoneal cul
de sac, or upon  the prostate, to make it  allowable for us to expose
ourselves  to this  risk.  When  they are very high up, no matter in
what direction, the operation  is at the same  time  more difficult and
more  dangerous; not that we  have seriously to  fear wounding the
peritoneum, even though the fistula should  be as  high  up as the sa-
crum.  Practitioners who have poiited out this danger, had doubtless
forgotten that the morbid  opening perforates only through the mu-
cous and muscular membrane, without implicating the serous tunic ;
that the pus is effused  into the cellular tissue and not into the cavity of
the abdomen; that if the peritoneum was ulcerated there would be 
FISTULAS.
1131
an effusion into the belly, and a disease almost inevitably fatal, or at
least, one too serious to think of an operation ;  and that the bistoury,
from its  not leaving  the groove of the director which has been se-
lected, cannot, scarcely by  any possibility, reach the  peritoneum,
even though the surgeon had that intention, and that the lesion of this
membrane is not, if all things are well considered, more to be dreaded
above than  below, or in front or behind the intestine.   The danger
arises from  the fact that we may incise beyond the lower limits of
the ischio-rectal aponeurosis, or, in  truth, of the internal  border of
the pelvic aponeurosis, and which would expose to the risk of puru-
lent filtrations between those two layers in the  first place, and after-
wards into the pelvis between the peritoneum and the fascia pelvica.
  II. What  precedes is to be understood only of those fistulas in the
anus which  are  kept  up exclusively by some local affection, or by
the destruction ofthe cellular tissue, or  the perforation ofthe rectum.
Those  which  depend upon a caries, a necrosis,  or any alteration
whatever of the ischium, coccyx, sacrum, or vertebrae, and the source
of which lies in a deep-seated suppuration in the abdomen or chest,
are purely symptomatic, and the cure of which cannot be thought of
until their cause  has  been removed.  When  they are complicated
with syphilis or  any  morbid diathesis, we must at least, should we
decide upon operating,  subject the  patient at the same time to the
particular or general treatment required by the nature of the affec-
tion.  It  is from having proceeded in a contrary manner that certain
operators have found  the wound continue open to an indefinite pe-
riod, and the  suppuration resist every attempt to dry it up, though
there may have been no circumstance nor any anatomical alteration
which could interfere with its cicatrization.
  III. Experience proscribes  the performance of the operation in
consumptive patients :  1st, because in most  instances the fistula
moderates the progress  of the pulmonary disease ;  2d, becaitse it is
usually caused by the  ulceration of one of the thousand tubercles
with which  all the organs are then cribbled; 3d, because the wound
rarely heals  up, but suppurates abundantly and reacts in an injurious
manner upon the  ensemble of the organism; and 4th, because, if by
chance it closes up, it is remarked that the pulmonary affection, which
was momentarily suspended, rarely fails to become thereby aggra-
vated.   This however is not an argument for creating a complete
artificial  fistula in the anus of tuberculous patients, by  introducing
into the rectum a long darde inclosed in a large canula, from whence
it may escape when we wish, in such  manner as to traverse the in-
testine from within outwards and from above  downwards, so as to
come out at the margin of the anus, while  dragging after it a seton
destined  to remain in  the wound, as has been proposed, and in one
instance practised by M. Heurteloup, at La Charite.  Nothing more
can be hoped for from a resource of this kind  than from a seton  at
the nape or  a blister on the arm.  I am of opinion even that in cer-
tain cases, a fistula at  the anus may co-operate from the  pus which it
furnishes to  the general circulation, in the production of tubercles, and
in creating a pulmonary diathesis, instead of being a remedy for it.
  IV.  The little frequency of internal blind fistulas is owing to two
causes: 1st, because  they are speedily transformed into  complete 
1132         NEW ELEMENTS OF  OPERATIVE SURGERY.

fistulas; and 2d, because in the contrary case the ulceration is suffi-
ciently moderate to allow of their spontaneous cure.  This is what
I saw happen in a patient in whom I was obliged to lay open, through
the interior ofthe rectum, an extremely painful abscess, which  it was
impossible to recognize externally,  and which made a decided pro-
jection into  the intestine, and from which there escaped more than a
tumbler full  of pus.   Moreover, to operate upon fistulas of this kind,
we endeavor to transform  them into complete fistulas, either by re-
taining the pus in their interior by means of a tampon introduced over
their opening, or by a stem curved  into a hook and passed through
the anus, with its short branch lodged in the ulcer.  These  resources
enable us to ascertain the point on the perineum which corresponds
with the fistula, and  thus to lay it open with a cut  of the bistoury.
Moreover, when the intestinal orifice has once been  discovered, it is
not necessary to  have  recourse to  so many means of exploration.
The bistoury introduced flatwise upon the finger and having a small
ball of wax  on  its point, would succeed perfectly well, by incising
the rectal wall ofthe fistula from above downwards  and from within
outwards, in the same way as if it were an ordinary abscess, and in
such manner as to divide through the sphincter, should that be  deem-
ed advisable.
  V.  As to  the question whether it  would  be proper to operate for
the fistula with the same cut which lays open* the stercoral abscesses,
as was recommended by Faget,  or whether it wrould not be preferable
to make a puncture only at  first and  to operate subsequently, as Fou-
bert has advised, opinions at the present day have unanimously deter-
mined in favor of this last mentioned author: 1 st, because the intro-
duction of the finger or gorget would then occasion too much pain;
2d, because, from our  not  being able to ascertain where the open-
ing is nor to what point the decollement has  extended, it would be-
come necessary in most cases to repeat the operation after the expi-
ration of a certain period of time;  and 3d, because many of these
abscesses, when they are once laid open  heal up without  any other
operation, which Foubert had already noticed, as is shown also by sev-
eral cases which I have published, and other instances of which I have
since met with.  To operate upon multiple fistulas at several times, and
at intervals of several days, as was done by Fichet de Flechy, (Diet.
de Mid., 2d ed., t.  III., p. 38,) and as others have since proposed, would
not be advisable except it were impossible to find their various orifices
on the first  day.  I have elsewhere, (France Medicate,  X.  I., pp. 57,
61, 73, 78,)  mentioned  the  special circumstances connected with fis-
tula in ano in women.
   VI. The subsequent dressings is a point of great importance after
the operation for fistula in ano.   Almost all French surgeons maintain
that a large meche should be constantly kept up in the rectum, or
that there should  be at least always a portion of it kept between the
lips of the wound.  Unless that were done  the  cicatrization, they
say, would  first take place upon the mucous membrane, and the fis-
tula be thereby reproduced.  The cure cannot be complete and per-
manent unless  it proceeds from  the bottom to the borders of the
wound.  A  patient who was doing very well, was temporarily left
by Sabatier, who ascertained at the end of three weeks, that the fis- 
CANCERS OF THE ANUS.
1133
tula had formed again, when it was found that the assistant to whom
he had  entrusted the care of the meche, had not employed it in a
proper  manner.  The incision was  then repeated.  Each dressing
was performed by Sabatier himself  with the greatest care, and this
time the disease entirely disappeared.  Boyer holds precisely the
same language, and relates facts  that are exactly similar.  Pouteau,
nevertheless, who contended zealously against this doctrine, affirms
while he supports himself also upon  the facts which experience has
furnished, that the meche is not only  useless but even injurious, from
the irritation and compression which  it causes upon the bleeding sur-
face, which latter, according to him, requires no other treatment than
that of  simple wounds, which we wish to take on  suppuration.  In
England the principles of Pouteau are universally adopted.   A strip
of fine.linen or some strands of lint is all that is allowed to be placed
between the borders of the wound, and M. S. Cooper among others,
is unable to comprehend what he denominates the French practice.
On this point, as on so many others, we may,  I think, readily furnish
an explanation.  It is not probable that the same differences in this
respect exist in practice as is found in books.  The object is to pre-
vent the reagglutination of the lips of the wound before we have
modified its bottom, and forced  it, in fine, to  become  cicatrized by
degrees, from its sides  towards its deepest portions.   To effect this,
what have  we to do ?   A  slender meche would not always answer,
because in  most cases  it would be found to be  expelled by the wound
of the  anus itself.   On the other hand the large cylinder of thread
which  is used  among us is not  indispensable, for we  may with a
meche,  which is more supple  and smaller, keep the solution of conti-
nuity sufficiently open.  It has moreover the  positive inconvenience
when it is persisted in for too  long a time, of flattening down the cel-
lular granulations, whose development also  it interferes with.   Rea-
soning  and experience concur in showing that a meche of medium
volume is advantageous during  the ten or fifteen first days, that we
may afterwards without any disadvantage make it gradually smaller
and smaller, and that it is advisable to dress flatwise with soft lint as
soon as the traumatic  surface is of a vermilion color and appears to
be disposed to cicatrize.   As  to the rest, this wound is to be treated
like any other, which  remark applies also  to the various  accidents
local or general  which may take place during the progress of the
cure.

              Article IX.—Cancers of the Anus.

  No part is more liable to lardaceous, and even cancerous degene-
rescences, than the  termination  of the rectum.  They present them-
selves here sometimes under the form of tumors, which are more or
less projecting, and with a base of greater or less width; sometimes
with the appearances  of a perforated diaphragm, especially when it
is  the  valve described by M.  Houston,  (Dublin  Hosp.  Reports,
p. 162,) which constitutes their seat;  and at  other times, under the
aspect'of plates, which are more or  less extensive, either  in height,
thickness, or breadth,  and which  sometimes occupy the entire con-
tour of the  organ.  When topical applications,  debridements, and 
1134
NEW ELEMENTS OF OPERATIVE  SURGERY.
compression, have proved insufficient, and that the disease continues
to progress, we have to apprehend, whether it be cancerous or not,
that it will terminate fatally, unless we resist it by more efficacious
remedies.
                              § I-

  Extirpation is  a last refuge towards which  the mind then  natu-
rally turns.   This suggestion has occurred  to various  persons who
have ultimately recoiled from the operation, or become alarmed with
the difficulties attending its  performance.   Desault does not con-
sider extirpation admissible, but for those tumors which are of a bad
character, perfectly defined and movable, and the various prolonga-
tions of which may be reached without any  difficulty.  Boyer  is of
the same opinion.  All the school of the ancient Academy of Surgery
adopted this principle, which  originated with Morgagni.  The sur-
geon who ventured to make trial of it at the time of Morgagni", was
unable to finish the operation; and  Beclard, who, according to M.
Paris, maintained  in his  course  of operative surgery at La Pitie, in
1822 and 1823, that at the improved state to which surgery had then
arrived, schirrous indurations of  the rectum ought no longer  to be
considered necessarily mortal, and that we  ought  to remove the al-
tered  parts while  adopting all the precautions required by the prox-
imity of the bladder, and numerous vessels which surround the lower
extremity of the intestine, had not an opportunity of putting this pro-
cess into practice.  It was Faget who appears to have been the first
who successfully  performed this  operation,  viz., on 9th June, 1739,
in presence of Boudou and his brother.   He excised about an inch
and a half of the whole circumference of the rectum.  What chiefly
struck his attention was, that the stools could be  made with the new
anus in the same  way as they had been made before the operation,
although almost the entire sphincter or plane of circular fibres which
surround the anal opening had been excised.  After having endeav-
ored to explain the formation  of a new constricting muscle, and th%
mode by which M. Gele, his patient, was enabled to retain both solid
and liquid matters, and even air, Faget came to the conclusion  that
extirpation of the anus,  even at  a  very considerable height, was a
practicable operation.   M. Lisfranc has furnished  the proof of this.
His first patient, who was operated upon on  the 13th of Feb., 1826,
found himself, it is said, completely restored  on the 13th of April fol-
lowing.   He obtained a similar success in  the month  of January,
1828, in a woman, and afterwards a third, in another woman opera-
ted upon the 15th of July, and cured the 28th of October ofthe  same
year.   In a fourth patient, the cure remained doubtful, and the fifth
died on  the 10th of March, 1829, 4 days  after the  operation, from a
suppuration in the pelvis, and probably with a phlebitis.  A  sixth,
who was a man 72 years of age,  succumbed on the following day,
but the body could not be examined.   His seventh patient died at the
expiration of 25 days, and also had pus in the pelvis and veins.   But
the thesis of M. Pinault, which contains all these facts, also gives two
instances of cure ; by which it would  appear, that up to the month
of August, 1829, M. Lisfranc, out of nine operations of this description,
counted five successful results, one of partial success, and three deaths, 
CANCERS  OF THE ANUS.
1135
if we may be allowed to accord an entire degree of confidence to the
facts derived from the practice of this surgeon.
  A. The ordinary process.—The  patient  being arranged,  and
placed, and held in  the  same manner as for fistula, except that his
two thighs, and not one  only, are to be separated by a pillow, and
bent at a right angle upon the trunk, while  an assistant keeps open
the  buttocks and  stretches the skin, the surgeon encircles the dis-
eased part below by means of two semilunar incisions, which unite
at the coccyx and perineum, so as to  form an ellipse ; dissects this
ellipse on its outer side  from below upwards, and to the right, and
then to the left; detaches it by degrees from the surrounding tissues,
while taking care to leave nothing  altered external to it; stops when
he  arrives at the sphincter ; introduces the left forefinger into the
anus; makes use of it as a hook to depress the scirrhous ring, which
latter he endeavors to  bring to the outside at the same time that an as-
sistant makes traction  upon the dissected ellipse ; retakes the bistoury
in his right hand, and  continues to cut in a circular direction the ad-
hesions which exist between this portion and the circumjacent layers,
as  far as to above the limits of the disease, if it is possible, and ter-
minates the operation  by detaching the whole by free strokes with
the scissors curved, flatwise, or even by means of the bistoury which
he has made use of up to this time.
   I. When the cancer is  deeper, and more adherent, or  comprises
 a  greater thickness of the tissues, M. Lisfranc divides  vertically
the angle  or posterior wall of the dissected ellipse, by commencing
 with a  strong  pair of  scissors and  prolonging his incision  to a point
 sufficiently high in the rectum.   The  assistants  afterwards make
 traction upon  the  remainder of the  circle by means  of erignes or
 strong forceps, while  the  operator prolongs the dissection above as
 far as possible, by means  of the  bistoury guided upon the finger,
 introduced in the  anus, and by the thumb applied upon the outer side
 of the flap.   When he has gone beyond the limits of the disease the
 curved scissors may be substituted for the bistoury as before, in order
 to separate, circularly,  the  dissected  mass  from the  portion of the
 rectum which is to remain.  We introduce its extremity into the poste-
 rior incision, in order to embrace in succession its two  halves, and to
 divide  them from behind forwards, while taking care to act on the
 sound tissues, and to increase our precautions  as we approach the
 genito-urinary organs.
    IL In women an intelligent assistant, with one or two fingers intro-
 duced into the vagina, watches the movements of the bistoury or scis-
 sors in this direction, while the surgeon dissects  the cancer in front, or
 endeavors to excise it at its depth.  In man the urethra, prostate and
 bladder render this stage of  the operation  still more delicate.   A
 strong catheter, kept  up the natural passage, is doubtless  a valuable
 o-uidet but one which  would be but of feeble assistance if the surgeon
 had not constantly present before  his  mind his knowledge of the sur-
 gical anatomy which relates to the perineum, or if he were unprac-
 tised in the employment of cutting instruments.
    Ill When the excision is finished, the operator reapplies his finger
 upon every point of the wound,  if he perceives any tubercles, flaps,
 or remnants of altered tissues which have escaped  him, he irnme- 
1136         NEW  ELEMENTS  OF OPERATIVE SURGERY.

diately seizes them  with an erigne or a forceps, and instantly excises
them with the bistoury or scissors, whether they be in the interior or
on the skin.  The arteries divided belong to the same branches as in
the operation of fistula  in ano.   To these must be added,  in some
cases, the transverse artery and the superficial  arteries of the peri-
neum.  The ligature is to be applied  upon all  those which can  be
seen, in proportion as we divide them.   Otherwise we should run so
much the greater risk of not finding them afterwards, because from
being stretched and elongated at the moment of making the section,
they ascend very high  up into the pelvis, and, if  we wish  to bring
them to the  outside  by making traction upon the extremity of the in-
testine, the compression we exercise upon  them prevents the blood
escaping from their mouths.   Nevertheless they are rarely of suffi-
cient size to give rise to  the apprehension of any serious hemorrhage.
Should  this hemorrhage have taken place we combat it by refrige-
rants, styptics, small balls  of lint methodically applied, tamponing, or
in a  word, by one of the methods  pointed out in the preceding arti-
cles.  If during the course of the operation the blood should flow to
such extent as to interfere with the surgeon, we might, as, according
to M. Pinault, M. Lisfranc directs, wait a few  moments  and  check it
with lint saturated with cold water, should it  not  be  practicable  to
have recourse to the ligature or torsion.
  IV. The meche is still more important after this operation than in
any  of the others.   It should be of large size and long.   It is requi-
site that the finger should precede it and incline it strongly backwards
in order to  find  the new  opening of the rectum, and that it should
afterwards  make it  vibrate in  the contrary direction in order that it
may penetrate with  facility.    A portion of linen  besmeared  or
covered with  cerate  and applied over  the bleeding surface, then
receives the extremity of the meche, over which we place coarse lint,
several plumasseaux and compresses, and the double T bandage.
  V. When we omit the meche in the beginning, and  limit ourselves
to spreading upon the wound the perforated linen which is to receive
the lint, so as not to have recourse to tents until at the tenth  or fif-
teenth day, the  first  dressing  becomes  more prompt  and is per-
haps a little more easy;  but we create  for ourselves difficulties in
perspective, so that  it would be more rational to proceed in the man-
ner I have just pointed out.
  VI. The wound,  which is  inundated for some days with a copious
suppuration of a grey and  blackish color, mingled with faecal  matters,
becomes cleansed by degrees, and  begins  to  contract from the fif-
teenth to the twentieth day.  At the same time that the skin is being,
as it were, dragged in towards the pelvis, the  intestinal  orifice reag-
glutinated to the parts which surround it, approximates  to the exte-
rior ; so that finally nothing more remains than an annular loss of sub-
stance to the height of an inch or even less; and that the preserved
fibres of the levator ani, of the aponeuroses and termination of the
rectum, and of the  other lamellae, by being blended together in  one
ring reproduce, to a certain extent, the  sphincter  muscle, supposing
it should have been necessary to have removed this, leaving in  this
manner after the cure, infinitely less deformity than could have been
at first anticipated. 
CANCERS OF THE ANUS.                 1137
  VII. In order that this cure  may be  certain and permanent, it is
important not to abandon suddenly the  use of dilating bodies.   The
new anus has so great a tendency to  contract, (coarcter) that  if the
meches were not continued at least for  some weeks after the cicatri-
zation  of the wound, and renewed from  time  to  time, during the
space of  several months, the greater number of patients would not
fail to become soon affected with so great a degree of contraction as
to counterbalance the price of the  sufferings they have endured and
the benefits of the  operation, though it may have been performed in
the most  judicious manner.
  B. New process.—If the cancer constitutes a  ring which is only
an inch in height, I commence by laying it open behind.  Afterwards,
securing  it with the finger or a good pair of erignes, I bring it  down
completely to the outside.  A curved needle then enables me to pass
through its root a series  of threads  from above downwards, or from
the rectum towards the  skin.   The cancer being now detached from
the sound parts  by  means of a circular  incision,  either from the skin
towards the mucous tissue, or from the latter towards the former,
by  means of the bistoury or  scissors,  is  immediately removed at
three or  four  lines  on  this side of each point traversed by the
threads.   By seizing these latter, in order to knot them outside, we
approximate and place in contact the two circles of the  wound, in
such manner as to accomplish their union by first intention.  When
the disease goes higher up, I first dissect it  from below upwards as in
the ordinary process, and even to a certain distance  beyond.   It is
at this  moment that I insert the threads  from space to  space upon the
sound portion of the detached  rectum, and above the altered tissue,
as if for  the purpose of securing it, and afterwards from  above
downwards through the  cutaneous lip of the wound.  A  few cuts
with the  scissors or bistoury immediately cause the cancer to become
separated, and the approximation of the two halves of each thread
afterwards brings down without any difficulty the  intestinal  circle,
preserved, as far as to a  line with the tegumentary circle.   Should it
become necessary to remove  unequal plates instead  of a  complete
ring from the anus, we might circumscribe each of them  in  an
ellipse, the two  lateral angles, and the lower angle of which should
be immediately  reunited, and  each  closed  by two points  of suture.
These  three modifications of the process have been used by me in
practice.   From their enabling us to  fill up the wound with mucous
or cutaneous tissue,  and by first intention, they render the occur-
rence of  hemorrhage more difficult, the cure more  prompt, and the
reaction  less serious, without at the same time leaving any inodular
cicatrices.
                     § II.—Appreciation.

  Cancer of the anus, therefore, may be submitted to  the chances of
extirpation, like that of the breast, when without causing too great a
destruction of parts, it would appear  to be practicable to  remove it
entire  that is to  say, when we may reach completely beyond it with
the finger, and when it  is limited to the walls of the  intestine, or at
least retains a certain degree of mobility, and has not yet  extended
beyond its line of demarcation with the constituent parts of the is- 
1138         NEW ELEMENTS  OF OPERATIVE SURGERY.

chio-rectal excavations.  In other cases, and in all  those in which
its adhesions with the vagina,  bladder, prostate, or urethra, shall be
found to be too intimate to be  destroyed with facility, it will be ad-
visable to  renounce it in the same way as we should do also in any
other region.   The patient operated upon  by M. Ricord, (Journ.
Hebd., X. XL, p. 534.) died in  consequence of it;  while those of M.
V. Mott were perfectly restored.  It was a cancerous tumor of the
rectum, and not the anus itself which was successfully extirpated by
M. Torri,  (Sul. le Extirpazz.  di un Cancero, &c, Bologna, 1837.)
We cannot very clearly understand what the disease was in the pa-
tient whom M. Stirling. (Transact. Med., 1833, t. IL, p. 349,) states
that  he cured.  M.  Mandt, (Rev.  Mid., 1836, t.  III., p. 264—Klei-
nert's Repert., Jan., 1836.) in one case had a recto-vaginal fistula.  M.
Baumes, (Bull. deFAcad.  Roy. de Med., X. I., p. 936,) asserts that he
has completely succeeded with this operation.   The same remark
applies to  M. Maurin, (Rev. Med., 1831,1.1., p. 194.) In the patient of
M. Haime, the incontinence of the  faecal matters  persisted.   Of the
six patients operated upon by  me, one died of phlebitis at the expira-
tion of ten days, a  second from exhaustion on  the  seventh day, a
third with a pound of blood effused into  the upper part of the rec-
tum, while the fourth and  fifth were radically cured.   The sixth can-
not retain  his faeces, and is at the present day, (1839,) which is three
years since the operation,  in a state approaching  to marasmus.
           [CONCLUDING  REMARKS,

                        BY V.  MOTT.

  In regard to  spina bifida, to which  allusion  has been made in a
note in the last  volume, [see Supplemental Appendix, Vol. IL, p. 99,]
a remarkable case has recently presented itself  in  my practice.  Its
locality was very unusual, that is, in the lower part of the cervical
vertebrae, and upper dorsal, in a female child aged  nine  days.  The
tumor was congenital and globular,  about  one  and a half inches in
diameter, and attached by a narrow pedicle, about half an inch dia-
meter, between the spinous  processes.   It was  said to  have dimin-
ished slightly since the child's  birth, and  evidently contained a lim-
pid fluid.   There was no deficiency or defect of development in the
median line between the spinous processes, where  it was situated.
Pressure on the tumor produced no effect on  the child, which was
otherwise perfectly healthy and well formed.   No fluctuation could
be produced by pressing  the fontanelles and  tumor alternately.  It
was, however,  believed to have a communication with the cavity of
the spine, and with the consent of the parents, its extirpation was de-
termined upon.  This I accordingly did on the  following day, when
a communication, about the  size of  a crow-quill, was found  leading
into the cavity of the spinal  marrow.  The  tumor contained  the
fluid of an ordinary spina  bifida.   An elliptical incision was made 
CONCLUDING REMARKS.
1139
on each side of the tumor into the sound portion of the integuments,
and the mass  extirpated at its root.   The  lips of the wound were
closed, as in hare-lip, by two interrupted sutures, aided by adhesive
plaster.  The plaster was renewed twice in the course of ten days,
at the expiration  of which period the wound was found perfectly
healed.
  Immobility of the Lower Jaw.—This malady, as far as I know, has
never formed a distinct chapter in any  systematic work on surgery.
I therefore,  perhaps, may claim some originality for introducing it to
the notice of the profession.  The more  so,  from my having for the
last thirty years and upwards, met with many cases of this kind and
treated them successfully.  The means which I have resorted to, may
possibly  have been used by  others before my time, but I  am not
aware of the fact.   We are sure that many of the  cases we have
met with, had been abandoned by others as  altogether hopeless and
irremediable.
  All surgeons no doubt would, or  ought to think of expedients  to
relieve difficulties and  embarrassments  connected with the full and
normal functions of organs.  But as this subject has not claimed that
share of attention which its importance demands, we think  no apol-
ogy on our part need be offered  for here introducing it in a distinct
article.  And we know of no epithet more appropriate  to  the affec-
tion, than  that which  is implied by the  name  we have given to  it.
It is, in our opinion, an important surgical subject, and especially so,
as it is one which frequently is very difficult  to treat.  The difficulty
in this affection depends, according to my observation, upon three dif-
ferent causes.
  First.—The first and most frequent cause is the formation of firm
unyielding cicatrices, resembling as it  were  adventitious  ligaments,
connecting the upper and the lower jaw  bones, in such a way as ut-
terly to prevent any downward movement of the lower jaw; which
fastenings,  if they have continued for a number of years, as we have
seen in several instances, create  a positive deformity in the configu-
ration and symmetrical proportions of the features of the face.  As,
for example, in the remarkable disproportion in  the development of
the chin and the entire  lower jaw bone, as compared with the rest
of the face.   And from the long continued  fixedness of the lower
jaw bone, we find that besides this outward deformity, the front teeth
also  frequently present, especially in  the cases of long standing, an
irregularity, and also a disproportion, which is utterly un-human in ap-
pearance. *  When not  opposed to each other, they grow to  an inor-
dinate length, and exhibit a carniverous or canine aspect, as though
they were intended exclusively for tearing purposes, instead  of ful-
filling the functions of incisors.
  Second.—The second cause appears  to lie  in the  muscles them-
selves, in the form  of a  preternatural rigidity or  dynamic con-
traction, as is evident to  the  sight as well as to the touch.   Most
of the cases I  have seen and treated of this description, have been
young persons, in whom the disease  was the  result of the violent
action of mercury upon the  mouth and adjacent parts, exhibited for
some  form  of fever, for scarlatina, &c.  I  have traced these cases
to that cause, though it is difficult to understand how such an effect 
 1140         NEW ELEMENTS OF  OPERATIVE SURGERY.

 should be produced by it;  unless it is from the unwillingness  m  the
 individual to exercise the muscles of the lower jaw, while in the  en-
 gorged condition which exists in the tissues during mercurial action ;
 the muscles from this quiescent state seeming by degrees to take on
 an unnatural spastic  rigidity.  In all  the  cases  but  one which we
 have encountered, there was more or less of a normal action in  the
 pterygoid  muscles, by which a trifling lateral  movement  of  the
 lower  jaw was perceptible.  In the case in which  none of these
 movements could in any way be detected, all my efforts, which were
 varied  and very powerful, were utterly unavailing in opening  the
 mouth; as will be seen in the details farther on.
   Third.—It may be proper to enumerate a third cause.  This,  ac-
 cording to recent pathological observations, as is seen in a note in the
 text, has been found to consist in an osseous  union, by means of a
 bony plate which  extended from the coronoid process to the supe-
 rior  maxillary bone, by which the  lower jaw  became  perfectly im-
 movable.   These, we hope, are rare instances, but it is possible that
 the irremediable case  we have above alluded to, may have been ren-
 dered incurable by such an adventitious  formation.  If such a con-
 dition of things could be known at the time, probably some  sort of
 an operation might be devised to sever or exsect this bony commu-
 nication, and thereby  at once open the jaws.  In all  my cases but
 one, even though  there was not any appreciable  movement of the
 jaw downwards, I have been enabled  to ascertain by a careful ex-
 amination, that there still existed some trifling lateral motion.   As
 far as my experience has gone, I would therefore consider this as the
 best diagnostic or test for justifying the process of opening the jaws
 which  I have adopted so frequently with  success.   Indeed, I  should
 be unwilling to offer a favorable  opinion of the result of the  opera-
 tion, without this previous evidence of the natural condition  of  the
 articulating surfaces.  My  process of surgical treatment for the  re-
 lief of this distressing difficulty, will be better understood by the details
 of the  following cases ; by  which it will be found, that almost every
 case has had some peculiarity which has made it necessary  to vary
 the steps ofthe operation.    The instrument upon  which  I have  re-
 lied, after preparing the patient by the  necessary  previous incisions,
 is constructed upon the screw and lever  principle. It is one which
 I got up to meet the exigencies of the third case, without ever having
 seen or heard of any thing   of the kind.  Though  I  confess  I have
 since met in the Armamentarium  Chirurgicum of Scultetus, the figure
 of one of a similar construction.
  Case I.—The first case occurred about the year 1812, in a little
 girl.  There was extensive  exfoliation of all the alveolar margin on
 the upper jaw on both sides. The lower jaw was quite firmly fixed.
 After removing the necrosis, and waiting until the gum healed,  the
 cicatrices  were then  freely divided from within  the mouth.  Then,
 by forcibly seizing hold of  the chin and side of  the  jaw with both
 my hands, and putting my thumbs on  the  teeth  of the lower jaw
 through the opening made by the removal of the necrosis, while  the
 head was  very firmly held, I  succeeded in  depressing the lower
jaw so as to open it sufficiently wide.   The little girl was about nine
 years  old,  and of good healthy constitution,  and the disease was 
CONCLUDING REMARKS.
1141
produced by the action of mercury given for a remittent fever. She
entirely recovered the use of her jaw by the process mentioned.
  Case II.—The second case was an officer ofthe U. S. army, from
Green Bay.   His lower jaw was almost immovable from a cicatrix
extending from the last  molar tooth, to some  distance forward.  It
had been of several months' duration, and was, I think, also the re-
sult of mercurial  action.  The  cicatrix was divided with a scalpel,
and the jaw forcibly depressed at  the chin, by which means the
mouth  was opened, and the cure was perfect.
  Case III.—During the  winter  of 1828, a young man about 21
years of age, from North Carolina, called upon  me with  the lower
jaw almost immovably fixed to  the upper.   There was not the least
motion to be discovered in a  downward direction, nor was the most
powerful effort with the hand upon the chin, able in the  slightest de-
gree to alter its situation.
  He had been in this deplorable  state for between ten and eleven
years.   Unable during  that time to chew a mouthful of food, he in-
troduced all the solid aliment which passed into his stomach through
an opening on the right side, occasioned by a small aperture from an
irregularity  of the bicuspides teeth.
  On the left side, just within the  angle of the mouth, and opposite
the situation of the cuspidatus tooth, a very firm band was to be seen
and felt, reaching from  this  point, along  the alveolar ridge to the co-
ronoid  process.   It was of more than ligamentous hardness.
  Along the whole course of this  adhesion of the  cheek to the gum
of the  lower jaw, there was not the  vestige of a tooth; and he
stated that from this part a large piece of the jaw had been formerly
separated with the teeth attached  to it.  This morbid adhesion had
been several times freely divided, but no depression of the lower
jaw could be effected.  It was cut from within the mouth in different
directions, but never allowed  the least  motion to the jaw.
  From his being able to  give a little lateral motion to the lower
jaw, I felt encouraged  to hope, that some  relief  might  be afforded
him, and that  his  mouth, by some  powerful efforts, might  yet be
opened.  He consented with great cheerfulness to any operation
which I thought could be performed, to enable  him to receive food
with more satisfaction, and  restore  the power of speaking, which
was also very much impaired.   If this could be accomplished, it
would, moreover, very much improve his expression  generally, as
his face had become very much contracted and misshapen.
  Seated in a  chair, I made an  incision from the angle of the mouth
on the  left side, through the cheek, and carried it to near the edge of
the coronoid process, dividing  the firm cicatrix  within completely.
Then cut the adhesion freely from the upper and lower jaws, so as to
relieve the jaws entirely from all restraint from that cause.  A piece
of very broad tape was now conveyed between the teeth by means
of a probe and spatula, and tied some  distance below the chin.  The
head was now firmly held, and  with all the force I could exert in
the loop of this tape, not the least yielding of the  lower jaw could be
discovered.
  As  no force which  I could exert would enable me to open the
mouth, I was prepared to apply  the mechanical principle of the screw 
1142          NEW ELEMENTS  OF OPERATIVE SURGERY.

and lever.  For this purpose we had prepared the instrument already
alluded to, and which is composed of two steel plates, about three inch-
es in length.   When applied to each other they were of a wedge shape.
To the large end was attached a screw, with a broad handle, which,
when turned, caused the thin extremity of the plates to expand. (See
figure.)  This powerful combination of the lever and screw enabled
us to open the mouth completely.
  With considerable difficulty we succeeded in  insinuating this vice
between the  range of teeth on the  left  side, being careful to have
it rest along their whole course as much as possible.  It was then
expanded  by turning  the screw, and such was the report that at-
tended the yielding ofthe lower jaw, that several exclaimed that the
jaw was broken; but to me the noise was like the laceration  of lig-
aments, and not such as attends the fracture of a bone.  The  mouth
was immediately opened to a sufficient extent.
  The wound of the cheek was closed with three interrupted sutures,
aided with strips of adhesive plaster.  From the mouth being kept
constantly open for several days, by the instrument secured between
the teeth, it occasioned much strain upon the stitches, and made the
adhesive strips of material importance.
  Either the  instrument or a  soft piece of wood was placed con-
stantly between the jaws to keep the mouth sufficiently open until
the cheek had healed.  During this time he received his drinks  and
liquid nourishment  from a spoon or the spout of a tea-pot.  When in
this way they were conveyed well towards the  base of the tongue,
he was enabled to  swallow without much inconvenience.
  As  soon as  the  external wound in the cheek was healed,  the in-
strument was removed, except at night, and occasionally during the
day, and he was now permitted to move the lower jaw.  To prevent
the cheek  from adhering to the jaws internally,  pieces of sponge
were constantly interposed.  To enable the jaws to approximate, it
was necessary to remove the last molar tooth of the upper and lower
jaw of the left side.  Several of the incisors were of the most ex-
traordinary length, and required to be filed  off, before a proper use
could be made of the others.
  He gradually acquired  the power of closing the jaws, and  was
greatly delighted with the result of an operation which enabled him
to chew his food, and enjoy his meals as  other  persons, which had
 
CONCLUDING REMARKS.
1143
given proportion to his features, and the ability to converse and arti-
culate distinctly.  [See this case in  Am. Journ. Med. Sc, 1829, vol.
V., p. 106.]
  Explanation of the Figure.—aa,  the two levers bent at right an-
gles, and united to the fulcra cc,  by a joint,  d, the screw passing
through the centre  of the bar, and acting upon the angles bb, which
are notched to receive its point.
  Case IV.—A merchant  from  Louisiana, and also  the result  of
mercury.   There was not, nor had there been, any necrosis in either
jaw.  When dividing the bands of adhesion with the narrow straight
bistoury, the screw instrument, found  so  efficient in  the last case,
was passed between  the incisores,  and the mouth  readily opened.
The cure was perfect.
  Case V.—The  fifth case was that of the young lady from Massa-
chusetts, where I found it necessary  also to procure a large patch  for
the whole side of the  cheek, from the neck, by a  geno-cheiloplastic
process; previously exsecting all the  cicatrix, and unlocking the
jaw by the screw lever.  See this case in  a  note under Anaplasty,
in Vol. I., p. 706 of this work.
  Case VI.—This (1831) was an  interesting young lady from Louis-
iana, about eighteen  years old, who for six years had had the jaws
closed.  The cause was the  action of mercury.  The adhesions
were firm on each side.  They could easily be got at from within the
mouth and divided, but the jaw could be  opened only a  little way.
although a screw instrument was used on each side  instead  of in
front, as in  the previous cases.  In order  to get access, several  of
the teeth were filed or sawed off.   All efforts, however, were inef-
fectual.  Three different attempts were made at intervals of several
weeks, and each were persevered in for some time.  In no  instance
have I used half the force employed in the present case.   The last
attempt I made  almost brought  on convulsions from the pain pro-
duced, and  I only wonder that the lower jaw did  not  break.   I  re-
gret that the  knowledge of myotomy we  now possess, was  not at
that time understood ; for I am persuaded, that if I had then known
as much of the benefit of dividing or excising muscles and  tendons,
which we now have, I might  have  restored  this  interesting young
lady.  The subcutaneous division by a straight bistoury of the mas-
seter muscles, would in all probability, with a moderate amount of
force, have opened  the  mouth.—I had previously, on  several occa-
sions, divided in part this muscle, where I  was  obliged to lay open
the cheek.   All this disagreeable deformity might in  her case have
been avoided by the complete subcutaneous division of these mus-
cles.  I was grieved to  abandon this case, the only one in  which  I
had then, or have hitherto, failed in  effecting a perfect cure.
  Case VII.—This was a young  man, who when a boy eight or  ten
years before, had a necrosis and ulcerations from the operation  of
mercury.  Various attempts had been made some years antecedently
to open the  mouth, but  they all  failed.  I removed the adhesions
freely  with the probe-pointed bistoury, and with the screw-lever
readily opened the mouth to its full  extent.
  Case VIIL—An  eighth case, (also 1831,)  was a child from  the
District (now State)  of Maine,  who had had six months before, 
1144         NEW ELEMENTS OF OPERATIVE SURGERY.

scarlatina anginosa.  Considerable ulceration took place about the
cheek and gum, followed by necrosis of the upper jaw.  When the
ulcerations healed the jaw became closed.  The necrosed portion of
the bone was loose, containing several of the teeth, all of which
were  taken  away.   The  screw was then applied, and the  mouth
opened.
  Case IX.—A little girl from South Carolina.  It was the effect of
salivation and necrosis.  The adhesions were divided  within the
mouth, the instrument applied, and the jaws readily opened.
  Case X.—(Dec, 1841.) A little girl  from Dutchess County, aged
ten years.  From the free use of calomel for a supposed inflamma-
tion of the intestines, a profuse ptyalism was the consequence.  The
ulcerations which took place on the inside of the cheeks were fol-
lowed, on healing, with a perfect closure of the jaws, since the month
of Feb., 1840.  There  was  no necrosis  of either jaw bone.  After
dividing the  adhesions  on eacn siae freely, with a  straight  probe-
pointed bistoury, within the mouth, I was enabled by means of my
fingers to depress the lower jaw sufficiently  to admit one finger. The
instrument was now placed between the incisor teeth, and the mouth
opened to the full extent. This case resulted in a perfect cure.
  Cases XL, XII., XIIL, XIV., XV., XVI.—These  cases were  all
of a similar nature to the generality of the cases  above described,
and all  resulted  in a perfect  cure by the means  above employed.
One of these, (1843,) I will remark was  a fine  boy, aged twelve
years,  son of Bishop W---- of Maryland, whose jaws had been
firmly closed for  eight years.  The cause was a. fall upon his chin on
the bannister of  a staircase.  In the fall, he was received under the
chin, from which the inability to open the mouth ensued.  About a
year before I saw7 him, a ladder in falling,  struck the  anterior and
upper part of the chin,  which suddenly opened his mouth ; but after
a short time  the  rigidity returned, and  the  jaws were again closed.
There were no morbid or adventitious adhesions or bands to be found.
The masseter muscles on each side were remarkably small and hard.
The most trifling lateral motion only was  perceptible.  The lower
jaw was so closely shut that it was difficult to introduce a half dollar
between the teeth.  In this case there was  the least lateral motion I
ever saw, except in the young lady above, in whom alone I  did not
succeed by my process.  This  case had been given  up as  hopeless
by  all the surgeons whom he had consulted in different parts of the
country ; none of whom had recommended any mechanical power
to overcome the difficulty.   The case required a  great  depressing
effort upon the chin, and a small lever between the teeth, to  enable
me to introduce  the blades  of the screw-lever  between  them.  As
soon as it was barely between  them, the action of the screw readily
made room enough to place the instrument fairly between the inci-
sores.  The mouth was then sufficienly opened.  I gave  him an in-
strument, with a request that it should be used at night between  the
molares teeth, while asleep, in order to keep the mouth open.  After
a week or two, I had made  for him a small instrument on the same
principle, which  he used from time to time  for many months, in order
to continue  the  success of the treatment. In all the cases upon
which I have operated, my plan has been,  for some time after open- 
CONCLUDING  REMARKS.
1145
ing the mouth, to use  the  instrument from time to time, either be-
tween  the  molares, or between the incisores in front;  and partic-
ularly, where the instrument was not thus employed, to  introduce  a
piece of soft wood or fine piece of cork on  either side, between the
molares, at night, securing  it by a string around the neck.  During
the day I have insisted upon the practice of chewing hard crackers
or hard bread, or sea-biscuit, in order  to  initiate  the muscles into
their normal functions.
  It may be interesting to those who have  not seen these cases, for
me to state, that  it is my opinion, that where there is no lateral mo-
tion whatever perceptible, from the action of the pterygoid muscles,
then it may reasonably be  inferred that anchylosis  has taken place,
and that but little hope can be  entertained for  the success  of this
treatment.  Where there is the least lateral motion, there will  then
be the  greatest difficulty.   I may say that my last case occurred be-
tween  two  and three months since, (Nov.,  1846,) in a little girl who
was successfully treated by the mode above described.  V. Mott.]
  New York, Feb., 1847.
FINIS. 
 
INDEX.
Abdomen Bandages, i.    -    -     -    169
         Operations on, iii.    -     -    523
         Paracentesis of, iii.   -     -    523
         Parietes, Tumors of, iii.    -    540
Abdominal aorta—see Mott and Town-
    send.
[Abscess of the liver  from fracture of
    the head,  ii.    -     -    -     -    938
Abscesses, incisions for—see Incisions.
          Psoas,  puncture  for — see
            Guerin.
Actual cauteries—see Cauteries.
Acupuncture for un-united fractures, ii.    690
            See Punctures, also Ame-
               can Appendix, i.     -    675
            in the treatment of aneu-
               rism, ii.   -    -     -     63
Adhesive plasters, i.       -    -     -    127
         strips, or straps in dressing, i. 206,207
Air in the veins, precautions against, i.    229
Air-passages, special operations requir-
    ed for, iii.      ..--    464
[Albuginea, Tunica, incision of, for cure
    of Orchitis, iii.       -    -     -    759
Alimentary passages, special operations
    for, iii......485
[Alveolar Hemorrhage—see Townsend.
Alveoli—see Maxillary Sinus.
Amputation of the Limbs, ii.   -    439—662
           in general, ii.      -     -    441
            limbs entirely divided, ii.      ib.
           in cases of gangrene, con-
              gelation,  deep bruises,
              traumatic lesions, aneu-
              risms, ii.       -  _  442—447
            in fractures and luxations,
              and wounds from fire-
              arms, ii.       . -    448-452
            in various affections,  ne-
              crosis, cancer, exostosis,
              fibrous tumors,   white
              swelling,  suppuration,
              ulcers, lupus, tetanus,
              &c,ii.          -    455-457
            in cases of bite from rabid
              animals, ii.      -    -    459
            in cases of anchylosis, de-
              formities,   supernume-
              rary fingers, loss of sub-
              stance, &c., ii.   .. 46°-^
            Preliminary cautions, n.
            Counter-indications, ii.
            the  period  when  to  am-
              putate, ii.   -
            place where to amputate,
              ii.
 ib.

466

471
Amputation,  preparations,  dressings,
              &c., for, ii.     -    473—475
           in the continuity, and the
              methods, ii.    -    476—486
           in the contiguity, ii.    -   487
           Dressing and consecu-
              tive treatment, ii.    490—496
           Accidents from, ii.     496—507
           Organic changes from,
              and prognosis, ii.    507—508
           Bandages for, i.     -    -   196
[Amussat M.,  Note  on—see Cicatrices
    and Townsend.
Anal bandages, i.    -    -     -    -   176
Anaplasty, (by some  called  Auto-
             plasty,)i.      -    588-850
           by restitution of parts, par-
             tially  or wholly divid-
             ed, i.      -    -    589-595
           Transplantation, i.     599—601
           Remote flaps, on  the  Ital-
             ian method, i.     -    -   603
           Indian method of, i.     -   605
           separation  or decollement
             and glissement  or  slid-
             ing of the tissues, i.  606—609
           with  internal or  external
             incisions and  scorings,
             or both, i.   -     -     -   608
           by transportation  of a cu-
             taneous bridge, i.      -   609
           by raising  an arcade of
             integuments, i.   -    -    ib.
           by invagination, i.       -    610
           for the  cranium [Cranio-
              plasty,] i.   -     -    -     ib.
           for  the ear,  or Otoplas-
              ty, i.        -    - _  -    611
           for the  nose, or Rhino-
              plasty, i.        -     613—626
           for the  eyelids, or Blepha-
              roplasty, i.      -     627—632
           for a new cornea, or Kera-
              toplasty, i.       -    -    633
           for the lachrymal sac, i.      634
           for the  lips, or Cheiloplas-
              ty, i.       -     -    635—641
           for  the  cheek,  or Geno-
              plasty, i.       -     644-648
           for the  uvula  and velum
              palati, or  Staphyloplas-
              ty, i.       -     -     650—652
           for the larynx and trachea,
              or  Bronchoplasty, i.  654—661
           for  the  thorax,  [Pectoro-
              plasty] i.   -    -    -   662
           for  stercoral  fistulas and 
1148
INDEX.
Anaplasty—continued.
             artificial anus, [Fistula-
             plasty] i.                 664
           for  the  scrotum  and pe-
             nis,  [Scrotoplasty  and
             Penoplasty] i.          -   666
           for the urethra, or Uretro-
             plasty, i.     -     -     -   667
           for the vagina, or Elytro-
             plasty, i.     -     -     -   669
           for the  perineum,  [Peri-
             neoplasty,] i.             674
[Anaplasty as applied in the treatment
             of immobility of the low-
             er jaw by M. Serre, i.      831
           as applied to the masseter
             muscle, Note—see Mas-
             seter.
[Anchylosis,  true and  false, Note on,
    ii.         .....840
Anchylosis, i.  -    -     -     -   478, 479
    See also  Deformities.
Anchylosis, false, of the lower jaw—
    see Immobility of the  lower jaw
    and Mott.
Anchylo-glossus—see Tongue.
Anel, his method in aneurisms, ii. 93,  98—102
Aneurismal tumors,  deep-seated, diag-
             nosis of, ii.       -    -   262
           Varix — see  Mott  and
             Townsend.
[Aneurism, able Memoir on the Diag-
    nosis of, by Dr. A. Pereira, ii.   p. Ixxxi
[Aneurism  and  other  lesions of the
    heart and large  trunks, Note, ii.    xxxiv
[Aneurism, cure of, in  the temporal
    artery, by  galvano-electro punc-
    ture, by M. Petrequin, ii.   -    - lxxix
Aneurisms, substernal,  diagnosis of—
    see Substernal Aneurisms.
[Aneurisms, substernal,  Diagnosis of,
    Note on,  ii.     -                  260
[Aneurisms, account of at  Mahon, by
    Dr. Foltz, (U. S. N.,) ii.    -    - lxxvi
[Aneurisms ofthe Aorta, general prin-
    ciples of, treatment,  Note,  ii.    -   xlv
Aneurisms, general  remarks on, ii.  -     4
           Traumatic   Hemorrhages
             of heart and arteries, as
             a cause of, ii.     -    -     8
           [Tubular  Aneurisms  and
             Compression—see Mott
             and Townsend.
           Operations for the  cure of,
             various methods, con-
             consequences, &c, ii.  86—107
           — See also Dorsalis pedis,
           anterior and posterior ti-
           bial, fibular, popliteal, fem-
           oral, external and  internal
           iliac, gluteal, primitive il-
           iac,  abdominal aorta, ra-
           dial, ulnar,  brachial, axil-
           lary,  sublclavian, tempo-
           ral, occipital, facial, exter-
           nal  maxillary,   lingual,
           thyroid, vertebral, pharyn-
           geal, secondary carotid.and
           primitive carotid, intercos-
           tal, internal mammary, and
Aneurisms—continued.
            epigastric  arteries — also
            those ofthe hand and like-
            wise  the  innominata—see
            also Mott, Townsend, Gu-
            ettet, Diday, &c, ii.    118—258
Ankle — see  Malleolus  and Tendo
     Achillis.
[Ankle, amputation above the, Note on
     —see Supra-Malleolar amputation.
Ankyloblepharon—see Eyelids.
Anomalies  of arteries—see  Arteries,
     anomalous deviations of—see also
     Townsend.
Anterior tibial artery, ligature on, in
     Aneurism, ii.                      120
Antrum  highmorianum — see Maxil-
     lary Sinus.
Anus, artificial, in hernia—see Hernia,
              cure of— and Town-
               send.
     Bandages for—see Anal Bandages.
     Cancers of, iii. -    -    -1133—1138
     Fissure or fissures of, iii.  -  1108—1116
     Foreign bodies in, or  in the  rec-
      tum, iii. ---    - 1096—1098
         See also Rectum.
     Prolapsus of the,  or Prolapsus
      ani, iii.      -    -       1103—1108
Aorta, wounds of, ii.      -    -    -     9
Aponeuroses, deep-seated, their treat-
     ment, division, &c. i. -    -    -   474
Appendix, Supplemental, of  M.  Vel-
            peau, i. -     -    -    -   xliii
         [concluding American,  i. 675—850
         [supplemental to vol. ii. by P.
            S. Townsend, M. D., i. xix—xcix
Arm, amputation of, ii.    -    -    -   546
[Arm, artificial, Note,  ii.   -    -    -   550
Arm, Exsection of the  bones  of, ii.
                             672, 752—797
Arteries—see Aneurism.
[Arteries, compression of,  for hemor-
        rhage, according to  M.  Mal-
        gaigne, i.                     836
Arteries of the arm — see  Brachial or
         Humeral Artery.
      of the fore-arm—see  Fore-arm
         and Ulnar and Radial Arte-
         ries and  Hand.
      ofthe hand—see Hand.
      of the head, ii.                  219
         See also  Townsend.
      Operations on,  &c, ii.  -    -  I—4
      of the neck—see Neck.
      of the penis—see Penis.
Arteriotomy,i.     -    -      -    -   263
Artery-presser, ii.   -     -    -    -    60
Artery, Basilar, aneurism of—seeRus-
         chenberger, and Townsend.
      Brachial  or   Humeral — see
         Brachial Artery.
      Carotid—see Carotid  Arteries.
      Epigastric—see Epigastric Ar-
         tery.
       Facial—see Facial Artery.
       Innominata — see  Innominata
         Artery.
       Internal Mammary—see Mam-
         mary Artery. 
INDEX.
1149
                                     PAGE
Artery, Lingual—see Lingual  Artery.
      Occipital — see  Occipital  Ar-
        tery.
      Pelvic—see Internal Iliac.
      Pharyngeal — see   Pharyngeal
        Artery.
      Pulmonary — see   Pulmonary
        Artery.
      Radial—see Radial Artery.
      Temporal—see Temporal Artery.
      Ulnar—see Ulnar Artery.
      Vertebral—see Vertebral Artery.
Arteries, Intercostal — see  Intercostal
         Arteries.
       Thyroid—see Thyroid Arteries.
       trunks of, near the Heart—see
         Heart.
Articulations, exsections of, ii.  -   778—866
            of the ribs—see  Costo-
              Chondral,   and  Costo-
              vertebral.
            Supplementary, special
              operations for, iii.     -   428
Artificial Cataract—see Eye.
        Eyes—see Eye.
       [joints, i.     -    -    -     806,807
        pupil—see Eye.
[Astragalus, Exsection of, ii.   -     -   820
            See  Townsend, ii. -     -   762
Atresia ofthe mouth—see Lips.
Auditory apparatus, special operations
     for, iii......428
Autoplasty—see Anaplasty.
Axillary artery,  ligature on in aneu-
     rism, ii.                          203
       See also Mott and Townsend.
B
Back, myotomy of the muscles of, or
    dorsal  or rachidian myotomy—
    see Guerin.
Ball  wounds,  perforating the entire
    brain, i.   -    -    -    -    -   H7
Bandages of linen, i.     -    -    -   H7
            upper part of limbs, i.   -   177
            lower extremities, i.     -   182
        for amputation—see Amputa-
             tions.
            hernia—see Hernia Ban-
             dage.
[Bandages, suspensory,   commodious
    for scrotal tumors, hypertrophy,
    &c, with plates, i.   -    -   175—1/6
Bands, i.  -    -    -    ;    -        llb
Basilar artery, aneurism of—see  Rus-
    chenberger and Townsend.
Baths, i.   -    -    -     "             -o.
Beds, surgical, i.    -     -    -  .
Belly, lower—see Abdomen, operations

Bernd,' A., of Paris—see Townsend.
Bird-peck  punctures,  (moussetures,)
    by the lancet, i.  -     -     -     "   ^'u
Bistoury,; manner of holding and po- ^ ^
    sitions, i. -    "...   '    " .»_,  '1(y-Q
Bladder, puncture of in.  -    - 1071-J Jg
       Perineal puncture of, m. -        1073
       Rectal puncture of, m.   -     -   1U74
       Hypogastric puncture of, ui.   -     i&.
Bladder, puncture through the symphy-
        sis, iii.     -     -    -  1076—1078
       See Calculi of.
[Bladder, fungus hematodes in, iii.   -   129
Bleeding at the arm, i.    -    -    -   236
              neck, i.                 254
              foot,i.     -    -    -   258
        in various regions, i.   -    -   262
        by  moussetures,  (bird-peck
        punctures,) i.    -    -    -    ib.
Blepharoplasty, late operations in, i.  -   796
[Blepharoplasty and Blepharoplasty in
    America—see Anaplasty, i.     -   632
    —and Nsvus Maternus.
Blepharoptosis—see Eyelids.
Blistering and blisters, i.    -    - 279—282
Blood, state of that drawn from the
    veins, i.   -    -     -    -    -   261
Bones, deformities of,  from alterations
    —see  Deformities.
Bones, tumors of—see Exostoses.
Bouisson,  Prof,  of Montpellier—see
    Gluteal Artery.
Brachial, or humeral artery, ligature on,
    in aneurism, ii.           -    -   195
    See also Mott and Townsend.
[Brachial  artery, wounds of, in vene-
    section—see Mott.
Brasdor, his method in aneunsm, ii, 195, 102
    See also Mott.
Breast, extirpation of, iii.      -    -   498
Bridles—see Cicatrices, Tenotomy and
    Myotomy.
Bridles,  sub-cutaneous,  division  of,
    &c., i.    ...    -   381—396
Bronchotomy, iii    ...    -   464
Bronchoplasty—see Anaplasty.
[Buck, Gurdon, M.D.—see Knee-joint,
    &c.
[Bullen, Dr.,  his views on Polypi  of
    the Uterus, iii.        -    -   820—825
[Burns—see Anaplasty and Mutter.
Burns—see Cicatrices.
Buphthalmia—see Eye.
Bursas Mucosa,  properly Burs® Sero-
     sse, i.     ....    -  791
     See Cysts and Townsend.
Calcis, os,  exsections of, ii.    -    -   760
    See Townsend, ii.    -    -    -   762
Calculi ofthe bladder, iii.      -    -   887
Calico bandages, i.       -    -   #-   H8
Callus, exsection of, when deformed, ii.   700
       deviations of, and breaking and ^
         excision of, i.   -    -   486—488
Cambric muslin bandages, i.   -    -   118
Cancers of the eye—see Eye.
Cancer ofthe mouth—see Lips.
Cancers of the neck of the uterus, iii.    825
Cancerous  tumors,  iii.    -    -    -   HI
[Cancerous and fibrous tumors—Note
    on the discussion in the Paris Aca-
    demy,  &c, iii.   -     -     -  115—130
Caoutchouc bandages, i.   -     -    -   118
Carden,  Mr., his  treatment of enor-
    mous cicatrices from burns,  ante-
    rior to Mutter, Note, i.             801
    —see  also Mutter. 
1150
INDEX.
JCaries of the articulations of the ribs
     —see Costo-chondral and Costo-
     vertebral.
[Carnochan, J. M., M.D.—see Conge-
     nital luxations.
Carotid arteries, ligature on, in aneu-
               rism, ii.        -         231
             See    also  Mott  and
               Townsend.
             successful ligatures  on
               both trunks by Dr. El-
               lis  of Michigan—see
               Ellis.
Carotid, primitive, artery, ligature on, ii.   233
     See Mott and Ellis.
Carotid tubercle—see Vertebral artery.
[Cartilaginous tumors of the face and
     scalp—Osseous tumors ofthe dia-
     phragm, iii.     -   -     -    - 88,89
Castration, as a cure for hernia—see
     Hernia also, iii.     ...    748
Cataplasms, or poultices, i.      -    -    211
Cataract—see Eye.
[Cataract. Note on, iii.   ...    301
Catheterism and  catheters,  bougies,
     sounds, &c.,  iii.     -      1032—1071
Catheters, or sounds, i.         -    -     95
Cat-tails, (for dressing) i.       -    -    107
Caustics,  cauteries  and cauterization,
     M. Malgaigne's views, i.   -   834—837
Cauteries, actual, potential, metallic,
     &c, i.     -     -   -        294—302
Cauterization, i.                  294—302
             in the treatment of an-
               eurisms, ii.     -    -     61
[Cephalalgia—see   Scalp,  incisions
     of, i.      ....   211—213
Cerate in dressings, i.    -     -    -    202
Cesarean operation, iii.   -     -   872—881
[Cesarean operation,  Note on, and on
     tearing out the  womb, iii.      881—887
Cephalematoma, or cephalematomatous
     or sanguineous tumors ofthe cra-
     nium, iii.        ....    186
Chain-saw—see Exsection of bones.
[Chalinoplasty,  or making  a new fre-
     num  preputii by anaplasty—see
     Appen. i.
[Chassaignac, M., his views on Exsec-
     tions and Disarticulations, ii.    -    851
Cheeks,  unnatural  adhesions  of—see
     Lips, and Immobility of the Jaw
     and Mott.
Cheiloplasty—see Anaplasty, also Mott.
[Cheiloplastic operation by  Dr. Mott,
     Note, i......648
[Cheiloplasty and Genoplasty—see Ge-
     nocheiloplasty and Mott.
[Cheiloplasty for cancerous lips, Note, i.    789
[Cheiloplasty, views of M. Serre, i.  -    819
Chest, operations on, iii.        -    -    498
      tumors of, iii.                     ib.
Chest-sound, i.                          95
Chin bandages, i.     -   -     -    -    159
[Chopart, Note on his process for Dis-
     articulation of the Tarsus, ii.    -    588
Cicatrices, morbid,  from burns, &c,
     treatment, i.    -    -     -   377—380
     See also Mutter and Carden.
 [Cicatrices of wounds and arteries, by
     Amussat, Note, ii.    -    -    -   416
 Circular bandages, i.     -    -    -   139
 Clavicle, exsection of, ii.  -    -   755—809
     See Mott, ii.                       N94
     Townsend, ii.        ...   757
 [Clavicle, Mott's case of exsection of, ii.   809
 [Clavicle, particular case of fracture of,
     ii.......858
 Clitoris—see Vulva.
 [Close cavities—see  Cysts—M.  Vel-
     peau's views thereon, iii,   -    -   101
 Club-foot, or Pes, or Talapes Equinus
     —see  Sub-cutaneous surgery of
     tendons and muscles, also Appen-
     dix, i.     .....784
 Coccyx, Exsection of, and ofthe point
     of the Sacrum, ii.    -    -    -   741
 Collutories,  (Eye-washes,) i.            221
 [Commissure of the lips, anaplasty of,
     by M. Serre, i.  -     -     -     -   825
 Complex incisions—see Incisions.
 Compound incisions—see Incisions.
 Compresses, i.  -     -     -     -     -414
 Compression on arteries,  ii.     -     15—33
 [Concussion from fracture of the cra-
     nium, Note, ii.   ....   930
 Condyles of the femur, exsection of, ii.   795
 [Congenital  luxation  of the head of
     both  femurs—as first accurately
     described by Dr. Carnochan of
     New   York, (now  of Florida,)
     with plates, A7o<e, ii.  -    -     -   86
 Congenital hydrocele—see Hydrocele.
           luxations,   sub-cutaneous
             sections for—see Guerin.
 [Conservative surgery to  save the limb
     from amputation, Note,  ii.  -     -   653
 Containing bandages, i.                 138
[Contraction of the legs—see Softening
     of the Brain, Note.
[Contraction of the limbs in cerebral
     hemorrhage, Note, ii.  -     -     - xxix
Corectomy  for  artificial pupil—see
     Eye.
Coredialysis  for  artificial pupil—see
     Eye.
Coretomy for artificial pupil—see Eye.
Cornea—see Keratroplasty.
[Corns, operations for, i.   -    -    359—363
 [Costo chondral, and costo-vertebral ar-
     ticulation, Note on caries of, ii.    -   949
 [Cotton for dressing, i.    -    -     -   107
 Couching or depression in Cataract—
     see Eye.
 [Coxo-femoral amputation—see Thigh,
     Disarticulation of.
 Cranium,  exsection of the bones of, ii.   707
 [Cranium, fractures of, Note on, ii,   -   931
 Cranioplasty—see Anaplasty  for  the
     Cranium.
 Cranium or head bandages, i.   -    -   153
 Cranium,  sanguineous tumors of—see
     Cephalematoma.
 Cricoidean  laryngotomy — see Bron-
     chotomy.
 Croup—see Bronchotomy.
 Crural hernia—see Hernia.
 Crushing, or ecrasement of arteries for
     arresting hemorrhage, ii.   -     -   62 
INDEX.
1151
                                     PAGE
Cruveilhier, his opinions on fibrous and
    cancerous tumors, iii. -    -    -   116
Cupping, i.     -     -    -    -   273—275
Cushions in dressing, i.                 130
Cutting instruments for operations, i.   327
Cysts, abdominal—see Abdomen, ope-
       rations  on.
     Incisions for—see Incisions.
     properly so called, iii.               56
     Sebaceous, iii.                      ib.
[Cysts, sebaceous, Note on a remarkable
       case, with plates, iii.    -    -    60
Cysts, hematic,  iii.                      64
[Cysts, Note on the treatment of, iii. -    74
     Serous or mucous, (bursse muco-
       sa so called,) iii.  -    -    -    76
     Synovial, (nodus-ganglions,) iii.    83
     [Note on  crushing as  the  true
       treatment, iii.    -    -    -    88
     [Note on Ganglionic, Serous  and
       Mucous Cysts, and Iodine In-
       jections, and on Close Cavities,
       and M. Velpeau's views there-
       on, and on Iodine injections, iii. 89—91

                    D

[Darling, Wm., M. D., of New York—
          his tables of the muscles  of
           the human body in French
           and English, i.    -  xix—xxiv
           his description  of the pro-
           cess  of  cutting  down on
            the median nerve, for its
           section or excision, ii.   -   434
          his  account  of anomalous
            arterial  trunks—see Ano-
            malies of Arteries.
Deep-seated ligaments  and  aponeuro-
     ses—see Ligaments and Aponeu-
     roses.
Definition of Operative Surgery, i.   -^     1
Deformities, i.  -     -     -   >  -   377—850
         —See also  Cicatrices,  Te-
         notomy,  Myotomy,   Deep-
         seated ligaments and Aponeu-
         roses,  Anaplasty,  Anchylo-
         ses, Supplementary Articula-
         tions, Callus, Discussion on
         Tenotomy, New  Operations
         in Tenotomy  and  Myotomy,
         General remarks on Myoto-
         my and Anaplasty in Amer-
         ica, Strabismus and Anaplas-
         ty in  all its divisions and va-
         rieties—all in Vol. I.
 Dental nerve, superior, ii. -    -     -    424
              inferior, ii.  -     -     -    *"^
 Deposits  or abscesses, how to open-
     see Incisions.
 [Depression  in injuries  of  the brain,
     Note on—see Frontal Bone.
 Depression or couching in  cataract-
     see Eye.
 Dextrine-see Glutinous, Starch, and
     Dextrine  Bandages, and  Van Bu-

 r Dextrine bandages, review of the mer-
     its of and of M. Seutm's process
     with the same, u.    -    - lxvi—lxxiu
[Diagnosis  of substernal  aneurisms,
    Note on—see  Substernal Aneu-
    rism, and Townsend.
[Diagnosis of fractures by  the  stetho-
    scope, Note on, ii.     -    -    -   667
Diapalm—see Vigo.
[Diaphragm,  Note  on osseous plate in
    the, Si.    -    -    -    -      88,416
[Diday, M., Note on his views on An-
    eurisms of the  Innominata, ii.  263—274
Dilatation of  the urethra, and dilating
    catheterism—see Catheterism.
Dilatation, abnormal, ofthe urethra, iii.  1071
Director, generally called in French a
    grooved  or canulated sound,  or
    conductor, i.    -     -    -    -    97
Disarticulations and exsections in ge-
    neral, ii.        ....   851
[Discussion,  Note  on, in  the Royal
    Academy of Medicine  of Paris, on
    Tenotomy, and especially on Teno-
    tomy as  applied to the tendons of
    the fingers, i.         -    -    489,490
[Diseases that might be relieved by sub-
    cutaneous operations—see  Hunter
    and Guerin.
LDislocations  of the Ankle-joint,  and
    tenotomy applied  to the treatment
    thereof—see Tendo Achillis.
[Dislocation of the Thumb  with wound
    —see Thumb.
L Distal  operation  for  aneurism of the
    innominata—see Mott, Townsend,
    Diday and Guettet.
Divided compresses, i.     -    -    -   114
Dividing bandages, i.      -    -    -   163
Division of the work, i.    -    -    -     1
[Dorsal or  rachidian myotomy,  Note
    on, of M. Gu6rin, i.       -    760—776
Dorsalis pedis artery, ligature on, in
    aneurism, ii.    -     -    -    -   118
Dossils (or bourdonnets) of lint, i.   -   103
    See also Rolls of lint.
Douches, i.     -    -     -    -    -   227
Drains—see Issues, Setons, Cauteries
         and Caustics.
       accidents from, i.   -             292
Dressings  saturated  with various  li-
    quids, i.        ....   215
 Dressing of wounds—see  Wounds.
 Dry linen in dressing, i.       -     -   112
 [Dublin Surgeons, their improved mode
     of treating aneurisms by compres-
     sion—see Townsend.
 [Dubovitsky, Professor, his account of
     the division of the tendons of the
     fingers in his  case, i.       -        776
     See also discussion in the Royal
     Academy  of  Medicine of Paris,
     and also  Dorsal  and  Rachidian
     Myotomy and Guerin.
 Dystochia, or difficult parturition, iii.    872
E
Ear—see Auditory apparatus.
Ear-bandages, i.     ....
[Ear,  hemorrhage from—see  Petrous
    Bone.
Ear, external—see Auditory apparatus.
163 
1152
INDEX.
Ear, internal—see Auditory apparatus.
    perforation or boring of, i.       -   313
Ecrasement, or crushing of arteries—
    see Crushing.
Ectropion—see Eyelids.
[Elbow, exsection of, by Prof. Syme, i.   807
                       Dr. Buck, i.     808
        ligature on arteries of, in aneu-
          rism,  ii.        ...   189
        exsection of, ii.   -    -    -   789
        See  Starch  bandages   after
        such exsections, Townsenu, ii.   792
        partial exsection of, ii.       -   795
Elbow-joint,  exsection of—see Elbow,
    exsection of.
Electro-puncture,  or  Galvano-punc-
    ture, i.    -     -     -    -    -   676
Elephantiasis in the  genital organs, iii.   715
Elephantine tumors,  iii.                  48
[Elephantine tumors, Note on, iii.    -    49
[Ellis, Dr., of Michigan, his success-
    ful ligature on both carotid trunks,
    ii.   -----    -   377
Elytroplasty—see Anaplasty.
Embrocations, i.     -     -    -    -   220
Empyema—see Thorax.
Empyesis—see Eye.
Encephalocele, operations for, iii.    -   178
[Encephaloidal   tumors,   congenital,
    Note on, iii.     -                   130
Encysted hydrocele—see Hydrocele.
Enemata, i.    -     -     -    -    -   224
English lint, i.       -     -    -    -   106
[Enterotomy—see Townsend.
Entropion—see Eyelids.
Eperon, or spur—see Hernia.
Epigastric artery, ligature on, ii.      -   282
Epiplocele—see Hernia.
Epiploon—see Hernia.
Epiploon, plugs of—see Hernia.
[Episcoplasty, or artificial occlusion of
    the vagina, i.         ...   805
Epistaxis—see Olfactory apparatus.
[Erysipelas,  new and successful treat-
    ment of, by Prof. Velpeau, i.    67, &o.
[Erysipelas, treatment of, by nitrate of
    silver, i......703
Eustachian tube—see  Auditory  appa-
    ratus.
Eversion ofthe mouth or lips—see Lips.
        of the uterus—see Reversion
          of Uterus.
        of the vagina—see Reversion
          of Vagina.
Exorbitism of the eye—see Eye.
Exostoses,  or Tumors of  the bones,
    iii.        "     *    "    :   131—143
Exsections and disarticulations in  ge-
    neral, ii.'        ....   851
Exsection,  or excision of bones,  ex-
    tra-articular,  or in the continui-
    ty, ii......664
Exsection of the bones ofthe pelvis, ii.   744
External iliac—see Mott and  Town-
    send.
External iliac, ligature on, in aneurism,
    ii.   -    -     -     -    -    -   147
[External  iliac,  ligature on, by Mr.
    Liston, his statement, ii.    -   p. xxxix
Extirpation of the uterus—see Uterus,
     extirpation of.
Extraction in cataract—see Eye.
Extremities, lower—see Bandages for.
Eye bandages, i.     -     -     -    -   156
Eyelids, special operations for, iii.    -   232
        See Levator Palpebral.
[Eye,  action of the oblique muscles,
     Note on, ii.      -    -     -   p. xxxiii
Eye, globe of, special operation for, iii. 254—303
Face-bandages, i.    -     -     -    -   156
[Face, myotomy of the muscles of, i.     680
      See also Levator Palpebral.
Face, operations for diseases in the, iii.   194
Facial artery, ligature on, ii. *  -    -   223
Facial nerve, its trunk and  branches,
     temporo-facial, and cervico-facial,
     ii.   -     -      -    -    -    426,427
Falsejoints—see Articulations, Supple-
     mentary, also Shoulder.
Fanons, i......129
[Fascia palmaris,  contraction of, Note
     on—see Hawkins.
[Fascia palmaris,  aponeurotomy for,
     Note on—see Hawkins.
Fauces, posterior,  special  operations
     for, iii.    -     -     -     -  377-400
Femoral artery,  ligature on  in  aneu-
           rism, ii.  -    -     -    -   135
       See also Aneurisms, Mott and
           Townsend.
       Hernia—see Hernia.
       Hernia, operation for, its com-
           plication with  foreign bo-
           dies—Cases of Drs. Mott
           and Proudfoot, iii.  -    -   691
       Nerve, ii.                        433
[Femur, compound fracture  of, by Dr.
     Mott, ii......866
Femur, exsection of, ii.   -     -  682—771
       See also Townsend, ii.   -    -   777
       Exsection of the head of, ii.   -   845
[Femur, exsection  of the head of, by
     Dr. Batchelder, ii.     -     -    -   p. 1
Fibrous tumors, iii.  -     -     -    -   108
        See  also   Cruveilhier,   and
         Cancerous and Fibrous Tu-
         mors.
Fibular artery, ligature on in wounds,
     &c., ii......127
Filasse or tow, i.     -    -     -    -   106
Filet of the tongue—see Tongue.
[Fingers, contraction of, Note on—see
     Hawkins.
[Fingers, tenotomy and myotomy  for
     contractions   of,  Note on — see
     Hawkins.
[Fingers, section of the flexor longus
     pollicis, Note on, i.   -    -     -   779
Fingers, amputation of, and the meth-
     od, ii.     -     -    -    -   510—521
Fissure of the anus—see  Anus,  fis-
     sures of.
Fistula in ano, or  fistulas of the anus,
     iii......1116—1133
Fistulas of the stomach, iii.     -    -   541
        Vesico-vaginal, iii.     -    -   848
        Recto-vaginal, iii. -     -    -   861
        Entero-vaginal, iii.     -    -   864 
INDEX.
1153
344

786
 [Fistulaplasty—see Anaplasty.
 Fistula lachrymalis — see Lachrymal
     Passages.
 Fistulas, urinary—see Urinary Fistulas.
 Flaps, (lambeaux,)—see Incisions, i, -
 [Flexor longus pollicis digitorum pedis
     muscle, its  section, i. -
 [Foetus, debris of,  M. Velpeau's cele-
     brated diagnosis  of, Note  on, iii. 759—764
 Folded compresses, i.     -    -     -    115
 Fomentations, i.    -    -    -     -   220
 Foot,  disarticulation  of, and  the pro-
     cesses compared, ii.   -    -     -   592
 Foot, exsection of the bones  of, ii. 677—760
                              and 813—824
 Foot-board, i......133
 Forceps,  dressing and artery, or dis-
     secting, i.  -     -    -    -     90—91
 Fore-arm, amputation of, ii.    -     -   538
          Ligature on arteries of, ii.  -   185
          See also Arteries, Bleeding,
             Varicose  Aneurism,  and
             Aneurismal Varix, &c.
          Exsection  of the bones of,
             ii.  -     -    -   670—740, 795
 Foreign bodies  in various regions of
     the body, iii.     -    -    -   151—172
 Form of incisions—see Incisions.
 [Fossa, nasal, calculi in, Note on, iii.  -   416
             See Olfactory Apparatus,
               and Fauces, Posterior.
'[Fracture cot improved, by Dr. Foltz,
     (U. S. N.,) ii.    -    -    -     -    xc
 [Fracture of the os  petrosum of the
     temporal bone, Note on—see  Pe-
     trous Bone.
 Fractures, bandages for all the  varieties
     of, i......182—199
 [Fractures, diagnosis of at the base of
     the skull, by Laugier, Note, ii.
 Fractures, non-consolidated—see Un-
     united Fractures.
 [Fractures,  effects  of utero-geslation
     in, Note on, ii.  -
 [Fractures  ununited,  Acupunctura-
     tion for—see Acupuncturation.
 [Fractures of the leg, ankle, and mal-
     leoli,  Note on, tenotomy  applied
     to  their treatment — see Tendo
     Achillis.
 [Fracture of leg,  with deformed union,
     and exsection of the same—see
     Townsend.
 [Fractures of the clavicle,  new treat-
     ment  for, by M.  Gue"rin,  ii.
 Frenum preputii penis—see Penis, dis-
     eases  of.
[Frontal bone, or  os  frontis,  fracture
     of, with depression, Note on,  ii. -
Frontal nerve, operations on, ii. -
[Frontal sinus, Note on Polypi in, iii. -
Fumigations, i. -
Fungous tumors of the cranium,  ope-
    rations for, iii.   -
G
Galvano-puncture—see  Electro-punc-
    ture.
                        73
lxii
685
935
421
416
221

178
PAGE

  90

 436
[Ganglionic tumors, or cysts, Note on,
    iii.        .....
[Ganglionic transformations, Note on,
 Gangrene—see Amputation.
         in Hernia—see Herniotomy.
 Gargles, i.      -
 [Gastrotomy—see Townsend.
 Gateaux, or layers of lint, i.
 Generation, organs of, in man, iii.
 Genital organs, foreign bodies in, iii.
               bandages for, i.
 [Geno-cheiloplasty,  early  operations
    in, by  Mr. Liston, i.        -    -
 [Geno-cheiloplasty, or anaplasty of the
    cheek and lips—see Mott.
 [Genoplasty by M. Serre, Note on, i.
    See also Anaplasty.
 Globe of the eye—see Eye.
 Gluteal artery, ligature on, in aneu-
       rism, ii. -     -       -  -
    See also Mott and Townsend, and
       Bouisson.
 Glutinous bandages,  i.
    See also Van Buren.
 Goitre,  or Bronchocele, proposed cure
    of, by subcutaneous ligatures, i.
 [Guerin, M., on optical strabismus, dor-
    sal and rachidian myotomy, Note
    on, &c., i.     -     -     -     701—792
[Guettet, M., on aneurism of the inno-
    minata, Note on, ii.        -    -   263
221

101
702
803
171

799
830
160
122
834
H
[Ham-strings, tenotomy or division of, i.
Hand,  arteries  of,  ligature  on,   in
    wounds, &c., ii.     -    -    182-
    See Aneurisms.
Hand, exsection of the bones of, ii. 670-
[Hare-lip, anaplasty applied to, i.
    See also Mott, ib.
Head, arteries of—see Arteries of head.
      trephining of—see Trephining
        and Townsend, ii.    -    -
[Head, injuries of,  ii.      -
[Head, wounds of, statistical table of,
    ii.    -    -
Head, special operations on, iii.
[Heart, aneurisms  of the large trunks
    near  the, Note on—see Mott and
    Townsend.
Heart, wounds of, ii.       -
[Heart, rupture  of—see  Mott and
    Townsend.
Hematic tumors, iii.       -
Hematocele, iii.     -
Hemorrhages—see Aneurisms.
            traumatic—see Aneurisms.
[Hemorrhagic diathesis—see  Town-
    send, see also Leg.
[Hemorrhage from the ear, Note—see
    Petrous bone.
Hemorrhoids and hemorrhoidal  tu-
    mors, iii.       ....
Hernia, description and anatomy  of,
          and operations for, iii.
        radical cure of, iii.
        strangulated, iii.      -
        obstructed, iii.
 782

-184

-746
 800
930
 ib.

942
172
 50
741
1099

 542
 547
 560
  ib. 
1154
INDEX.
                                      PAGE
Hernia,  incarcerated, iii.       -     -    560
         various  means  of reduction
           of, iii.   -    -    -   560—580
         inguinal, iii.     ...    650
         irreducible inguinal, iii.     -     ib.
         crural, iii.      ...    681
         umbilical, iii.    ...    692
         ventral,  &c, iii.       -     -    698
[Hernia, diaphragmatic, iii.     -    701, 702
[Hernia, internal, iii.                     ib.
Herniotomy, or kelotomy, iii.        -    580
    See Hernia.
Hip-joint,  amputation at—see Mott,
    also Coxo-femoral amputation.
[Hip-joint, position for  the treatment
    of, Note, ii.    -     -    -    -   p. Iiii
Humerus, exsection of—see Arm, also
    Townsend, ii.       ...    759
[Humerus, exsections of, and  of the
    humero-cubital  articulation  and
    scapula, Note, ii.     ...    759
Humero-cubital—see Humerus.
Hydrocele, iii.       -    -    -#   702—741
Hydrocephalus, operations for, iii.    -    182
Hydrophthalmia—see Eye.
Hyoid—see Sub-hyoid  and submaxil-
    lary Gland.
Hypertrophy of the eye—see  Orbitar
               Cavity.
            of the mouth—see Lips.
Hypogastric, or internal iliac, or pelvic
    artery—see Internal Iliac.
Hypopyon—*see Eye.
Hypospadias, iii.    ....   1082
[Hypospadias, Note on, iii.      -     -   1085

                    I

 Ileum,  perforation of—see Townsend.
 Immobility of the jaw,  Note on, by
    Dr.  Mott,  and plate, iii.    -     -   1138
Imperforation of the vulva, or imperfo-
               rate vulva,  iii.       -    785
             of the rectum, or imper-
               forate rectum, iii. 1085—1093
[Incisions  of the scalp,  Note on—see
    Scalp.
Index, general, to the three vols., iii.     1147
Infra-orbitar nerve, ii.    -    -     -    423
Injections, i.   -    -    -    -     -    222
Innominata artery,  ligature on the
    trunk of, in aneurism, ii.  -     -    252
    See also Mott, Townsend, Guettet
    and Diday.
Instruments required for dressing in
    minor operations, i.     -     -     -   90
Intercostal arteries, ligature on, ii.    -    281
                  wounding of, iii.      518
Internal ear—see  Auditory apparatus.
Internal iliac,  ligature  on, in  aneu-
    rism, ii.                            156
    See also Mott and Townsend.
[Intussusceptio—see Townsend.
Invaginated integuments, plugs  of—
    see Hernia.
Inversion ofthe vagina—see Reversion
    ofthe Vagina.
[Iodine  injections in  various cavities
    and cysts, Note, iii.                   90
    See also Hydrocele  and Hernia.
Iris and tremulus iridis—see Eye.
Irrigations in dressings, i.       -     -   216
Ischiatic artery—see Townsend.
Ischium,  exsection of tuberosity  of
    the, ii......742
Issues, i......285

                    J

Jaw, exsection of lower, ii.     -     -   712
     immobility ofthe lower—see Mott
        and Immobility ofthe Jaw.
[Jaw, lower, particular case of fracture
    of, Note on—see Townsend.
 Jaw, lower, exsection of,  Note  on, ii.   857
 Jaw, lower and upper, cases of Mott's
    exsections of the jaws, ii.  -   882—915
Jaw, upper, exsection of, ii.     -     -   728
[Joints—see False Joints, and  Shoul-
    der, false joints of.
[Joints, artificial—see Artificial  Joints.
Joints, exsection of—see Articulations,
    exsections of.
[Joints, subcutaneous, incision of, Note
    on,i.      -----   786
[Jugular vein,  right internal, rupture
    of, by an abscess, Note on,  ii.    -   413
[Jugular vein, perforation of, ii.     -   415

                    K

[Kelotomy, sub-cutaneous, as applied
    to hernia, Note on, i.  -     -     -   779
Keratonyxis in cataract—see Eye.
Keratotomy—see Eye.
Keratroplasty—see Anaplasty, also ii. p. xxviii
Kidney, calculi in, iii.     ...   1019
Kneading or massage, i.   -     -     -   277
Knee-joint, amputation of, ii.   -     -   620
[Knee-joint, amputation of, Note on, ii.   627
Knee-joint, exsection of, ii.     -     -   826
          See Townsend, ii.   -     -   832
[Knee-joint, exsection of the  entire,
    by Dr. Buck, i.       -     -     -   809
      and ii.,  with plates,      -     -   833

                    L

Lachrymal glands—see Orbit.
Lachrymal passages, special operations

Lachrymal tumors — see  Lachrymal
    Passages and Orbit.
Laryngotomy—see Bronchotomy.
Laryngo-tracheotomy— see Bronchot-
    omy.
[Laryngotomy for foreign bodies, croup,
    &c., Note on, iii.      ...   478
Larynx,  catheterism of, iii.     -     -   484
        Exsection of, ii.   -     -     -   735
Leeches, i.     -    _-     -     -   264—270
Leg, amputation of, ii.     -     -     -   603
[Leg, amputation of, followed by liga-
    ture on the external iliac and fem-
    oral arteries  for hemorrhage, ii.  -    616
Leg, exsection of the bones of,  ii.    677, 763
[Levator palpebral  muscle, myotomy
    of, i......-   757
Ligaments, deep-seated, their surgical
    treatment, division, &c., L  -     -   471 
INDEX.
1155
Ligature in  mass,  how to  apply it,
    iii.   -    -    -    -     -    143—150
[Ligatures on important arterial trunks,
    Note, ii.                          lxxiii
Ligatures on  arteries, in the treatment
    of  Anuerisms, various  kinds of
    ligatures and the processes, ii.    66—82
[Ligatures, M. Malgaigne's views on, i.   837
Limbs, lower—see Bandages  for.
Linen in dressing, i.  -     -     -     -   111
      bandages, i.   -     -     -     -   117
Lingual artery, ligature on, in aneu-
    rism, ii.                            224
Liniments, i.    -     -     -     -     -   219
Lipoma,  lipomatous  or fatty tumors,
    loupes or wens, iii.   -     -     -    36
[Lipomas, Note on, and on lipomatous
    or fatty tumors, iii.    ...    48
Lips,  bandages for, i.      ...   159
    See also  Commissure of the Lips,
      and Cheiloplasty, and Mott.
[Lips, restoration of the upper lip by
    anaplasty, by M. Serre, i.  -     -   827
Lips, special operations for, iii.  -    329—354
[Liston, M., his anaplastic operations, i.   626
Lithotomy, iii.  -                   895—978
           Perineal or infra-pubic, iii.    ib.
           Lower operation, iii     -    ib.
           Lateral or cystotomy, iii. -    ib.
           Little operation, iii. -     -    ib.
           Median lithotomy, iii.     -    ib.
           Oblique, or lateralized ope-
             ration, iii.                  ib.
           Transverse,  Bi-lateral  or
             Bi-oblique, iii.     -     -    ii.
           Quadrilateral, iii.    -     -    ib.
           Recto-vesical, iii.              ib.
           Hypogastric, iii,     -    -    ib.
           In women, iii.                ib.
[Lithotomy and  Lithotrity,  Note on,
    iii.     ....     1025—1031
Lithotrity,  iii.   -    -    -      978—1019
[Liver,  abscesses of—see Abscess of
    Liver.
Liver, tumors of, and effusions in, and
    operations for, iii.     ...   534
Lobe of the ear—see Auditory Appara-
    tus.
Lotions, i.      -----   220
Lymphatic system, ii.     ...   419
           Tumors, iii.   -     -    -      1
[Lymphatic tumors, Note on, iii.     -      9
Luxations  of the clavicle,   bandages
    for.i.......185

                    M
[Malgaigne, M., his objections to dorsal
             myotomy, i. -    -    -   768
           See also Harelip, &c.
[Malleolar amputation—see Supra-Mal-
    leolar  amputation.
Malleolus,  fractures of— see Tendo
    Achillis.
Mammary  artery, internal, ligature on,
    y.......^H1
Mask,'or mask bandage, i.     -     -    160
Massage—see Kneading.
[Masseter muscle, division ot, i. -     -   £>l.7
   See supplemental appendix to vol. u.    xix
Mastoid cells, perforation of—see Audi-
    tory apparatus.
[Matico, as a remedy for hemorrhage—
    see Ruschenberger.
Maxillary sinus, special operatoins for,
    iii.    -     -    -    -     -   421—428
Meatus exjernus auditorius—see Audi-
    tory apparatus.
Meches or tents, i.   -    -     -     -    104
 [Median nerve—see Mott and Darling.
 Mediastinal tumors, Note on, iii.     -     88
Mehceromatous or melicerous  tumors,
    operations for, iii.    -     -     -    179
Metacarpus, amputation of, ii.   -     -    522
Metacarpus, disarticulation ofthe bones
    of separately, ii. -    -     -     -    782
Metatarsus, amputation of, ii.   -     -    573
[Metatarsal bones, amputation of, Note
    on, ii......577
Metatarsus, disarticulation of, ii.     -    578
           Exsection of the first bone
             of, ii.   -    -     -     -    813
[Metopoplasty, or anaplasty of the fore-
    head by Dr. John Watson, i.     -    711
[Mettauer, Dr., of Virginia,  his  case
    of penoplasty, i.      ...    805
Milky cataract—see Eye.
Minor surgery, art of dressing, instru-
    ments, lint, compresses,  bandages,
    plasters,  &c, &c, i. -     -     88—233
Mons veneris—see Vulva
Morbid cicatrices—see Cicatrices.
Mott, Valentine,  M.D.,  Professor,  &c.
    His Preface to vol. i., containing his
      letter to Prof. Velpeau, and Prof.
      V.'s reply, and Dr. Moti's sub-
      sequent remarks on exsections
      of the jaws, i.      -     -     -   p. ix
    Cheiloplastic operation,  i.   -     -    648
    Process for the cure of N«vi, i.  -    703
    Early operations in  geno-cheilo-
      plasty, i.     -    -     -     706,707
    Objections to  certain processes in
      hare-lip, i.                   -    800
    Views on  cancerous degeneres-
      cence, in the buccal lining ofthe
      lips in cheiloplasty, i.    -     -    821
    Case of anaplasty in the treatment
      of immobility of the jaw, i.    -    831
    Treatment of traumatic lesions of
      the large arterial trunks—direct
      compression,  ligature, &c, ii.      30
    Treatment of wounds of the arte-
      ries of the foot, ii.       -    -    32
    Case of rupture of the heart,  ii.  -     112
    Remarks on Aneurisms, with his
       cases and plates, ii.     -   283—365
    On exsection of the median nerve,
       ii.       -----    434
     His first case of  amputation at the
       hip-joint, ii.        ...    650
    Cases of ununited fracture, ii.   -    697
    Case of  compound fracture of the
       os femoris, ii.      ...    866
    Cases of exsection of the upper
       and lower jaw, with plates—his
       letter to Mr. Liston, &c., ii.  882—915
    Case of spina bifida, ii.     -    -    950
    On erectile tumors, ii.     -    -    990 
1156
INDEX.
                                      PAGE
Mott—continued.
     Case of extirpation of the parotid,
       with plate, iii.      ...   451
     Complication of foreign bodies in
       the operation of femoral hernia,
       iii......691
     Concluding remarks to vol. iii.     1138
     Another case of spina bifida, iii.     1138
     Cases of immobility of the lower
       jaw, iii.      -     -    -     -  1139
Mouth, special operations on—see lips.
[Mouth, restoration of the entire mouth
     by anaplasty, by M. Serre, i.     -   828
Mouth, tumors of,  special  operations
     for, iii......367
     See also Lips.
Moxa, i.......299
     See also Actual Cauteries.
[Muscles, complete table of  all the, by
     Dr. Darling—see Darling.
[Mutter, Professor, his anaplastic pro-
     cesses, i.  -    -    -    -   652—697
[Myotomy,  or section or  division of
     the muscles—see  Division of the
     Muscles of the Face, i.    -     -   680
     Also  Levator Palpebral, Dorsal or
     Rachidian Myotomy, &c, see also
     Subcutaneous Surgery.
[Myotomy and anaplasty, general re-
     marks on tenotomy, myotomy, and
     anaplasty in America, i.   -     -   517

                    N
[Naevus maternus, blepharoplasty for, i.   703
     See also Mott, ib.
Nail, diseases of, and operations for nail
     in the flesh, i.  -    -    -   359—375
Neck, arteries of, ligature on, in aneu-
     rism,  ii.        -     -    -     r   224
Neck, operations on, iii.             -   443
[Neck of the thigh-bone, fractures of,
     ii.   -    -    -     -    -     -   859
Neck of the uterus— see Cancers of the
     neck of the uterus.
Needles, i......99
Nephrotomy—see Kidney.
Nerves ofthe cranium, face, neck and
     extremities, ii.       -    -    421—438
Nervous system, and operations on the
     nerves,  ii.      ...    420—438
[Neuralgia, surgical treatment of, ii. 434, 435
Neuromas, or neuromatic tumors, iii.      24
Nippers—see Exsection of bones.
Nitrate acid of mercury, i.               295
[Non-consolidated fractures—see Frac-
     tures, ununited.
Nose bandages, i.   -     -    -     -   158
Nose,  special operations  for  diseases
     of, iii......194
Nymph®, or labia minora—see Vulva.

                    O
Occipital artery, ligature on, in wounds,
     &c., ii......223
[ffisophagotomy, Note  on, iii.  -     -   496
Oesophagus,  catheterism of—see  Ali-
     mentary passages.
(Esophagus,  contraction of—see Ali-
     mentary passages.
ffisophagus, foreign bodies in—see Ali-
     mentary passages.
Ointment, or cerate, i.     -     -     -   113
[Olecranon, exsection of, Note on, ii.     749
Olfactory apparatus, special operations
     for, iii.     -    -    -       400—421
Onyx—see Eye.
Operations,  nature, classification, me-
     thods, precautions, &c. in, i.     - 2—62
Orbit,  or orbitar cavity, special opera-
     tions for, iii.     ....   251
[Osteo-sarcoma, successful  exsection
     of the lower jaw for,  by Dr. J. M.
     Simms  of Alabama, ii.     -      p. xxiv
[Osteo-sarcoma, exsection of a portion
     of the lower jaw for, by Dr. Mott;
     case drawn up  by P.  S. Town-
     send, ii.       .... xlviii
[Osteo-sarcoma, exsection of  do. for,
     by Dr. Batchelder, ii.       -     -  xlix
Osteotomas—see Exsection of Bones.
Otoplasty—see  Anaplasty.
Otoraphy—see  Auditory apparatus.
Ovariotomy, iii.     ...   535—540
[Ovariotomy, Note on, iii.       -     -  540
Ovarium, cysts and tumors of, and of
     the lower belly, iii.    -     -     -  535
Palatoplasty—see Anaplasty.
Palpebrae—see Eyelids.
[Pancoast's  operations  on  club-foot,
    rhinoplasty, cheiloplasty, &c., Note
    on, i.     -    -    -    -   684—696
Paracentesis of the thorax—see Thorax
    and Empyema, and Townsend.
Paraphymosis—see Penis, diseases of.
Parotid and  parotid tumors, iii.      -    443
    See Mott, iii.        ...    451
Parotid gland, fistulas of—see Salivary
    Fistulas.
Parturition,  difficult—see Dystochia.
[Par-vagum, division of, without caus-
    ing death, ii.                       427
Patella, exsection of, ii.    -     -    -    844
[Patella, fractures of, and  myotomy
    for—see Thigh, also Triceps  Fe-
    moris Muscle.
 [Pathology of aneurisms, Note on,  iii.    540
 Peace, Dr.—see Townsend.
[Pectoroplasty—see Anaplasty.
Pelvis, exsection of bones of, ii. -    -    741
Pelotes, i.      -    -    -     -    -    103
Penis, diseases of, iii.      ...    764
       Ligature  on arteries of, ii,     -    282
[Penoplasty—see Anaplasty, and Met-
    tauer.
Perforated linen, (linge troue or  cri-
    ble,) i......112
Pericardium, paracentesis of, iii.      -    520
Perineal bandages, i. -    -     -    -    176
Perineum, fissures, rupture, and suture
    of, iii.       -    -    -    -  865—872
Pessaries for the vagina and uterus, iii.   798
         See also Atlas.
[Petrous bone,  or os petrosum, Note
    on fractures of, and  hemorrhage
    from, ii.    -    -    ...    933 
INDEX.
1157
Phalanx, exsection of the first of the
    hand,ii.    -                        781
Pharyngeal artery,  ligature  on  in
    wounds, die., ii.      ...    039
Phlebitis—see Aneurisms.
Phymosis—see Penis, diseases of.
Piles—see Hemorrhoids.
Plasters, i.......205
Plugging of arteries in aneurism—see
    Tamponing, and Plugs.
Plugs or Tampons, i. -     -     -     -    104
Plumasseaux, or pledgets of lint, i.   -    101
Polypi of the nose—see Olfactory Ap-
               paratus.
             Uterus, iii.   -     -   803—820
! Polypi  of the uterus, Note on, iii.         ib.
 Polypi  of the rectum, Note on, iii. 1095,1096
Pomades in dressing, i.    -     -     -    103
Popliteal artery, ligature on in aneu-
    rism, &c., ii.                        128
[Popliteal aneurism — see Aneurism,
    and Townsend.
Porte-crayon, i. -     -     -    -     -     94
Porte-meche, i. -    -     -     -     -     98
Positions  of the  bistoury, knife, and
    scissors, i.  -    -     -     -   328—330
[Post, Dr. Alfred C, of New York, his
    anaplastic operations, sub-cutane-
    ous sections, &c., i.   -     -     -    714
Posterior tibial artery, ligature on in
    wounds, &c., ii. -                   123
[Posthioplasty or anaplasty to the pre-
    puce—see Pancoast.
Poultices—see Cataplasms.
Precautions in dressing, i.      -     -    229
Prefaces— see Velpeau,  Mott,  and
    Townsend.
Probes,  i.  ------     94
Profundus  flexor muscle of the  fingers
    —see Discussion on Tenotomy.
Prolapsus of the uterus, iii.     -     -    792
[Prolapsus of the uterus, Note on, iii.    796
Proptosis—see Eye. .
[Proudfoot, Laurence, M.D.—see Fem-
    oral Hernia.
Pubes, exsection of, ii.     ...    744
[Pulmonary artery, aneurism of, Note, ii. 261
Puncta  lachrymalia—see  Eye.
Punctures, their various kinds,  i.   346—348
Puncture of the eye—see Eye.
Pupil, artificial—see Eye.
     Immobility of—see  Eye.
Purulent cataract—see Eye.

                    R

[Rachidian myotomy—sec Dorsal and
    Rachidian myotomy.
Radial  artery, ligature on in aneu-
    rism, &c.,  ii.     -     -   -  185—195
[Radius and ulna, dislocation and  frac-
    ture of their extremities, as treated
    by  Dr. Barton, ii.     -   _-     -    860
Ranula, special operations for,  iii.  361—367
[Ranula, anaplasty for, Note on, i.   -    801
Razor, i. ------     93
Reclination, process of in cataract—see
    Eye.
Recto-vesical fistulas—see Urinary Fis-
    tulas.
Rectum, diseases of, its defects of con-
    formation,  extraction of  foreign
    bodies and polypi from, &«., iii.
                               1085—1098
[Rectus muscle ofthe thigh, myotomy
    and tenotomy of,  Note, i.  -     -   679
Redressers, or  straighteners, to ban-
    dage the head, i.      -    -     -   164
Reduction ofthe womb and vagina, iii.   797
Refrigerants, and styptics, in arterial
    lesions, ii.                           14
Restitutions, surgical—see Anaplasty.
Restorations, surgical—see Anaplasty.
Retroversion ofthe uterus, iii.     789—792
Reunion—see Sutures.
Reversion of the vagina, iii.             792
Rhinoplasty—see Anaplasty.
[Rhinoplasty in America, Note, i.    -   626
    See also Anaplasty.
[Rhinoplasty,   new  suggestions  for,
    Note,  i......798
[Rhinoplasty according to M. Serre,
    Note,  i......830
Ribs, exsection  of, ii.      ...   739
    See also Costo-chondral and Cos-
    to-vertebral.
[Rodgers,  Dr. John  Kearny—see his
    Ligature on the  Left Subclavian
    in Mott's chapter on Aneurisms.
Roller bandages, i.  -    -    -     -   121
Rolls, or dossils (or  bourdonnets) of
    lint, i......102
Rubefaction, i.      ....   278
[Ruschenberger, Dr., (U. S. N.) his
    remarks on Basilar Aneurism, &c.
    ii......373—376
Sacrum—see Coccyx.
Salivary fistulas, special operations for,
         • iii.  -    -    -    -   354—361
        regions, tumors of, iii.      -   443
Saphena nerve, internal and external,
    ii.   -                   -    430,431
Saturated dressings, i.                  215
Saws, various kinds, hand, chain, row-
    el, &c. — see Exsection of Bones,
    Amputations, &c.  [See Atlas.]
[Scalp,  long and deep incisions on,
    Note  on, as a cure for cephalal-
    gia, i.     .....939
[Scapula, disarticulation, avulsion and
    amputation of, Note on, ii.      565, 759"
Scapula, exsection of ii.        -   758, 811
Scarifications, bleeding by, i.   -   -   271
Schmidt, Dr. John W.—see Masseter.
Sciatic nerve, ii.     ...   -   433
Scissors, i.     -----     92
Scleroticonyxis—see Eye.
Scleroticotomy—see Eye.
[Scrotoplasty—see Anaplasty.
Scraped lint, i.       ....   105
Scrotum bandages, i.      ...   173
[Semilunar incisions ofthe integuments
    ofthe face in exsections of the jaws
    —see Letter of Prof. Velpeau to Dr.
    Mott,  and  the remarks of the lat-
    ter surgeon, i.        -     -    -   p. ix
[Serre, Prof, of Montpellier, abrege of 
1158
INDEX.
                                     PAGE
Serre—continued.
    his work on Anaplasty as applied
    to Deformities of the face, i.    821—831
    See also ii.     -                  436
Setons, i......288
[Setons in  the cure  of hernia— see
    Townsend.
Sexual organs in women, iii. _      777—887
Shoulder-joint, amputation at the, ii.     551
                         ofthe, ii.     562
[Shoulder, false joints at, Note on, ii.    753
Shoulder, exsection of bones of, ii.       676
                            and 798—811
Simple incisions—see Incisions.
[Sinus, lateral, of the brain, ulceration
    of, Note on, ii.       ...   412
[Softening,  or ramolissement of the
    brain, a cause of contraction  ofthe
    flexor  muscles  of the  legs and
    thighs, Note on, i.    -    -    -   794
Spatulas, i.    -----    93
Special bandages, i.       ...   153
       operations, i.     ...   172
Speculum vagina—see Sexual organs
    in Women, Cancers of the Neck
    of the Uterus, Atlas, Tiemann, &c.
[Spina bifida—see Mott.
[Spinal marrow, supposed entire divi-
    sion of,  and the patient restored!
    ii.  -    -    -    -     -      p. xcvii
Spine of the ilium, exsection of, ii.   -   742
Splints, i.                         -   132
Square bandages, i.       ...   149
Squinting—see Strabismus.
Stammering—see Velpeau.
Staphyloma—see  Eye.
Staphyloplasty—see Anaplasty.
Staphyloraphy—see Posterior Fauces.
              [Note on, iii.    -    -   395
Starch bandages—see Van  Buren and
     Glutinous bandages.
Stenon's duct, fistulas of—see Salivary
     fistulas.
Sternum, exsections of, ii.     -    -   735
Stomach, fistulas of, iii.  ...   541
[Strabismus, general view of the ope-
     rations  for this deformity, statistics
     of, &c., i.      -    -    -   726—760
[Strabismus, complete and full abrege
     of M. Velpeau's Memoir on this
     subject, i.      -    -    .   523—584
     See also i.                    -   726
Strangulation—see  Hernia.
Subclavian artery, ligature on, in aneu-
     rism, ii.                          210
     See also  Mott and Dr. John K.
       Rodgers.
Subcutaneous  bridles — see  Bridles,
     subcutaneous.
[Subcutaneous incision, according to
     M. Malgaigne,  i.     -     -     -   833
[Subcutaneous operations, diseases ad-
                apted to—see   Hun-
                ter and Guerin.
              surgery, as  applied  to
               tendons and muscles,
               i.   -     -     -    399-473
              tendons of the fingers, i.   407
                          hand, i. 412—438
                                     PAGE
Subcutaneous surgery, as applied to
    tendons of the elbow, i.     -  413—440
                         •  foot.i, 416—444
         tendo achillis, or heel,  i.
                            418—445, 679
         tendons ofthe thigh, i.        426
         tenotomy in wounds, i.   129—434
         tendons and muscles of the
           axilla, i.      ...    443
         tendons and muscles of the
           toes, i.  -    -    -    -    443
         club-foot, i.     -    -  449—462
         wry neck, or torticollis, i. 462—473
Sub-hyoid region, tumors of, iii.     -    456
[Sublimis flexor muscle of the fingers
    —see Discussion on Tenotomy.
Submaxillary gland, iii.   -    -    -    455
[Substernal  aneurisms,  difficulty of
    diagnosing, Note on,  ii.    -    -    260
Substitutes for lint, i.     -    -    -    110
[Supplemental Appendix to vol. ii. p. xix-xcix
[Supra-malleolar amputation, malleolar
    amputation,  &c, Note on, ii.    -    595
Surgical beds, i.     -    -     -    -    134
Sutures, their various kinds,  simple or
    interrupted, loop or continuous, or
    whip, or glover's, zigzag, basting,
    twisted, quilled, &c, i.    -  349—358
Sutures in the treatment of aneurisms,
    ii.   -     -     -    -     -    -     61
Symblepharon—see Eyelids.
 Syme—see Elbow.
 Sympathetic nerve, its influence, Note
    on, ii.     -----    439

                    T
T bandages, i.  -    -    -     -    -148
Table of contents, vol. i.  ...   xx\
                 Vol. ii. -     -    -    vii
                 Vol. iii.      -    -    ix
Tail bandages, i.     -    -    -    -    146
Tampons—see Plugs.
Tamponing or plugging arteries, ii.  -    59
Tapes in dressing, i. -    -     -    -   134
Tarsus, disarticulation of, ii.     -    -   585
       Exsections of, ii.  -     -   817—820
Taxis in  hernia—see Hernia.
Teeth, operations on,  instruments for,
    &c.,i.     ....  313—326
Temporal artery, ligature on in aneu-
    rism, ii.                           223
[Temporal  bone, fractures  of its pe-
    trous portion—see Petrous  Bone.
[Temporal  bone,  circumscribed  false
    aneurism of—see Townsend.
Tendo  Achillis  — see  Subcutaneous
    Surgery
[Tendo  Achillis, section of, for  frac-
    tures and  dislocations of the leg
    and ankle,  for  fractures  of the
    malleoli, &c, Note on, i.   -   784—786
[Tenotomy and  myotomy at the bot-
    tom of suppurating wounds, ii. -   xxxi
Tenotomy — see Subcutaneous  Sur-
     gery.
 [Tenotomy and  myotomy, new opera-
             tions in, Note  on, i.    -    511
         See also Fingers and Thumb,
             and Ham-strings. 
INDEX.
1159
Tetanus, amputation in cases of—see
     Amputation, and Townsend.
Thigh-bone,  neck of—see Neck  of
     Thigh-bone.
Thigh, disarticulation of, ii.              649
       Amputation of, ii.       -    -    629
                    Note on, ii.    -    636
       [Myotomy, or division of the
        muscles of, i.     -     -    -    781
Thorax bandages, i.  -     -     -    -    165
       Effusions into, iii.  -              507
       See also Empyema.
[Thorax, paracentesis of, Note on, iii. -    520
Thread-ribbon bandages, i.     -    -    120
[Thumb, section ofthe longus pollicis,
     Note on, i......779
     See also Fingers.
[Thumb, particular case of dislocation
     of, with wound,  ii.    -     -     -    859
Thyroid arteries, ligature on in  aneu-
     rism, ii.                            227
Thyroid body or gland, iii.      -     -    456
Thyroidean-laryngotomy — see Bron-
     chotomy.
Thyro-hyoidean  laryngotomy — see
     Bronchotomy.
[Tibia, trephining of, for an  abscess,
     diagnosed,  Note on, ii.      -     -    953
     See also Trephining.
Tibial arteries—see Anterior Tibial and
     Posterior Tibial.
Tibial nerve, anterior and posterior, ii. 431, 432
Tiemann, of New York, his improved
      eye-speculum, i.    -     -     -    723
     His  improved speculum  vagina
      et ani, with plates, iii.    -     -    882
Toes, amputation of several at once, ii.    573
Tongue-tied—see Tongue.
Tongue, special operations for, iii.  368—377
Tonsils, hypertrophy of—see Fauces,
     Posterior.
Torsion of arteries, ii.     ...    62
[Torticollis or wry neck, new form of,
     Note on, ii.     -     -     -     -    946
Tremulus iridis—see Eye.
Townsend,  P.  S., M.  D. — Some  of
      his principal notes to this work.
     P reface to vol. i.     ...     iii
     Effects  of climate  on  surgical
      operations, i.       ...    xlv
     Gangrene from cold, i.     -     -   xlvii
     Entrance of air  into  the veins, i.    39
     Abrcge of Velpeau on Erysipelas, i. 67—75
     On a  new and commodious scro-
      tal bandage, i.  -    -    -  175, 176
     Discussion on tenotomy, &c.  in
      the Paris Academy, i.    -    -    490
     New operations in tenotomy and
      myotomy, i.   -     -     -    -    511
     General remarks on anaplasty and
      myotomy in America, i.  -    -    517
     Abreo-e   of Velpeau  on  strabis-
     "■  =>   .       r          .   too___t;ai
      mus,  i.  -    -     -        ^^°   Ja*
     Concluding  American  appendix
      to vol. i.      -     -    "   675—850
      Embracing subcutaneous  sec-
      tions   in  tenotomy and myoto-
      my i.   -    -     -    -   678—681
      Anaplasty, i.  -    -     -   684—723
I Townsend—continued.
        Subcutaneous operations, i.  725—795
        Anaplastic operations, i.  -   796—850
     Preface to vol. ii.     -    -    -  p. iii
     Supplemental appendix to vol. ii.
                                  xix—xcix
     Note on alveolar hemorrhage, ii.  -    32
     Tubular aneurisms of Mr. Luke, ii. 34,35
     On the improved mode of treating
        aneurisms  by compression,  ac-
        cording to the Dublin surgeons,
           ii  ...    -     43—59
     Ligatures, compression, and tor-
        sion of arteries, ii. -     -     -    82
     Hemorrhagic diathesis, ii.  -    -   107
     Pathology of  aneurism, ii. -    -   111
     Rupture of the heart, ii.   -    -   112
     Spontaneous  cure of aneurism by
        Valsalva's method, ii.    -    -   146
     Popliteal aneurism in a child, ii. -    ib.
        Case of successful ligature on the
        external  iliac, by Dr. Peace of
        Philadelphia, ii.    -    -    -   154
     Note on a case of femoral  aneu-
        rism,  cured by a ligature on the
        externa) iliac, ii.   -     -    -   155
     Prof.  Buisson's ligature on  the
        gluteal and ischiatic  arteries in
        aneurism, &c., ii.  -    -   161—168
     Two rare cases of aneurism ofthe
        abdominal  aorta,   as described
        by Mr. J. A. Wilson, ii.  -    -   181
     M. A. Berard's views on  aneuris-
        mal varix,  and varicose  aneu-
        rism, ii. -    -    -    -   196—201
     Cure of varicose aneurism at the
        bend  of  the arm by compres-
        sion, ii......202
        See also text of Velpeau.
     Rupture of the brachial artery, ii.   203
     Spontaneous  aneurism at the bend
        of the arm, ii.                    ib.
     Ligature on  the  axillary artery,
        or axillary  portion of  the sub-
        clavian, ii.    -                  209
        Below the  clavicle, ii.             ib.
        On the subclavian, within the
        scaleni muscles, ii.      -    -   211
     False circumscribed  aneurisms of
        the temporal artery, ii.   -     -   220
     Aneurism of the basilar artery, ii.   222
     Ligature on  the carotid, near  the
        innominata, ii.     -    -    -   247
     Ligature on the ascending branch
        of the external carotid, ii.     -   251
     Wounds of the carotid,  causing
        aneurismal varix,  and varicose
        aneurism, ii.  -    -    -     -   252
     Aneurism  of  the   large trunks
        near the heart, ii.  -    -   258—260
     Difficulty of  diagnosis  in subster-
        nal aneurism, ii.   -    -     -   260
     Diagnosis of aneurisms, ii.       -    ib.
     Review of M. Guettet's remarks
        on aneurism of the innominata,
        ii.  -     -    -    -    -     -   263
     Review of M. Diday's remarks on
          aneurism of the innominata, ii.
                                  265—274 
1160
INDEX.
Townsend—continued.
    Distal operation  for aneurism of
      the innominata, ii.  -    -   274—278
    Simultaneous ligature on the sub-
      clavian and carotid, ii.   -    -   280
    Anomalous deviations of arteries, ii.   365
    Supplemental note on aneurisms, ii.    ib.
    Account of operations on the prim-
      itive iliac, ii.  -    -    -    -   367
    Account of a remarkable case of
      aneurism ofthe basilar  artery,
      by Dr. Ruschenberger, ii.     -    373
    Account of Dr.  Ruschenberger's
      experience  in the  virtues  of
      Matico, ii.                        375
    Further  remarks on  the cure of
      aneurism by compression, ii.  -    377
    Successful ligature on both  carotid
      trunks by Dr. Ellis, ii.             ib.
    Varicocele and the  processes  of
      M. V. de  Cassis,  M. Velpeau,
      &c, ii.      -    -     -    407,411
    Wounds  of veins, ii.        -     -    412
    Ulceration of the lateral sinus of
      the brain, ii.       -              ib.
    Obliteration of the  large venous
      trunks, as the cava, &c. ii.   412, 413
    Rupture  of the right internal jugu-
      lar, ii.   -    -    -     -   413—415
    Perforation of the internal jugu-
      lar, ii.                            415
    Ossification and obliteration ofthe
      vena portarum, ii.        -     -     ib.
    Amussat's opinion of cicatrices of
      arteries and veins,  ii.     -     -    416
    Internal  lining membrane of arte-
      ries, ii.                          418
    M. Velpeau's claims to priority in
      the treatment of varices, ii.    -     ib.
    Electro-puncture in neuralgia, ii.     435
    Inutility of exsection  of nerves for
      neuralgia, ii.      ...     $.
    Amputation of the fingers and arm
      for neuralgia, ii.    -     -     -     ib.
    Remarkable  ganglionic transfor-
      mation of nerves noticed  by M.
      Serre,  ii.     -                   436
    Nervous  substitutions, ii.   -    -    437
    Influence of the sympathetic, ii. -    438
    Amputation for tetanus, ii.      -    458
    Period when to amputate, ii.    -    470
    Hospital  gangrene in  respect to
      amputation, ii.     ...    505
    Artificial  arm,  ii.     ...    550
    Disarticulation of the scapula and
      arm  together — avulsion — the
      possible disarticulation  of the
      scapula by another mode, ii.  -    565
    Amputation   of  the  metatarsal
      bones,  die., ii.      ...    577
    Disarticulation of the tarsus by
      Chopart's process, ii.     -    -    588
    Supra-malleolar and malleolar am-
      putation, ii.        ...    595
    Ligature  to  the external iliac
      and femoral  arteries for hemor-
      rhage after  amputation   of the
      leg, ii.                            616
    Amputation of the knee-joint, ii.     627
    The  circular process in amputa-
Townsend—continued.
      tion in  the continuity of  the
      thigh, ii.
    Coxo-femoral amputation, or  dis-
      articulation of tne thigh, ii.
    Conservative surgery to dispense
      with amputation, ii.
    Diagnosis of fracture by the stetho-
      scope, ii.     -
    Effects of  utero-gestation in frac-
      tures, ii.       -
    Acupuncture  for  ununited frac-
      tures, ii.       -
    Exsection of the ends of bones in
      a case  of fracture, consolidated
      and  leaving deformity, by  Dr.
      Barton, ii.
    Exsection of portions of the bones
      ofthe pelvis, ii.
    Exsection ofthe olecranon, ii.
    False joints at the shoulder, ii.  -
    Exsection of the clavicle, ii.
    Exsection of humerus, scapula and
      humero-cubital articulations, ii.
    Exsection of the os calcis and as-
      tragalus,  ii.   -
    Dislocation ofthe astragalus,with
      fracture of the fibula, ii.
    Exsection ofthe femur, ii.
    Starch bandages  after  exsection
      of the elbow, &c., ii.
    Exsection of the knee-joint,  ii.  -
    True and false anchylosis, ii.
    General remarks  on disarticula-
      tions and exsections, ii.
    M.  Chassaignac's  processes  in
      these operations, ii.
    Some particular cases of fractures
      and dislocations, ii.
    Account of  Dr. Mott's exsection of
      half of the lower jaw, (Baker's
      case,) Nov. 23, 1844, ii.
    Injuries ofthe head, ii.
    Diseases of the vertebra, trephin-
      ing, &c. ii.  -
    Erectile tumors, ii.    -
636

649

653

667

685

690
704

744
749
753
757

759

762

769
777

792
832
840

851

 ib.

857
908
930

946
987
60
74
Preface to Vol. III., iii.
  Claims   of  Drs.   Brasheah,
    Francis, &c., iii.
Fatty tumors, iii.     -
Elephantine tumors, iii.
Remarkable  case  of three  enor-
  mous tumors of the nose, with
  plates, successfully removed by
  P. S. T., iii.
Treatment of cysts, iii.
On crushing  of serous (or mucous
  so called,)  bursa? and iodine in-
  jections, close cavities, M. Vel
  peau's views, cartilaginous and
  osseous,  and  mediastinal  tu-
  mors,  treatment of tumors in
  general, &c, iii.   -    -    83—105
Cataract, iii.    ....    301
Staphyloraphy, iii.         -    -    395
Nasal fossa,  osseous plate in the
  diaphragm, calculi in the frontal
  sinus, &c., iii.     -             416
Laryngotomy and tracheotomy for
  foreign bodies, croup, &c., iii. 478—484 
.INDEX.
1161
 To wnsend—-continued.
     Organic stricture and  contraction
       ofthe oesophagus, iii.    -    -   489
     ffisophagotomy, iii.        -    -   496
     Paracentesis of the thorax, iii.   -   517
     Ovariotomy, iii.      ...    540
     Enterotomy, gastronomy, artificial
       anus, intussusceptio,  perfora-
       tion ofthe colon and ileum, &c.,
       iii.      ...     .    645—650
     Cure of artificial anus and radical
       cure of hernia by the seton, iii.    680
     Internal hernial sacs, diaphragma-
       tic hernia, statistics of hernia,
       &c.,  iii.       -                   700
     Iodine injections in hydrocele, and
       the late  discussions in  Paris
       thereon, with M. Velpeau's opin-
       ion, iii.       -     -     -    738—741
     Scrotal hematocele, iii.     -     -    744
     Incision of the albuginea for  the
       cure of parenchymatous orchi-
       tis—new cure for pseudo-fungus
       of the testicle;  M. Velpeau's
       diagnosis  of  the  debris of  a
       foetus in the scrotum, iii.    759—764
     Vaginal occlusion, iii. -    -     -    788
     Prolapsus of the uterus, iii.     -    796
     Polypi of the uterus, iii.    -   820—825
     Lithotomy and lithotrity, iii. 1025—1031
     Polypi of the urethra, iii.   -     -   1070
     Hypospadias, iii.     ...   1085
 Trachea, exsection of, ii.   -     -     -    735
 Tracheotomy—see Bronchotomy.
 [Tracheotomy, Note on, for foreign bo-
     dies, croup, &c. iii.   -     -     -    478
 Traumatic hemorrhage—see Aneurism.
 [Traumatic  lesions—see Mott.
 Trephining, operations for, ii.   -     -    918
           the Cranium, ii.     -     -     ib.
           Sternum, ii.   -    -     -    943
           Ribs, ii,  -     -     -     -    945
           Spine, ii. -     -    -     -    946
             See also Townsend.
           Metatarsus, ii.  -    -     -    951
           Metacarpus, ii. -    -     -     ib.
           Tarsus, ii.     ...     ib.
           Leg, ii.  -     -    -     -     ib.
           Tibia, ii.      ...     ib.
           Fibula, ii.     -    -     -    953
           Centre of the femur, ii.   -     ib.
           Pelvis, ii.     ...    954
           Fore-arm, ii.   -     -     -    954
           Humerus, ii.   -    -    -   956
           Clavicle, ii.    -    -    -    ib.
           Scapula, ii.    -    -    -    ib.
Triangular bandages, i.   -    -    -   149
[Triceps cruralis,  rupture  of  the ten-
     don of, on both sides,  Note, ii.   -    lvii
[Triceps femoris muscle, and ligamen-
     tum  patella,  rupture and treat-
     ment of, Note on, i.   -    -    -   782
Trichiasis—see Eyelids.
Trough-boxes, or gutters, i.    -    -   133
Trusses—see Hernia.
Tubercle, carotid, of M. Chassaignac—
     see Vertebral artery.
ETubular aneurism—see Townsend.
 Tumors, erectile—see Mott, ii. -    -   990
                Townsend, ii. 987, 990, 991
 Tumors, incisions for—see Incisions.
        Operations for, ii. -    -   957—992
          * «      »  iii.-    -     1—151
          See also Special Operations.
        in general, iii.    -    -    -   105
        Fibrous, iii. -                  108
        Cancerous, iii.    -    -    -   HI
        Breast, iii.   -    -    -    -   498
        Thorax, disconnected with the
          mamma, iii.    -    -    -   506
 Tympanum—see Auditory apparatus.

                     U

 Ulna, dislocation  and fracture of the
    extremity—see Radius.
 Ulnar artery, ligature on in aneurism,
    ii.    -    -    -    -    -   185—195
 Ulnar nerve, ii.      ...    -   430
 Uniting bandages, i.      ...   163
                  for fractures, i.    -   199
 Ununited or non-consolidated fractures,
    ii.......684
    See also Mott.
 Upper jaw—see Jaw.
 Ureters—see Ureterotomy, iii.   1019—1021
 Urethra, contraction of, iii.     -    -  1042
        Calculi in, iii.    -     1019—1025
        Diseases of, iii.   -      1032—1085
        Polypi of,  iii.     -    -    -  1069
 [Urethra,  polypi of, Note on, iii.     -  1070
Urethral fistulas—see Urinary Fistulas.
Uretroplasty— see Anaplasty.
Urinary fistulas, iii. -      -      1078—1082
               Recto-vesical, iii.    -  1078
               Internal, iii.    -    -  1079
               Urethral, iii.              ib.
Urinary calculi external to the bladder,
    iii.    --..;---  1019
Uterotomy, vaginal, iii.    ...   881
Uterus, extirpation of, and for what af-
    fections, iii.     -    -    -  835—848
Uterus, excision of, iii.    ...   792
      Fall  of— see  Cancers  of  the
        Neck of the Uterus.
      Occlusion of, iii.   ...   789
      Puncture of, iii.                   ib.
 Uvula—see Fauces, Posterior.
Vaccination, i.  -     -     -     -   305—309
Vaginal calculi, iii.   -     -     - 1021—1025
[Vaginal occlusion, Note on, from Dr.
    Mott's practice, iii.    ...    78g
[Vaginaplasty—sse Elytroplasty.
[Valsalva, his method of treating arterial
    lesions, ii,  -     -    -    -    -  p. ii
Van Buren,  Dr. Wm., his remarks on
    glutinous,  starch, and dextrine
    bandages, i.     -    -     -     -    123
Varices in general, treatment of, ii. 382—388
         particular,    "    " " 389—398
[Varicocele—see  Velpeau and Town-
    send.
[Varicose  aneurism — see  Mott and
    Townsend.
[Varicose veins, treatment of, ii. -  399—406
               [Pathology  of, Note
    on, ii......4n 
1162
INDEX.
[Varix, aneurismal — see  Mott  and
    Townsend.
[Veins, compression of, for hemorrhage,
    by M. Malgaigne, Note on, i.   -   836
[Veins, wounds of, Note on, ii.      -   412
    See also Townsend.
Velpeau, Professor.
    His letter to Dr. Mott,  in reply to
      the letter ofthe last named sur-
      geon, i.       -    -     -    -  p. xii
    Preface to his first edition of this
      work, i.      ....   xxv
    Preface to his second edition, i.  - xxxix
    Supplemental Appendix, i.      -   xliii
    [Memoir on erysipelas, abrege of
      his, i.        -    -     -     67—75
    [Memoir on  strabismus, abrege of
      his, i.        -     -     -    523—584
    [Remarks on tenotomy, in the dis-
      cussion  on this subject in the
      Royal Academy of Medicine of
      Paris, i.'     -    -    -    489—490
    [Subcutaneous  section  of bursa,
      cysts, &c, i.       ...   791
    [Proposed division  of  the   hyo-
      glossus  muscles for  stammer-
      ing, i.   -     -    -     -    -   793
    [Opinions on treatment of varico-
      cele, ii.       ....   410
    [His claims to priority in1 the treat-
      ment of varices, ii.       -    -   418
    [On close cavities in general, and
      iodine injections, iii.    -    90—101
     His opinions on fibrous and can-
      cerous tumors, iii.      -    121—124 |
Velum palati—see Fauces, posterior,
    and Olfactory apparatus.
[Vena cava, obliteration of, ii,       -   412
[Vena portarum, ossification and obli-
    teration of, ii.        .    -    -   415
Venous system, wounds of, and opera-  .
    tions for, ii.     -    -     -   381—418
Vertebral artery, ligature on, in aneu-
    rism, ii.                           228
Vertebra, exsection of, ii.      -    -   738
[Vertebra,  abscesses near, and  their
    danger, Note on, ii.        -    -   947
[Vertebra,  fracture of, Note on, ii.   -   948
Vesication—see Blistering and Blisters.
Vigo, or diapalme plasters, i.    -    -   127
Vulva, contraction of, iii.      -    -   792
       tumors of, iii.     ...   777
W
Warts—see Tumors.
Watson, Dr. John, of New York—see
    Metopoplasty.
Wet bandages, i.    -    -     -     -    122
Wet linen for dressing, i,       -     -    112
Wilson, Dr. J. A.—see Townsend.
Woolen bandages, i.      -     -     -    118
Wounds, treatment of, i.  r    -   230-233
Wrist, amputation of, ii.  -     -     -    535
Wrist, exsection of, ii.    -     -     -    787
[Wrist,  particular case of fracture of,
    Note on, ii.     ....    858
THE  END. 
 
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