*- \\ 3\0IK&3£KT for the: FSE OF students WITH FL.1TES fn $ AlMINfr PROKliSSOK OF MiO.liKY IN THE lM\i:RMTY OF PENNs^ LVANI.V. (iM: OF TJIi: .->l Klil:i»S OF THE TEVNnYLVAM \ HOSPITAL lie. VOL.1. _____, for want ol* timely cai■< Millions luive died of medicable wounds. Umftronp P HI1-V1) ELPHIA. V\ bl'slu-d bv Kdward I'arker J above and below the wounded part; and when the parts are examined, a short time after the hemorrhage has completely stopped, we find a stratum of coagulated blood between the artery and its sheath, extending from a few inches below the wounded part, to two or three inches above it, and somewhat thicker, or m«re promi- nent over the wounded part than elsewhere. Hence, rather than say the hemorrhage is stopped by a coagulum, it is more correct to say, that it is stopped by a thick lamina of coagulated blood, which, though somewhat thicker at the wounded part, is perfectly con- tinuous with the coagulated blood lying between the ar- tery and its sheath. When an artery is punctured, the hemorrhage imme- diately following, by filling up the space, between the artery and its sheath, with blood, and consequently dis- tending the sheath, alters the relative situation of the puncture in the sheath to that in the artery, so that they arc not exactly opposite to each other; and by that means a layer of blood is confined by the sheath over the punc- ture in the artery, and, by coagulating there, prevents any further effusion of blood. But this coagulated blood, like the external coagulum of a divided artery, affords only a temporary barrier to the hemorrhage; its permanent supprt^ion is effected by a process of reparation, or of obliteration. It has been doubted by many respectable surgeons whether arteries when wounded, can heal without an obliteration of the cavity of the vessel, in such a manner as to cany on the circulation of blood. The experi- ments of Dr. Jones upon a number of animals prove that in brutes this very generally happens, when the artery is wounded only to a small extent; the cicatrization in these cases is so complete, that no vestige of the wound can be perceived, either on the external or internal sur- face of the artery, and that even oblique and trans- 40 ELEMENTS 01' SURGERY. verse wounds when they do not exceed one fourth of the circumference of the vessel, arc filled up, and healed by au effusion of coagulating lymph from their inflamed lips, so as to occasion little or no obstruction to the canal of the artery. It may still be questioned whether in the human body the same mode of union is effected. When an artery of considerable magnitude is punctur- ed, even by a sharp lancet, the circular fibres of the artery in most cases contract go much, as to separate the sides of the wound to a considerable distance from each other, it appears as if a piece of the vessel had been actually re- moved.* To effect the reparation here, a coagulum forms as explained by Mr. Petit, inside of the artery, and ex- tends through the wound, to a coagulum situated on the outside of the vessel,! in this manner the aperture is tem- porarily closed, and the permanent closure depends on the secretion of coagulating lymph, which is poured out in considerable quantity, and in many cases (probably a large majority of cases) obliterates the arterial tube, but in some instances the artery heals as in the experiments upon brutes related by Dr. Jones, and then the cicatri- zation is completed without a destruction of the arterial cavity. Mr. Petit records an instance of this, and in professor's Scarpa's learned treatise on Aneurism, I find another very decided instance in which this mode of union was effected in the brachial artery of a man. Scarpa denies that when the artery heals in this manner the cure is radical. He supposes the vessel weaker at the cicatrix than at any other part. A case of wounded brachial artery which healed without an obliteration of * Such is the common opinion, but I have seen several cases of punctured arteries, in which no gaping was evident, the wound being a mere slit, the sides of which were nearly or closely in contact, though they had not united. As this has been the case in all the punctured arteries I have seen, I cannot doubt that it very often happens. •{■ The inner clot he calls " bouchon," a cork, or plug, the external if called " couvercle." ELEMENTS OF SURGERY. 41 its canal may be found in the New York Med. and Phil. Journal, No. 4. Having thus stated the natural process by which a wounded artery is repaired, we may next mention that these powers of reparation appear to exist in an inverse ratio to the size of the vessel, small vessels healing much more readily than large ones. In incised wounds the flow of blood is always much greater than in contused wounds of similar parts. The effect which laceration has in preventing hemorrhagy may be estimated from a case related by Cheselden, in which a millers arm was torn off, together with the sca- pula from the chest, of course some of the largest arte- ries of the body were divided, and yet no fatal hemor- rhagy ensued. I have known a boys arm ground off in a mill within a few inches of the shoulder, and so little bleeding resulted, as scarcely to stain his clothes. Dr. Physick has attributed this effect of contusion, 1st, To the diminished power of the vessels to carry on the cir- culation. In an incised wound the vessels are only in- jured at the divided surfaces, in a contused wound they are injured to a considerable distance and therefore cir- culate the blood less rapidly. Sdly, In a contused wound the blood escapes less readily by the external open- ing, and becomes extravasated into the cellular texture making lateral pressure upon the blood-vessels.* 3dly, The blood coagulates much more promptly in contused than in incised wounds, and this coagulation is a power- ful barrier to the escape of the blood. The extremities of divided vessels are often actually killed by the con- tusion, and blood, when in contact with dead matter speedily coagulates. The coagulation of blood in the • This lateral pressure is increased by ecchymosis, from a number of ruptur- ed blood-vessels which have no external communication, and bleed into the fir- terstices of the neighbouring parts. VOL. I. G 42- ELEMENTS OF SURGERY. divided extremities of the vessels, forms another obstacle to hemorrhage. TREATMENT OF INCISED WOUNDS. In the treatment of an incised wound, the first object is to stop the bleeding. In many cases a wound bleeds profusely at first, and gradually stops without any atten- tion from the surgeon. In some cases moderate pressure upon the wound by holding its sides in contact, puts a stop to the flow of blood, and this, if no large artery be obvious, should always be tried. If, upon removing the pressure the wound continues to bleed, or if previ- ously to trying this, a bleeding artery is observed, it must be taken up upon the point of a tenaculum, and a ligature applied round it. If the bleeding is so great as to prevent an accurate inspection of the wound, so that the artery cannot be perceived, pressure must be made upon the trunk of the main artery which supplies the parts with blood. This pressure may be made with a finger, or if the wound be seated in an extremity, with a tourniquet; that of Petit is to be preferred for simplicity and facility of application to all others.* When the tourniquet is to be applied, it must be placed above the knee or elbow, because, as there is only one bone in these parts, a cir- cular bandage will compress all the vessels of the limb. After the tourniquet is applied and screwed so tight as to interrupt the circulation, the surgeon is to wash the wound with a sponge and warm water, and then, whilst his eye is fixed on it, the screw is gradually loosened, and the divided vessels may be seen by the stream of blood escaping from their extremities. It is to be recollected, that if the wound be too high up on an extremity for the application of a tourniquet, the , • I mean the tourniquet in common use, invented by Petit, and Improved by Freke. ELEMENTS OF SURGERY. 43 compression of the vessel may still be effected. The sub- clavian artery may be compressed as it lies over the first rib, and the circulation in the arm may thus be complete- ly prevented, and from pressure in the groin, the trunk of the femoral artery ceases to pulsate. In every instance where the bleeding does not speedily cease, and the ori- fice of the bleeding artery can be seen, it is to be tied up. And whenever large arteries are wounded, there is no other mode of stopping the hemorrhage to be confided in. Dr. Jones having made a number of experiments to as- certain the effects of the ligature upon an artery included in it, and properly tied, states, that the internal and mid- dle coats of the artery are cut through and kept in close contact by the ligature ; inflammation supervening they adhere and unite firmly. There are however some situations in which it is ex- tremely difficult to tie up a wounded artery. If a vessel be opened in a deep wound of small extent, it becomes sometimes necessary to dilate the wound, in order to ex- pose it. Sometimes we are able by enclosing in the li- gature a portion of flesh through which the artery passes, to put a stop to hemorrhage. In other cases the applica- tion of lint and moderate pressure effects the purpose (but this can only be trusted when the bleeding is from small vessels. The application of stiptics and escharo- tics, is nearly out of use among surgeons; and yet cases sometimes occur, in which they may be employed with advantage, as when the bleeding vessel is beyond the reach of the ligature, and in such a situation, as to preclude compression.* I have once known the hot iron necessary to put a stop to a most alarming hemor- rhage from a large artery in the posterior fauces, which had been wounded in extirpating a tumour from the * Powdered agaric. Flour sprinkled over the surface, by exciting coagu- lation often stops the bleeding, Sp. turpentine, alum, blue vitriol, the mineral acids, lunar caustic, &c. &c. &c 44 ELEMENTS OF SURGERY. mouth. It sometimes happens that a proper posture of a limb restrains hemorrhagy. The posture should be one in which gravity favours the descent of blood through the veins, and retards its motion in the arteries. The form of the ligatures used by surgeons is not an object of much consequence when the vessels are small; when a large artery however is to be secured, Dr. Jones recommends them to be round and very firm ; he states, that though a slight force only is necessary to cut through the internal and middle coats of an artery, it is better to tie the vessel more lightly than is necessary, merely to cut through its inner coats, because the cut surfaces will be more certainly kept in contact, the separation of the liga- ture expedited, and the danger of ulceration spreading to the newly cicatrized part diminished. I would here state, that round bobbin forms an excel- lent ligature for the larger arteries, and for smaller ves- sels, a number of sewing threads waxed together of a proper thickness may be used. When the bleeding from an incised wound is arrested, the next thing demanding the attention of the surgeon, is the removal of all extraneous matter ; the clotted blood, dirt, &c. must be carefully washed away, and the sides of the wound are then to be approximated and kept in contact. The measures to be employed for this purpose are strips of adhesive plaster, compresses, bandages, and a proper position of the part, rest, and lastly sutures. The adhesive plasters are in most cases sufficient, when aide dby bandages and a proper posture, without the use of the needle. The sides of the wound being placed in contact, are to be held so by an assistant, and the surgeon is to apply strips of plaster spread on linen or leather across the wound. These strips should be of considerable length, so as to act on a large surface of sound skin, and from half an inch to an inch in width. They ELEMENTS OF SURGERY. 431 should be placed at a small distance one from the other, so as to allow the escape of any extravasated fluid through the interstices. If this caution be neglected, and the plasters placed so as to cover the whole wound, they often convert it into an abscess, by preventing an outlet for superfluous blood or serum, and in case of sup- puration the pus is confined, the parts already united are torn asunder, and the inflammation is extended. If, from the small extent of the wound and other circum- stances, there is reason to expect its union by the first intention, or by the adhesive inflammation, nothing more is necessary than to apply a compress of folded linen, or a pledgit of dry lint over the adhesive strips, and secure them by a few turns of a roller. Should there be no good prospect of so speedy a cure, and reason to expect suppuration, a pledgit of lint spread with simple cerate, and covered with a pledgit of tow or folded linen, may be placed over the adhesive strips and confined by the many tailed bandage, or roller; but it is of no importance to make any difference of treat- ment on account of the uncertainty respecting the man- ner in which the wound is to heal, and it is best to treat incised wounds generally as if the union by the first in- tention were certain. The pledgit of tow or linen which adds somewhat to the pressure, and is calculated to ab- sorb any fluid which may escape from the wound, may readily be superadded if found necessary. In all incised wounds the sides should be placed and kept as much as possible in contact. There can be no application to wounded flesh more natural or proper than the flesh from which it has just been violently separated, and if it do not adhere to it entirely, yet in all proba- bility a very considerable part will, and thus the extent of the wound will be lessened. The rapidity with which incised wounds sometimes unite, is really astonishing to any one not conversant 46 ELEMENTS OF SURGERY. with these wonderful powers of nature. I have seen a considerable tumour cut out from the breast, and in forty-eight hours a complete union of the wound had taken place. The wound may be examined in warm weather in forty-eight hours, in winter it is best not to disturb the dressings for three or four days. If fever and inflammation attend, the usual depleting remedies are to be used : if on the contrary, there be rea- son to apprehend tetanus, wine, opium, and a generous diet are to be prescribed. The blood effused from the wound is in many cases the bond of union in incised wounds, but very often this is lost and adhesive inflammation supervenes; in this case the secreted coagulating lymph becomes the unit- ing medium, and this is soon assimilated to the wound- ed part, becoming bone, tendon, muscle, or skin, ac- cording as the wound has been in any of these parts. The cicatrix however, differs considerably from the ori- ginally formed parts. Posture is of great consequence in the treatment of wounds. The sides of a wound on the anterior part of the thigh cannot be kept in contact, unless the leg be kept extended upon the thigh, to aid the surgeon still more in relaxing the parts, the thigh should be flexed on the pelvis. A wound through the tendo achillis should be treated by extending the foot upon-the leg, &c. Sutures by attending to these preceding directions are very rarely necessary ; and if possible they ought to be dispensed with, as they produce considerable pain, oc- casion great and permanent irritation by creating a num- ber of punctured wounds, which are kept from healing by the ligature left in them ; this ligature passes through a part of the original wound, and never fails to excite suppuration in that part, in addition to these objections, sutures occasion deformity by increasing the extent and irregularity of the cicatrix. Page 47. '*k.>\J'' ///#>■> "M'S - J"'" ' '' PLA1$ ' •X ■W&fc {■■■«£' <*** iff/ \\ ., ,#J I / i.. l % man j.3.i''rXiy '■''• ELEMENTS OF SURGERY. 47 Notwithstanding these objections sutures are some- times necessary in wounds of projecting parts, as the ears, nose, tongue, lips, scrotum, &c. Sometimes the peri- toneum is wounded, and in these cases ligatures are ne- cessary to keep its edges in contact. In all these instan- ces the interrupted, or twisted suture are to be used. The interrupted suture consists in making the necessary number of stitches with an armeo* needle, and tying them in such a manner as to keep the sides of the wound to- gether.* The twisted suture is chiefly used in wounds of the lip ; in the annexed plate these sutures are repre- sented. In the twisted sutures two or more pins of sil- ver with moveable steel points are passed through the flesh, and a ligature twisted round them, so as to con- fine the sides of the wound in contact. In treating hare lip, this suture is generally employed. The pins ought to be made of smooth silver wire, the extremities of which fit into steel points which are taken off when the ligature is applied. If these be not at hand, a piece of wire filed sharp at the end will answer, but after the ligature is bound on, the point must be cut off with a pair of scissors, or a file. When ligatures have been applied upon bleeding ar- teries, the ends of them are to be left long enough to pro- ject a short distance out of the wound, they are to be left out of one of its angles, (the most depending if prac- ticable) and the wound treated as we have already di- rected. When in cases of incised wounds it becomes evident that union cannot be effected without suppuration, the adhes've plasters, and every pressure, every irritation are to be removed, and a soft poultice substituted. When suppuration is fairly established and granulations • The knots should be on one side of the wound. It is right to have the needle shaped so as to form a regular segment of a circle-, and to have t. > cutting edges continued from the point. 48 ELEMENTS OF SURGERY. begin to form, the means already recommended for re- taining the sides of the wound in contact, are to be re- sumed and a cure will generally be soon effected. CHAPTER X. Of Contused Wounds. In contused wounds, besides the simple solution of continuity, there is an injury of the adjacent flesh, great- er or less according to the nature and violence of the force applied. Contused wounds are produced by blunt instruments. It has already been remarked, that these wounds bleed less profusely than simple incisions, and the reasons of this difference have been explained. The indications of cure are to prevent excessive in- flammation, to wait for the separation of the bruised and deadened flesh, and when suppuration is established and granulations form, to approximate and retain in contact the sides of the wound. The best local application is a boiled bread and milk poultice. If inflammatory symptoms run high, blood- letting is to be directed. If great pain or irritation come on, opiates may be given; should gangrene result^ a blister is to be applied. Lacerated wounds partake of the nature of con- tusion, but there is a difference, as their mode of union proves. A severely contused wound never heals by the first intention, because there is an interposition of clot- ted blood and injured flesh, between the sound parts, whereas I have known half the scalp torn off in a lace- rated wound? and the whole of it has reunited bv the elements of surgery. 49 first intention, except the edges which' were greatly bruized. Punctured wounds have considerable depth, and very little external opening: they are made by pointed instruments, as a small sword, bayonet, nails, needles. They are attended with various consequences, according to the nature of the parts injured. In other wounds the nature of the mischief is generally apparent; in punctur- ed wounds, the surgeon is unable to ascertain with ac- curacy the parts which are injured; important nerves, blood vessels or tendinous fasciae are sometimes wounded: very violent inflammation often follows a small punc- tured wound, and collections of matters are sometimes formed, great irritation occasionally occurs, the consti- tution suffers and fever comes on. Tetanus is a fre- quent occurrence after punctured wounds, though 1 have as often seen it a consequence of other contused wounds. Convulsions, tremour, and nervous affections, arc also occasioned. In the treatment of punctured wounds, the first thing demanding attention is hemorrhage. If any blood ves- sel of considerable size have been opened, it must be sought for by dilating the orifice of the wound with a probe and scalpel; the vessel being exposed in this manner, should be tied up with a ligature. In some cases, the bleeding at first profuse gradually ceases, and altm%gh from the rapidity with which it flowed, there may be reason to apprehend the puncture of a large ar- tery, yet the patient is unwilling to suffer his wound to be dilated in order to secure the vessel; and it is a fact that such vessels have sometimes healed without the interference of art. I have been informed of a case in which a very large artery in the thigh, pro- bably the femoral,* was opened by a small sword, * I speak thus cautiously because there was no dissection, but I have no doubt that the wounded vessel was the femoral artery, because the stream of blood was so copious at first as to lead the surgeons present to that opinion, VOL. I. H 50 ELEMENTS OF SURGERY. and although the stream of blood at first was very alarming, yet it soon ceased, and did not recur, until the tenth day, when an officious surgeon forced his probe into the vessel and the patient died in consequence of the bleeding; there is great reason to believe that this patient would have recovered but for the improper inter- ference of his surgeon. Whenever therefore the bleeding ceases spontaneously, or after the wound is dressed, the patient should be kept still and vvatehed carefully, as a return of hemorrhage is to be apprehended. If the punc- ture be on a limb, a tourniquet may be applied and left loose, so that an assistant may have it in his power in a moment to put a stop to the effusion of blood, until the artery is finally secured by a ligature. The healing of a large artery, however, is an event never to be trusted to, and there is no surgical maxim of greater importance than the necessity of tying up all wounded arteries when it is practicable. It is only in cases where this cannot be done that the surgeon is to avail himself of other means for suppressing the hemorr- hage. As all such means furnish important resources to the surgeon, I shall mention a plan which I have known successful in stopping the flow of blood from an artery in the foot. The patient was a child in whom several una- vailing attempts to tie up the divided vessel had been previously made, and the wound was in a state of great inflammation. A compress was applied over the trunk of the anterior, and another over that of the posterior tibial arteries about two inches above the ancle : over these a strip of sheet copper was passed round the leg, and a tourniquet was applied over the copper; in this way, when the tourniquet was tightened, the tibial arte- ries were compressed, and the bleeding ceased, the cop- per prevented the tourniquet from compressing any other vessel, so that the circulation in the foot was not inter- rupted. In a few days the wound healed without any ELEMENTS OF SURGERY. 5t recurrence of hemorrhage. Probably in some analogous cases similar measures may be found successful. When punctured wounds contain foreign substances which are easily felt, they may be dilated sufficiently to allow the extraction of these substances, but in most in- stances it is best to permit them to be discharged by sup- puration. When convulsions, or great nervous irritation follow, the dilatation of a punctured wound frequently puts an im- mediate stop to these symptoms; a small incision upon a probe passed into the puncture, will suffice for this purpose. When punctured wounds occur in extremely hot wea- ther, it is safest to enlarge them by the scalpel, or to apply stimulating substances to excite inflammation; there is reason to believe that tetanus has in this way been often prevented. Erysipelatous inflammation in some instances follows punctured wounds, especially of the scalp ; an enlarge- ment of the wound has been found useful in these cases, and a blister should be applied over the inflamed parts. These are the principal circumstances in punctured wounds, which call for dilatation ; when suppuration is established, if matter be formed and confined, an outlet must be made for it as in any other case. The practice of dilating indiscriminately all punctured wounds is higTiry reprehensible. A soft poultice is the best local application. If the pain be great, opium may be ad- ministered, and if fever or inflammation run high, bleed- ing and depleting remedies may become necessary. They are always, however, and particularly in hot weather, to be prescribed with caution, as they certainly render the system more liable to tetanus: punctured wounds some- times unite by adhesive inflammation, but if extensive they generally suppurate. ;^ ELEMENTS OF SURGERY. CHAPTER XI. Of Gunshot Wounds. Since the application of gunpowder to the purposes of war, a new class of wounds has attracted the attention of surgeons, the nature and peculiarities of which have only within a few years been well understood. " Gunshot wounds are made by the forcible projec- tion of hard obtuse bodies, the greatest number of which are musket balls. " They vary according to the kind of body projected, the velocity of the body, and the nature and peculiari- ties of the parts injured. The kind of body projected, is principally musket balls, sometimes cannon balls, some- times pieces of broken shells, and very often on board of ship, splinters of wood. The effects of cannon balls on different parts of the ship, are the principal causes of wounds in the sailor, for a cannon ball must generally pass through the timbers of the ship before it reaches him; a greater number will be wounded by the splinters thus torn off, than by the ball itself. The wounds oc- casioned by these splinters, differ in no respect from contused and lacerated wounds from other causes. " Gunshot wounds are in general contused wounds, from which contusion there is most commonly a part of the solids surrounding the wound deadened, as the projecting body forced its way through these solids, which is after- wards thrown off in form of a slough, and which prevents such wounds from healing by the first intention, or by means of the adhesive inflammation, from which circum- stance most of them must be allowed to suppurate. This docs not always take place equally in every gunshot wound, nor in every part of the same wound ; and the ELEMENTS OF SURGERY. 53 difference commonly arises from the variety in the velocity of the body projected; for we find in many cases, where the ball has passed with little velocity, which is often the case with balls, even at their en- trance, but most commonly at the part last wounded by the ball, that the wounds are often healed by the first intention. " Gunshot wounds, from the circumstance of com- monly having a part killed, do not generally inflame so readily as those from other accidents; this backward- ness to inflame, will be in the proportion that the quan- tity of deadened parts bear to the extent of the wound. " From the circumstance of a part being deadened, a gunshot wound is often not completely understood at first; for it is at first, in many cases, impossible to know what parts are killed, whether bone, tendon, or soft part, until the deadened part has separated, which makes it a much more complicated wound than at first was known or imagined; for it very often happens, that some viscus, or a part of some viscus, or a part of a large artery, or even a bone, has been killed by the blow, which does not show itself till the slough comes away. If for instance, it is a part of an intestine that has received a contusion, so as to kill it, and which is to slough, a new symptom will most probably appear from the sloughs being separated, the contents of the intestine will most probably come through the wound ; and probably the same thing will happen when any other containing viscus is in part deadened ; but those cases will not be so dangerous, as if the same loss had been produced at first, for by this time all communica- tion will be cut off between the containing and contained parts; nor will it be so dangerous as when a consider- able blood-vessel is deadened; for in this case, when the slough comes off, the blood, getting a free passage into the wound, as also out of it, probably death will im- &4 ELEMENTS OF SURGERY. mediately follow. If this artery is internal, nothing can be done ; if in an extremity, the vessel may generally be- taken up. When the bone is deadened, an exfoliation must take place." (Hunter.) The velocity with which the ball passes has a great influence on the circumstances of these accidents. If the velocity be small, there is not so great a chance of their being compounded with fractured bones; but if the velocity be sufficient to break the bone it hits, the bone will be much more splintered than if the velocity had been very considerable for where the velocity is very great, the ball as it were, takes a piece out. In a very hard bone the splinters will be most numerous. The direction of a ball is influenced by the celerity of its motion. If it move with but little force, it is easily al- tered from its straight direction, by a bone, where the velocity is greatest, the course is most direct. The greater the velocity of a bullet, the greater will be the extent of the deadened parts, consequently the slough is always greater at the entrance than at the exit of a ball, and in some cases the part at which it passes out, heals by the first intention or by suppurative inflam- mation without casting off any slough. Gunshot wounds like all other contused wounds, bleed less than simple incisions, the explanation of this has already been offered. If, however, large vessels are deadened by the ball, when the sloughs separate there will be great danger of hemorrhage from the opening formed in the artery. , There is very frequently extraneous matter contained in gunshot wounds, as the bullet carries in with it all the clothing which had been on the wounded part, and often remains itself in the wound, much altered in form from the effects of bones upon it. I have seen a bullet beat out nearly as thin as paper,, by passing through a rib and lodging in one of the vertebrae. These extraneous ELEMENTS OF SURGERY. 55 substances however do less mischief than in any other kind of wounds, because as they are in contact with dead parts, they occasion no irritation, and as these dead parts are themselves foreign matter and must be discharged by suppuration, the wound is not much de- layed in healing by their presence. TREATMENT OF GUNSHOT WOUNDS. The various phenomena of gunshot wounds, being of a nature not very readily explained by the older sur- geons, induced some to believe that they were poisoned, others imagined the ball to be intensely hot, and sup- posed the peculiarities of these accidents to depend on the burning of the sides of the wound. The essential difference, and the only difference between gunshot and other contused wounds, is found to consist in the death of those parts through which the ball has passed, and the necessity for the separation of these parts before union can be effected. Jt was formerly the custom to dilate all gunshot wounds, and much mischief has resulted from the prac tice. There is nothing in the nature of this kind of ac- cident that calls for dilatation in every case, nor is there any thing forbidding the practice when particular cir- cumstances render it proper. If an artery be opened by a gunshot wound, and the enlargement of the wound by a knife will enable the surgeon to tie it up, he ought surely to perform the operation. In general it is unne- cessary to dilate a gunshot wound for the purpose of ex- tracting a bullet or other extraneous matter, because suppuration must come on, and this process w ill gene- rally effect the object. If extraneous matter is perceived, and can easily be removed, it may be done; but it is wrong to enlarge the wound or take much pains to ef- fect, what will be more readily done at a future period. The same reasons which would induce a surgeon to di- 56 ELEMENTS OF SURGERY. late a punctured wound, or any other kind of wound, should lead him to dilate a gunshot wound, these reasons have been already stated. When a ball can be found without difficulty, it is right to extract it by means of forceps, the course of a ball however is so extremely irregular, that we are not always able to find it. The glancing of balls is in many cases very surprizing. Mr. Hunter has seen a bullet enter the ^kin over the tibia, and pass round the leg un- der the skin without injuring either the bone or the skin. Wiseman relates cases where balls have passed through joints without occasioning an injury to the bones or car- tilages. When the velocity of a ball is nearly spent, a slight resistance will turn it from its course; balls have been known to pass round half the skull between the cranium and scalp, and then pass out opposite the part at which it entered. In the same way they have passed round the thorax, and glancing from a rib and kept from passing out by the resistance of the skin. Mistakes have been occasioned by these irregularities, and bullets are said to have passed through the head and chest in many cases where no such thing has happened. The posture of the body when the wound was received, should be attended to when the course of a bullet is searched for; a ball has entered the arm and been found on the oppo- site side of the body, owing to the horizontal posture of the limb when wounded. In many instances balls pass immediately under the skin to a considerable distance, their course being mark- ed by a red line extending from the spot where it enter- ed, to that at which it escaped or is lodged. Where bullets are lodged superficially under the skin, they may with great safety and propriety be cut out, and no mis- chief in general arises from this new opening. The propriety however of extracting balls thus situated has been questioned, and Mr. Hunter remarks, that if the ELEMENTS OF SURGERY. 5J skin over it be quite sound, he would " in that case ad- vise letting it alone, until the wound made by the en- trance of the ball had inflamed and was suppurating." His reasons for this direction are, " 1st. We find that most wounds get well when the ball is left in (except- ing it has done other mischief than simply passing through the soft parts) and that very little inflammation attends the wound where the ball lodges, only that where it enters, the inflammation not arising so much from the injury done by the ball, as from the parts being there exposed to the suppurative inflammation, if it is immediately removed. There is always a greater chance of a slough where the ball enters than where it rests, arising from the greater velocity of the ball, for beyond where the slough is, the parts unite by the first in- tention."' " 2dly. In those cases where the ball passes through and through, we have two inflammations, one at each orifice, instead of the one at the entrance, or a continued inflammation through and through, if the ball has pass- ed with great velocity. Where the ball makes its exit, the inflammation passes further along the passage of the ball, than when the wound has been healed up to the ball and then cut out afterwards, so that by opening immediately the irritation will be extended .further, and of course the disposition for healing will be prevented. If this is the case, I think that two wounds should not be made at the same time, and what convinces me more of it is, that I have seen cases where the balls were not found at first, nor even till after the patients had got well of their wounds, and these balls were found very near the skin. They gave no trouble (or else they would have been found sooner) no inflammation came upon the parts, and afterwards they were extracted and did well." VOL. I. T 58 ELEMENTS OF SURGERY. " Again T have seen cases where the balls were found at first, and cut out immediately, which were similar to balls passing through and through : the same inflamma- tion came on the cut wounds that came on the wounds made by the entrance of the ball." On these remarks of Mr. Hunter, I beg leave to offer a few observations. A musket or pistol bullet will doubt- less in a majority of cases excite no unpleasant symp- toms, the parts will heal around it forming a sac; but a bullet is always extraneous matter, and in a majority of cases carries with it other extraneous matter, cloth, linen, &c. which cannot fail to irritate the flesh in which they lodge; they act like setons in keeping up suppura- tion and preventing the union of the wound, effects which I have witnessed in several cases ; in one a very large abscess was formed on the back in consequence of a ball being suffered to remain nineteen days under the skin near the angle of the scapula. It is with great diffidence that I would venture to op- pose on a practical point, the authority of Mr. Hunter, but I cannot but believe it right whenever a ball presents itself in such a situation, as that it may be extracted with facility, and without risque of injuring any important part to remove it immediately, without waiting for sup. puration. The wound made by the knife may common- ly be healed by the first intention. The ball should be suffered to remain whenever it is deeply buried among the flesh. All other extraneous matter if easily remov- ed should be extracted, but probing or other violence must be avoided ; the finger is to be preferred to all in- struments in examining gunshot wounds. Sometimes bullets are lodged in the substance of the bones, all violent attempts to remove them are wrong, the bone will exfoliate, and when suppuration takes place, the ball will be discharged. In some cases balls Paqe 59 JVrrvs bulht fi>nr/>s I'l. 'J. ELEMENTS OF SURGERY. 59 have remained in bones during life without exciting any unpleasant effects.* When an extremity has been shattered by a cannon ball, the extent of injury is in some instances so great as to require the immediate removal of the member, we shall mention the circumstances which call for this ope- ration, when we treat of amputation. The best local application to a gunshot wound, is a soft poultice of bread and milk, or linseed, to be con- tinued until the sloughs separate and suppuration is es- tablished. The treatment is to be similar to that of any other contused wound. The state of the constitution must be very carefully attended to. When there is reason to apprehend that the parietes of any considerable blood vessel has been killed by the ball, great care should be taken to attend to the separa- tion of the sloughs as serious and fatal hemorrhages have sometimes resulted from neglecting this cautioa. When bones are injured, the soft parts in some cases heal up, and when the injured bone exfoliates, an abscess forms, and the wound must be opened afresh. * For the removal of musket balls, a variety of forceps have been constructed. A prize was given by the French Academy of Surgery to Mr. Percy for one which appears to answer extremely well. The instrument is represented in PI. U, When a leaden ball is lodged in a bone, the screw which is contained in one of the handles may be easily made to enter it, and it can be extracted- This screw, however, is so seldom needed, that it is omitted in the bullet forceps used in the service of the United States. 60 ELEMENTS OF SURGERY. CHAPTER XII. Of Poisoned Wounds. Poisoned wounds are those attended with an introduc- tion of certain healthy or morbid secretions of animals or vegetables capable of producing disease and death ; as the bite of a venomous reptile, of a rabid animal, or a wound with a poisoned arrow.* The sting of a bee, w asp, or hornet, the bite of a mus- quitoe, and certain other insects, although in degree very moderate, probably partake somewhat of the nature of poisoned wounds. It is unnecessary to say much of these. Although frequent in their occurrence, they are generally not so severe as to require medical aid. The sting of a bee, wasp or hornet, is always extremely pain- ful, and i^followed by inflammation, and sometimes by great tumefaction. Cold applications afford great relief. Cold water or lead water may be used. When the patient has been attacked by a swarm of these insects, and his head and face (which generally in these cases suffer) are much swelled, bleeding and a purge become necessary. The bite of the musquitoe is in some parts of our coun- try extremely annoying, and excites considerable in- flammation, attended with intolerable itching. In some rare instances, owing probably to peculiarity of constitu- tion, gangrene has resulted from the bite of this insect. I once knew a case of it fatal in a lady of this city, whose health previously was very good. Camphorated spirits, brandy, or vinegar, generally afford relief of the itching, and the inflammation in a few hours commonly subsides. Violent rubbing to allay the itching should be avoided. t * With respect to the manner in which poisons act in producing death, the reader is referred to Fontana; the late experiments of Mr. Magendie upon the " upas tieute," and also to the interesting experiments of my friend Mr. Brodie, related in the Transactions of the Royal Society of London. ELEMENTS OF SURGERY. 61 The rattle snake, one of the most venomous reptiles in the world, is found in many parts of our country.* Like the cobra de capello in India, the bite proves speedily fatal, and we have very few histories of the effects of the poison. Professor Barton, whose indefatigable labours have thrown light on every branch of physical science, has published in the 3d vol. of American Philosophical Transactions, a valuable paper on the subject, to which the reader is referred for much interesting information. It appears from Dr. Barton's remarks, and from the ohservation of others, that " in the season of supervening languor and torpidity, the rattle snake in particular bites with seeming reluctance, and without any or with but little ill consequence arising from the wound;" and " even in those seasons when the sun powerfully exerts its influence, at which times these animals are best quali- fied to strike and to injure, individuals of the species must be often found, the cavities of whose venomous fangs are entirely or nearly destitute of their active poi- son, from the introduction of which into their body tfiose alarming symptoms which characterise the successful bite of this animal arise." Three chickens were bit by a rattle snake kept in a cage, on three successive days. The first died in a few hours; the second survived much longer than the first; the third swelled much, but never- theless recovered. On the fourth day several chickens were bitten, without receiving any injury. These cir- cumstances are mentioned by Dr. Barton, to shew that the various supposed vegetable specifics for the bite of the rattle snake owe their reputation to their having been used in cases where no bad effects would have resulted. As the poison of the rattle snake " exerts its principal effects on the sanguiferous system," immediate care • There are several species of crotalus. which is the most common species. I refer to the " crotalus horridus," 62 ELEMENTS OF SURGERY. should be taken to cut off the circulation of blood through the wounded part. When the poison enters a considera- ble vein or artery, death in general speedily ensues ; often in the space of two minutes. Of this Dr. Barton has been assured from a variety of sources, although he is unwilling to believe the wound necessarily mortal. The wound being generally in the lower extremities, he recommends the immediate application of a tight ligature round the limb, to prevent the access of the poison to the circulation either by the veins or absorbents. u As poi- sons of various kinds are liable to be detained for some time in the glandular appendages of the absorbent sys- tem, it would perhaps be of use to scarify these parts, and apply a blister to them, in order to promote the dis- charge of the poison." When the glands in the groin swell, as they speedily do after a bite in the foot, the scarifications are to be made there, and a prompt vesica- tion excited by the bark of the Daphne Griidium. I think there can be no doubt of the propriety of ex- tirpating immediately the wounded part, as this will effectually cut oft* all communication with the circulating blood. The use of the numerous vegetable remedies which have been employed in these cases appears en- titled to but little attention. The internal administration of volatile alkali has been very often employed, but pro- bably its virtues are much overrated. " When the poison of the rattle snake has actually been introduced into the general mass of blood, it begins to exert its most alarming and characteristic effects. A considerable degree of nausea is a very common symp- tom. We now discover an evident alteration in the pulse; it becomes full strong and greatly agitated ; the whole body begins to swell; the eyes become so entirely suffused, that it is difficult to discover the smallest portion of the adnata that is not painted with blood. In manv instances there is an hemorrhage from the eyes and ELEMENTS OF SURGERY. 63 likewise from the nose and ears ; and so great is the change induced in the mass of blood, that large quanti- ties of it are sometimes thrown out on the surface of the body in form of sweat. The teeth vaccillate in their sockets, whilst the pains and groans of the unhappy sufferer too plainly inform us that the extinction of life is near at hand." " In this stage of its action, and even before it has induced the most alarming of the symptoms which I have mentioned, the powers of medicine can do little to check the rapid and violent progress of this poison. The em- ployment of the ligature, the use of the blister, and of the other modes of treatment which I recommended in the local stage, it is obvious to remark, will be of little, if any benefit here." (Barton.) Perhaps the same remarks will be found applicable in cases of bites from the other venomous serpents of America, but my own experience does not warrant me in offering any thing on this subject. The bite of rabid animals is in all instances to be treated by extirpation with the knife, and when any doubt exists as to the removal of all the injured parts, caustic should be applied, so as to render their separation absolutely certain. This is to be done even if months have elapsed after the healing of the wound, upon the principle of leaving nothing undone which can possibly be instrumental in preventing so terrible a disease as hydrophobia. Inoculation with morbid poisons is foreign from our present subject, and with respect to poisoned arrows, and the effects of the " upas tieute," I refer to the experi- ments of Mr. Magendie. 61 ELEMENTS OF SURGERY. CHAPTER Xni. Of Particular Wounds. The Scalp is liable to all the varieties of incised and contused wounds ; they are often accompanied with in- juries of the brain. A mere wound of the scalp is to be treated as a similar wound in any other part. The hair is to be carefully shaved, the extraneous matter removed, the divided parts replaced in contact, and secured so by adhesive plaster, or if necessary, by stitches. The vessels of the scalp seldom bleed so as to require the use of a ligature. When a large artery, however, is opened, as the occipital, or one of the principal branches of the tem- poral, it must be taken up: the needle is found more convenient for tying up arteries in the scalp than the tenaculum. Punctured wounds of the scalp often occasion violent inflammations, in consequence of the parts underneath the tendon of the occipito frontalis muscle being injured. The usual remedies for inflammation relieve it. In extensive lacerated wounds great portions of the scalp are separated, leaving the pericranium, and in some places, the bone bare. It was the practice for- merly to remove all such detached portions by the knife than which nothing can be more absurd. The doctrines of adhesion, taught by Mr. Hunter, have in this, as in many other important instances, triumphed over the bar- barisms of former ages, and demonstrated the propriety of preserving, in every instance, the separated scalp. The parts are to be cleansed and placed in contact, and they will generally unite by adhesive inflammation ; and if suppuration should even take place, granulations will form, and the union, though more tardy, will be equally certain. I have seen nearly one half the scalp torn off, ELEMENTS OF SURGERY. 65 and covered with dirt and splinters of wood, which, when rarefully cleansed and replaced, united in a few days With very little suppuration. WOUNDS OF THE FACE. The face is liable to the various kinds of wounds which have been described, and they require no particu- lar mode of treatment from their situation, except that it is of peculiar importance to make the cicatrix as small and as smooth as possible, to prevent deformity. Sutures are of course to be avoided, and sticking plaster to be used. In wounds of the eyelid, however, it sometimes happens that a stitch or two are necessary. In these eases great care must be taken not to pass the ligature through the adnata, as in that case great irritation will be the consequence. In the treatment of wounds of the eye, the great objects are to extract all foreign matter and to make use of very powerful measures to prevent and relieve the inflammation of this important organ. The various re- medies for inflammation of the eye will be detailed when we speak of ophthalmia. Where the lip is cut through, if the wound be small, sticking plaster will be found sufficient to keep its sides together ; but if it be half an inch or more in extent, the interrupted or twisted suture will be neces. sary. When the tongue is cut, stitches must be used. In children we often find the tongue wounded by the teeth in consequence of falls. A hook is in these cases generally necessary to keep the tongue sufficiently for- ward to enable the surgeon to perform the operation. A piece of soft wood should be placed between the teeth to prevent the child from biting the surgeon. In the course of six or eight days the stitches may be removed. Dur- ing the cure the child should not be allowed to chew any solid food, but must be nourished entirely on fluids. VOL. I. K 66 elements of surgery. When the ears are wounded, if a portion is nearly detached, stitches are necessary ; but in many cases the adhesive plaster is found equally effectual, and should therefore be preferred. Contused wounds of the face are to be poulticed until suppuration commences and granulations form, and then the adhesive strips are to be applied. wounds of the throat. From the important parts which are here situated, and from the magnitude of the blood vessels generally divi- ded, wounds of the throat are among the most dangerous to which the surgeon is called. Superficial wounds of the throat require no particular treatment, but generally heal as readily as wounds of other parts. Sometimes, however, the trachea is divided, together with large veins and arteries, even the oesopha- gus, and carotid artery, without immediate death.— Whenever the carotid artery is opened freely by a sharp instrument, fatal hemorrhage very promptly takes place; but Mr. Abernethy has recorded an instance in which a lacerated wound of this vessel was occasioned by the horn of a cow, and the bleeding was not attended with fatal consequences. Wounds of the throat most frequent- ly occur in attempts to commit suicide; and as the in- strument is commonly a razor or very sharp knife, the hemorrhage is profuse, and is always the first thing de- manding attention. Every bleeding vessel should be immediately secured by a ligature. The external jugular veins are generally opened, and these, as well as the divided arteries, are to be tied. The carotid itself should be tied up, if the surgeon arrive in time to effect it. Mr. Abernethy, in the instance just noticed, secured this vessel by a ligature, and his patient survived thirty lumrs. He remarks that, "shonld it become necessary at any time to tie the carotid ELEMENTS OF SURGERY. 6? artery, it may be done without much difficulty or danger, even without an accurate dissection of the part. If the incision be made on that side of the artery which is next the trachea where no important parts can be injured as was done in the present instance, the finger can then be passed behind the artery so as to compress it. The ves- sel being sufficiently bulky and firm to make its form and outline distinctly perceptible, a needle may then be pass- ed behind the artery as near as possible to that edge of it which is next to the internal jugular vein ; there can be little risk of wounding that vessel, or of including in the ligature the eighth pair of nerves which lies between them. In attempting to secure the carotid artery I passed behind it in the manner described, a blunt hook with an eye in the point, and having previously introduced a liga- ture into it, I drew back the instrument and thus enclos- ed the artery." In an incised wound of the carotid artery a very dif- ferent and much more expeditious method w ould be ne- cessary. The operation has hitherto never been done, but a case may possibly occur in which the surgeon may be present. In such a case 1 can see no impropriety in passing a sharp armed needle round the carotid without attending to nerves or any thing else. This ligature be- ing given to au assistant, a second should be instantly passed in the same manner round the upper orifice. The hemorrhagy could now be restrained until the wounded vessel could be drawn out separately with a tenaculum or forceps, and both its cut extremities tied; after which the first ligatures which had been used as tourniquets should be removed. The hemorrhage being stopped, the sides of the wound are to be brought together, if possible without the use of stitches. Where the trachea is only partially divided, adhesive plaster may always be used ; if it be cut com. pletely through, it is generally recommended to make 68 ELEMENTS OF SURGERY. use of the interrupted suture ; but in some cases the stitches occasion great irritation, and are ulcerated out before the union of the wound, leaving it in the same state in which it had been before the use of the needle. The interrupted suture is, however, to be used, whenever the wound of the trachea cannot be approximated without it; and whenever it is used, great care must be taken to pass the needle merely through the cellular texture surround- ing the trachea, as the thread, if allowed to pass through the inner membrane of this canal, would add greatly to the irritation. In addition to this the head must be bent forward so as to favour the approximation of the sides of the wound, and it is to be kept so by bolsters and banda- ges. Great care, however, is necessary in all such cases, to guard against a collection of blood or mucus in the trachea, as death has been occasioned by a neglect of this caution. Whenever blood flows in this way into the tra- chea, and is not readily coughed up, the wound should "be opened, in order that it may be discharged. Where the oesophagus is also opened, it is difficult, unless the external wound be very extensive, to make any application to it. Desault in these cases recommends the introduction of an elastic catheter of large size, through which the necessary food may be injected into the stomach, and this practice has been found extremely useful in a number of cases. It should be suffered to remain during the cure, and will produce no ill effect, but on the contrary will preclude all that irritation w hich would arise from the action of the muscles in attempts to swallow. The tube may be passed either through the mouth or nostril, according to circumstances. The oeso- phagus is sometimes punctured by a sword, bayonet, or knife, without any wound of the trachea. In this case, if the blood vessels escape, the wound generally heals readily. The great contraction of the parts in large wounds of ELEMENTS OF SURGERYr 69 the throat produces a very unpleasant appearance of loss of substance. I have seen several cases in which scarcely any soft parts intervened between the lower jawr and the sternum ; the throat seemed to have sunk into the thorax, or to have been cut away and removed In the medical commentaries a case is related by Mr. Stark, in which this retraction was so great that " between the clavicles and os hyoides there was only one cqntinued gash, which looked as if the windpipe and gullet had been cut out entirely." In these cases great attention must be paid to keeping the head close to the top of the chest. Longitudinal wounds of the trachea heal in general without difficulty by the application of sticking plaster. It has been doubted by some surgeons, " whether the oesophagus can ever be wounded without destroying at the same time the large blood vessels and nerves, so that the patient must instantly die."* There is no doubt that the escape of food and liquids through the external open- ing has been considered a proof of a wound in the oeso- phagus in cases where the knife or razor has passed above the os hyoides and entered the mouth ; but it is equally certain, that in many cases the trachea has been completely divided, and the oesophagus not merely open- ed, but cut nearly asunder, the wound extending almost to the cervical vertebrae, without injuring the carotid ar- teries. Mr. Stark's case was of this kind. " The pharynx was cut through, except about a finger's breadth of the back part." I have seen a case nearly similar, in which the trachea was cut completely asunder, and the oesophagus opened, without any wound of the carotid ar7 tcries. * Latta, Vol. JII. p. 134. ?0 ELEMENTS OF SURGERY. CHAPTER XIV. Of Wounds penetrating Cavities. The thorax and abdomen are sometimes opened, and very dangerous consequences often result, especially if any of the viscera contained in these cavities are injured, WOUNDS OF THE THORAX. When the thorax is wounded to a depth sufficient to open the cavity of the pleura, the admission of air pro- duces an immediate collapse of the lung, and breathing is performed with great difficulty. The lung so comlpete- ly fills the cavity of the chest that it is generally injured in gunshot wounds and in stabs with a dirk or sword. When this is the case blood is coughed up. When a considerable blood vessel is opened either in the parietes of the thorax or in the lung, blood collects in the cavity of the chest, produces great oppression, and increases the difficulty of breathing. When the wound is a simple incision through the parietes of the thorax, it should be dressed with adhesive plaster, its sides being accurately brought in contact. A compress should be next applied, and over this a roller moderately tight round the chest. The patient should be kept at rest, and observe a strict antiphlogistic regi- men, and be bled to prevent the accession of inflamma- tion. Treated in this way, incised w ounds of the thorax very generally heal without difficulty. The great object of the surgeon in every sueh case is to effect as speedily as possible the union of the wound, because whenever the cavity of the thorax is opened, unless union by the first intention or by adhesive inflammation takes place, violent inflammation comes on, frequently followed by fatal consequences. ELEMENTS OF SURGERY. 71 The practice of closing the external wound after a violent effort to force out the air from the pleura, and in- deed all attempts to draw the air out from it, ate unne- cessary ; the wound may be closed without attending to the state of respiration, and the air left in the cavity of the chest will be absorbed without occasioning any ill effects. The great anxiety which has been shewn to eva- cuate the air originated in an opinion that the air of the atmosphere is a violent initant, capable of exciting great inflammation, an opinion not at all founded in truth. In the year 1790, Dr. Physick injected air into one side of the thorax of a kitten, through a small puncture be- tween the ribs. The wound healed by the first intention, and appeared to occasion very little inconvenience to the animal. On the fourth day the kitten was killed, and not a vestige of inflammation was observable. Many cases have occurred in the human subject in which the cavity of the pleura has been filled with air in conse- quence of a wound, and the wound being speedily heal- ed, no inflammation has resulted. I once saw an officer who had been wounded with a dirk; the air entered and passed out of the wound freely during respiration; this wound united by the first intention, and in a week he was completely well, not having experienced a single symp- tom of thoracic inflammation. It happens in many cases that the existence of pulmo- nary disease occasions adhesions between the pleura costalis and pleura pulmonalis, in such a manner as par- tially or even totally to obliterate the cavity of the pleura. When a wound is received in the chest under these cir- cumstances the danger of inflammation is much dimi- nished. Whenever inflammation comes on in consequence of a wound in the chest, bleedings, copious and repeated, must be employed ; all the remedies for inflammation are to be vigorously administered, and in general they are successful. 7% ELEMENTS OF SUHGE1U. When the lung is wounded the patient will cough up blood, and if a large vessel be opened, (and a great num- ber exist in the thorax of the largest size) fatal hemorrha- gy will in general quickly ensue, and yet the heart itself has in some cases been wounded, and also the aorta, without immediate death. There is reason to believe that the heart has often been slightly wounded without fatal consequences, and Dr. Babington has related a very interesting case in which the heart was wounded by a bayonet without immediate death. The patient was a marine on board a ship of war, and acting as centinel at the gang- way, fell through to the lower deck, and caught upon the point of his bayonet. " It entered his side a little below the false ribs, nearly in a perpendicular direction, and had penetrated to its hilt, having sustained the weight of his whole body. The poor man at the time did not feel himself much wounded. He drew out the bayonet without assistance, rose, lifted his musket, said he was not much hurt, and, as if he thought himself still fit to continue centinel, walked eight or ten steps, then dropt down suddenly in a faint. On being laid in a hori- zontal posture he soon recovered, and was brought to the hospital (at Haslar) about 7 o'clock in the evening, which was about two hours after the accident. He then made very little complaint of pain, but lay constantly on the side opposite to that which was wounded, was in- clined to sleep, and when asked a question, spoke slowly, as if in great distress. The wound was in the left side, about two inches above the hip bone, and penetrated into the cavity of the belly, but neither its direction nor depth could be ascertained. He did not seem to have bled much, but was very faint, his body cold, and the pulse scarcely perceptible. The circulation was so languid, that, though a vein was opened in both arms, no blood could be obtained." He soon after his admission int© ELEMENTS OF SURGERY. 73 the hospital began to breathe with difficulty, (which at first he had not done.) A great sense of weight was experienced about the chest. He felt some pain in the breast. A swelling next took place, proceeding from the breast all over the body. A little after two o'clock in the morning, (nine hours after the wound was received,) a sudden strangulation in the throat put a period to his life. Upon dissection it was found that the bayonet had penetrated through the integuments, the abdominal mus- cles and peritoneum, bad pierced the colon, the stomach, the left lobe of the liver, the diaphragm, and entered the thorax at its centre. Immediately within the. breast the pericardium had presented and yielded the instrument a ready passage to the heart. The right ventricle there received it. The point was thrust in at the lower part of the ventricle, and had forced its way out near the valve. From the heart, again passing the pericardium, it pierced through both the upper and middle lobes of the lungs, but even these were insufficient to detain it. It forced a passage on the right side near the sternum, between the cartilages of the second and third ribs, and had sheathed its point beneath the pectoral muscle. That muscle was slightly wounded, but the integuments above it were unhurt. A little bloody serum was found in the cavity of the belly, but scarcely any pure blood. The pericardium contained a little blood. The right side of the breast contained above two quarts of blood, partly in a fluid and partly in a coagulated state. I have quoted this abridgement of the case, because, although so terrible a wound as that here described must be considered necessarily fatal, yet, during the time the patient lived, a simple puncture of one of the cavities of the heart might have united. Mr. Pelletan, at present one of the surgeons to the French emperor, a man of the highest professional re- vol. i. t 74) ELEMENTS OF SURGERY. spectability, has lately published a case in which the aorta was punctured by a small sword in a duel. The weapon entered above the right pap, and from his bent posture, passed through his body and out of the left side near the lumbar region. The young man declared the wounds to have been made by the same thrust, (which was doubted at first from the strange course of the sword) and said he had himself pulled it out. The most dan- gerous consequences were expected, but many days passed without any. He complained of pain in the lumbar region, but the warm bath, two bleedings, and a low diet relieved this, and he. lived two months after the accident, at which time he expired in great pain, a tu- mour having formed opposite to the eighth dorsal verte- bra. Upon dissection the right side of the chest was found filled with blood coagulated in different degrees. This blood led to an opening as large as a writing quill, with which the aorta was pierced, above the crura of the diaphragm. These crura and the surrounding cellular texture were injeeted with extravasated blood. No viscus of the abdomen or thorax had any mark of injury (the sword having probably passed behind them) and there was no reason to expect a priori a wound of the aorta.* Hemorrhage from wounds of the chest cannot be com- manded by ligature, unless it proceeds from an intercos- tal artery. The intercostal arteries are sometimes wound- ed, and although not very large, bleed freely. It has been proposed to secure the vessel by passing a liga- ture round the rib, and tying a piece of lint upon it. As this operation, however, would leave a foreign sub- stance in the cavity of the thorax (a portion of the ligature) much inflammation would result from it; and although I have never seen such a case, I cannot but express my * Chinique Chirurgicale, torn. i. p. 92. A case of ruptured aorta is described by Mr. Linn, j\m. in which the patient Survived two weeks. Medical Records. ELEMENTS OF SURGERY. 75 opinion that a safer measure would be to make a free ex- ternal incision, and secure the vessel in the usual way, pulling it out with a tenaculum which could with com- mon dexterity be performed. Wounds of the larger vessels of the lungs generally terminate the existence of the patient in a few minutes. If the lungs be wounded, without injury to any of the great vessels, abscesses frequently form in the chest, attended with hectic fever, night sweats, great exhaus- tion, diarrhoea, and eventually death. In some cases, however, bullets and also small swords, have passed through the chest, and still the patients have recovered. Mr. Hunter remarks, " It is pretty well known that wounds of the lungs (abstracted from other mischief) are not mortal. I have seen several cases where the patient has got well after being shot quite through the body and lungs, while from a very small wound made by a sword or bayonet into the lungs the patients have died, from M which I should readily suppose, that a wound in the lungs from a ball would in general do better than a wound in the same part with a pointed instrument, #8d this difference in effects would in many cases appear to arise from the difference in the quantity of blood extra- vasated, because the bleeding from a ball is very incon- siderable in comparison with that from a cut, and there is therefore a less chance of extravasated blood, either in the cavity of the thorax or the cells of the lungs. Ano- ther circumstance that favours the gun shot wounds in these parts is, that they seldom heal up externally by the first intention, on account of the slough, especially at the wound made by the entrance of the ball, so that the external wound remains open a considerable time, by which means any extravasated matter may escape ; but even this has often its disadvantages, for by keeping open the external wound which leads into the cavity, we give a chance to produce the suppurative inflammation through 76 ELEMENTS OF SURGERY. the whole surface of that cavity, which would most pro- bably prove fatal." When the quantity of blood poured out into the cavity of the pleurals small, if it do n«t readily escape at the external wound, the absorbents take it up; but if the wounded lung continue to bleed into the cavity of the pleura, symptoms of an alarming kind are produced. Great prostration of strength, which proceeds from the nature of the parts wounded, and perhaps a fainting from the quantity of blood lost to the circulation. A great heaviness will be felt in the breast, and considerable difficulty of breathing. The causes of this difficult respi- ration will be the pain which the patient will have in ex- panding the lungs in inspiration ; the injury of some of those muscles w hich move the ribs ; and also the dimi- nution of the capacity of the thorax, from the effusion of blood into the cavity of the pleura which prevents the complete expansion of the lungs. The patient will not be able to lie down, but must sit nnright, because this posture throws the weight of the ei&sed blood upon the diaphragm and forcing this down- wards, somewhat enlarges the thorax. Wrherever a large, extravasation of blood into the cavity of the pleura exists, an opening for its evacuation must be made, and this should be done if possible before it coagulates, in order that it may the more readily escape through a small wound. In some cases it may be convenient to enlarge the original wound, but it is often necessary to make a new opening, which may be done w ith a scalpel, just above the upper edge of any of the ribs. If a small opening suffice to evncuate all the blood, it will be more apt to heal by the first intention, but if the blood be found coagulated, a larger aperture will be necessary. When the contents are evacuated the w ound must be accurately closed with adhesive plaster. ELEMENTS OF SURGERY. - 77 Sabatier takes notice that many writers recommend this operation, but that very few have performed it. He relates, however, one case in which it became necessary from a bleeding from the internal mammary artery after a gun shot wound. Mr. Saucerotte performed it, and his patient recovered.* The treatment of gun shot wounds penetrating the thorax, is to be extremely simple ; superficial dressings are to be applied, a soft poultice enclosed in a bag of gauze or muslin, or a pledgit of linen rag spread with simple cerate may be used. Great care is necessary to prevent the dressing from being drawn into the chest during inspiration, as much irritation would be the con- sequence of any foreign substance being introduced into the cavity of the chest. Gun-shot wounds through the chest, when the sloughs separate, leave very considerable openings into the cavity of the pleura, and although it is a fact that these wounds are less generally fatal than stabs with sharp instru- ments, from their bleeding less freely, yet they axe much more complicated, and often attended with fiw- tures of the ribs, and with extraneous matter in the tho- rax, as the clothing of the patient and the ball. They are followed by tedious exfoliations of the ribs ; by long continued suppurations and hectic fever, which however are not always fatal. In some instances the suppuration takes place from the whole cavity of the pleura, and im- mense quantities of pus are discharged. In some the luug gradually wastes away, and nothing remains of it but a hard diminutive tubercle at its root. '• When a man is shot through the lungs, if death be very near, it must be from suffocation, and you will find him with a bloody foam at his mouth, his face pale at the checks, and livid round the lips and eyes, heaving the breast with intolerable anguish, tossing from side to side • Medicine Operatore 78 ELEMENTS OF SURGERY. in bed, the bloody foam increasing, the breathing be- coming more difficult, and the blood and air rattling in the throat; then the pulse flutters, and the extremities continually grow colder, till struggling in something like a convulsion he expires." John Bell. In this manner soldiers frequently perish on the field of battle, their cases admitting of no relief. But many cases, as we have already stated, do admit of relief, and as the primary danger depends on suffocation from the air cells of the lungs being filled with blood, the remedy must be an immediate evacuation of blood by venisection, and this is to be carried to a greater length than in almost any other accident or disease, first with a view to unload the lungs and prevent suffocation, and afterwards to pre- vent and cure the succeeding inflammation. The French surgeons have been famous for the quantities of blood which they direct to be drawn in such cases. They have been censured for it, but I believe with Mr. John Bell, that it is hardly possible to carry the practice too Sabatier relates a successful case in which the pa- t was bled twenty six times, and I have myself known a young man to lose one hundred and eighty ounces of blood in twelve days, in consequence of a gun-shot wound in the chest. He recovered very rapidly, although a very large opening had been made by a load of small shot. In some cases emphysema occurs from wounds of the lungs. It commonly happens from the wound being of small size, and not entering in a direct line. " It is less frequent in large wounds with a knife or broad sword, because there the air has an open and unimpeded issue;" and " more frequent in deep stabs w ith the bayonet or small sword;" and it is peculiarly frequent in gun shot wounds, because the orifice in the skin inflames and swells while the wound is wider within." This singular affection consists in an escape of air from ITCTl ELEMENTS OF SURGERY. 79 the lung into the cavity of the pleura, and from thence'into the cellular texture over the wound, its escape being pre- vented by a closure of tfie external opening, the wound through the skin not corresponding with that in the pleura; sometimes it occurs without the lung being wounded from the air which entered the thorax by the external wound. In common, it confines itself to the vicinity of the wound, but sometimes it extent!^ very rapidly, swells the whole figure, closes the eyelids,? obliterates every appearance of the neck, which has thfi'same diameter as the trunk. The extent to which the body swells in emphysema may be judged of from a case Belated by Mr. Littre in the Me- moirs of the French Academy, in which the skin over the chest was distended to the distance of eleven inches from the ribs. The palms of the hand and soles of the. feet are the only parts which do not partake of the tume- faction. The treatment consists in making punctures through the skin with a lancet opposite to the wound in the thorax, * by which the air may be allowed to escape. If small punctures through the skin be found ineffectual, a free incision is to be made into the thorax, through the skin and muscles, which puts an immedate stop to the pro- gress of the complaint, care being taken to avoid the intercostal artery. In many instances it is not easy to ascertain whether the difficulty of respiration depends upon air or blood confined in the pleura. The incision is equally effectual in both cases. It is not by compressing the lung of the wounded side that the oppression is occasioned, for this lung must be in a collapsed state from the moment when the siir was admitted into the thorax, and of course re- spiration is entirely performed by the opposite lung. The oppression proceeds "from the pressure of air or blood upon this sound lung, its freedom of motion being there- by impeded. 80 ELEMENTS of surgery. A protrusion of a portion of the lung through a wound of the chest is an accident which has sometimes occurred. Sabatier recites several cases, and in some the surgeons appear to have treated the patient very roughly, having cut off the protruded lung with a hot iron in one instance, and applied stiptic powders after cutting it off, in ano- ther.* Notwithstanding these harsh proceedings the patients got well. The proper plan, if we are called before the pro- truded piece of lung is mortified, will be to replace it without delay ; and if necessary the wound may be enlarged to facilitate its reduction. After this the usual dressings are to be applied. If mortification have taken place, Sabatier recommends the application of a ligature round the part to prevent hemorrhage, and the excision of the mortified portion, a practice which I think ought never to be followed, because, if the liga- ture be applied tight enough to command the hemorrhage, it will infallibly produce gangrene and slough off; now the mortified part will as certainly separate without the ligature, and ought therefore in every case to be left. Until this separation happens, it will be safest to leave the mortified portion outside, because adhesions will form connecting the lung to the margin of the wound, so that when the separation of the slough takes place, the cavity of the thorax will not be exposed, whereas if a portion of mortified lung be returned into this cavity and there se- parate, it will undoubtedly occasion as great inflamma- tion as other foreign matter, and render it necessary to keep open the external wound. When foreign substances, as fractured bone, pieces of cloth, &c. are lodged in the thorax, they must if practi- ble, be immediately removed. Pieces of the rib are frequently broken off in such a manner as to project in- ward and irritate the lungs. In this case a pair of forceps * Medicine Operatoire, torn. ii.p. 27? ELEMENTS OF SURGERY. 81 must be introduced, and the splinter separated. A mus- ket ball sometimes lodges in or about the thorax, and, in general, it is " irrecoverably lost;?' but the clothing car- ried in with it may commonly be found, and should be then carefully extracted, for every thing of this kind has a tendency, like the setons of the French surgeons, to keep up inflammation and suppuration. I was called last winter to a carpenter wounded in the back by falling on a chisel; the wound penetrated into the chest, and as the muscular flesh through which the chisel had passed bled freely, an old lady emptied her snuff box into the wound. At every inspiration some of this stiptic powder entered into the thorax, and the consequence was a general suppuration from the cavity of the pleura, exposing the life of the patient to great hazard. Care should be taken to extract every foreign body within our reach, and to prevent our dressings, &c. from being drawn into the chest. VOL. f u 82 ELEMENTS OF SURGERY. CHAPTER XV. Wounds penetrating the Abdomen. In consequence of the great variety and importance of the viscera contained within the abdomen, wounds pene- trating this cavity must differ essentially in their nature and consequences according to the parts injured. In a wound through the parietes of the abdomen, in which none of these viscera are implicated, the great object of the surgeon is to produce a speedy union of the wound, in order to prevent the inflammation of the peri- toneum. There is no reason for believing that this in- flammation arises from the admission of air into the ca- vity,* neither is the diminution of its temperature the cause,f as the application of ice in cases of hernia fre- quently reduces the heat of the abdomen much below that of the atmosphere, without any such effect, and peritoneal inflammation is as apt to occur in the hottest summer weather when the thermometer rises nearly to the heat of the blood, as in the depth of winter. The real cause of this inflammation in wounded cavities, it is by no means easy to ascertain, it is much easier to ascer- tain that none of the alleged causes can explain it. The fact is all we have to» state. Whenever a large cavity, as the thorax, abdomen, or a large joint, is cut open, unless the wound be promptly healed, violent inflamma- tion occurs throughout the surface of that cavity. The * The cavity of the abdomen is a plenum, every part of it occupied with some- thing1, and no space exists for the admission of air. Into the thorax when wounded, air finds a ready entrance, but not so in wounds of the abdomen. f This opinion has been maintained by Dr. James Cocke in Ins Inaugural Essay, published in this city in 1804. ELEMENTS OF SURGERY. 83 imperfection of the cavity appears to be the only circum- stance necessary to the production of this inflammation, but how it effects it I am not prepared to say.:* If the wound be made by a sharp instrument, it is to be closed by the interrupted suture, care being taken to pass the needle from within outwards, about half an inch from the wound; it is most readily effected by having a needle at each end of the ligature ; none of the strings are to be tied until all the stitches are made.* The va- rious antiphlogistic remedies are to be used in order to prevent inflammation, and also to relieve it, if it super- vene. It is always of extreme importance to ascertain whe- ther any of the viscera of the abdomen are injured, be- cause the danger of the case, and the remedies to be em- ployed, depend greatly upon this circumstance. If any part of the bowels protrude, it should be examined care- fully before it is replaced. If the wound be a small inci- sion or a puncture, it is more difficult to ascertain the ex- tent and nature of the mischief. Some information is to be gained by examining the instrument with which the wound was inflicted, and by observing how much of it had entered, and in what direction. If a large quantity of blood escape at the wound, there is reason to appre- hend the injury of some of the viscera (unless the wound be in the course of the epigastric artery.) If bile, fceces, or any of the usual contents of the viscera, make their appearance, there can be no doubt of a wound in an in- testine. Very little is to be learned by examinations with probes, or even by passing the finger into the wound, and therefore unless some real good can result from it, it should be omitted. When a large blood vessel is opened, and the blood • Adhesive plaster is also to be used, and over it a compress and bandage. 84 LLEMENTS OF SURGERY. does not find a ready exit through the external wound, great debility comes on, fainting, a weak faultering pulse, cold sweats, swelling of the abdomen, and, if the bleeding does not stop, death. Gun shot wounds of the abdomen in general occasion complicated mischief, the ball passing through the vis- cera, and wounding them in several places. If the ball pass with considerable velocity, sloughs must take place, and greatly enlarge the various openings it has made. 6i If the ball pass with less velocity, there will be less sloughing, and the parts will in some degree heal by the first intention similar to those made by a cutting instru- ment ; but although the ball has passed with such velo- city as to produce a slough, yet that wound shall do well, for the adhesive inflammation will take place on the peri- toneum all round the wound, which will exclude the general cavity from taking part in the inflammation, although the ball has not only penetrated, but has wound- ed parts which are not immediately essential to life, such as the epiploon, mesentery, &c. and perhaps gone quite through the body ; yet it is to be observed that wherever there is a wound, and whatever solid viscus may be penetrated, the surfaces in contact, surrounding every orifice, will unite by the adhesive inflammation, so as to exclude entirely the general cavity, by which means there is one continued canal, wherever the ball or instrument has passed ; or if any extraneous body should have been carried in, such as clothes, &c. they will be included in these adhesions, and both these and the slough will be conducted to the external surface by either orifice." This quotation from Mr. Hunter explains the reason why so many patients get well of wounds in the viscera, and affords a wonderful proof of the resources of nature in providing against danger and death. Unless adhesive inflammation arise and agglutinate the injured bowels to- ELEMENTS OF SURGERY. 85 gether, at the circumference of every aperture made into them, death must inevitably result, from the escape of the contents of these viscera into the general cavity of the abdomen. From this view of the subject, and from repeated ex- perience, we learn that most of the viscera of the abdo- men may be wounded without fatal consequences. The gall bladder is perhaps an exception, because the acrid nature of its contents, and the facility with which the bile escapes whenever this viscus is punctured, cannot fail to occasion peritoneal inflammation; and we find no case recorded of a recovery after a wound penetrating the gall bladder. If any acrid substance escape from the stomach into the general cavity of the belly, as ardent spirit, &c. the same fatal consequences will result, of which I once saw a striking instance in a man whose stomach was wounded after drinking porter. The wound of the stomach was found on dissection completely heal- ed ; the patient died on the fourth day of peritoneal inflammation. The inflammation of the cavity of the belly which oc- curs whether the viscera be wounded or not, (unless the external wound be promptly united) calls for copious and active measures; bleeding, purging, low diet and blisters, over the abdomen. In general these remedies, if com- menced early, and pursued actively, are found successful, and the inflammatory symptoms subside. In others it terminates in adhesions, connecting together the different viscera, coagulating lymph being poured out, on various parts of the peritoneal surface. In others suppuration takes place, and large quantities of matter are formed in the abdomen. Mortification also sometimes occurs, and consequently death. If the remedies for inflammation do not succeed in re ducing it, and suppuration takes place, when its exist- ence is clearly ascertained, a lancet may be introduced, S6 ELEMENTS OF SURGERY. and afterwards a canula through which this matter may be evacuated. If no particular spot appear elevated more than the rest, the puncture may be made at th© usual place where tapping for dropsy is performed, about two inches below the umbilicus. In some wounds of the abdomen a protrusion of some of the abdominal viscera takes place ; where the protru- ded parts are uninjured, it is always best to replace them as speedily as possible within the cavity. If they be wounded, or if from long exposure and the stricture made upon them by the wound, they are in a mortified state, other measures are necessary. Previously to replacing them all extraneous matter should be carefully removed. Dirt, clots of blood, and every foreign substance, must be washed off with warm water. I have seen a large portion of the colon, together with the omentum covered with sand and dirt mixed with blood, protruding from a large wound in the abdomen ; great care was in this in- stance necessary to prevent the introduction of these irri- tating: matters into the abdomen. It often happens that a considerable stricture is made upon the protruded parts, and of course difficulty is ex- perienced in reducing them. To facilitate it, the patient should be placed in such a posture as to relax the mus- cles of the abdomen. If the difficulty arise from disten- tion with fceces or flatus, the contents may often be squeezed out, and the bulk of the intestine thus reduced. If, however, the reduction be still difficult, it is highly improper to use any violence in attempting it; it is better to enlarge very carefully the wound with a bistoury. The treatment of the case when a portion of the intes- tine is mortified, will be described in the chapter on her- nia, as it forms a very important variety of that com- plaint. Blood is sometimes poured out in considerable quanti- ties by some large vessel within the abdomen. If the ELEMENTS OF SURGERY. 8/ quantity be very great, swooning, and the usual debilitat- ing effects of hemorrhage quickly ensue. If the patient survive these symptoms, the collection of blood is easily perceived forming a tumour in some part of the abdomen. The abdominal viscera are so closely in contact that a general diffusion of this blood among them seldom hap- pens ; it is found, on the contrary, collected into one spot; and this, according to Sabattier, is in the lower and anterior part of the abdomen, just above the pubis.* He remarks that, in general, upon opening bodies in which these extravasations have happened, the blood is found in every part of the cavity, but that this is entirely owing to carelessness in the dissection, and that a cau- tious proceeding discovers that it is collected in one mass, and that after a time it becomes firmly surrounded by the matter of adhesions, in consequence of inflammation, forming a kind of sac or pouch. The changes which the extravasated blood undergoes, coagulating and irritating the surrounding parts, occasion very distressing symptoms. In the first place pain, and tension of the part, followed by hiccough, costiveness, vomiting, and sometimes suppression of urine. Some- times by great weakness, a small feeble pulse, and cold sweats. To relieve these symptoms, it becomes necessary to make an opening for the discharge of the blood. A puncture is to be made with a lancet, or trochar, and a canula introduced; if the blood be fluid it will readily flow through it; when it is found coagulated, it has been recommended to inject warm water into the wound, in order to wash it out; from the fact that injec- tions of warm water in cases of hydrocele, effect a radical cure by exciting inflammation, I have strong doubts of the propriety of this practice. * Me'decine Op/ratoire, torn. i. p. 35 88 ELEMENTS OF SURGERY. When the contents of the viscera are extravasated, the only remedies which can be employed are the remedies for imflammation ; rest, a low diet, bleeding, purging, &c. They sometimes form abscesses, and are discharged externally. I have known a piece of cheese which es- caped from a wouuded stomach, discharged after the wound had healed, by an abscess in the groin. WOUNDS OF THE ABDOMINAL VISCERA. The symptoms denoting wounds of the particular vis- cera of the abdomen are not always strongly marked, but in general we are able, from a careful investigation to ascertain with some degree of accuracy the parts in- jured. " From a wound in the liver there will be a pain in the part of the sickly or depressing kind; and if it is in the right lobe there will be a delusive pain in the right shoul- der, or in the left shoulder from a wound in the left lobe." " A wound in the stomach will produce great sickness and vomiting of blood, and sometimes a delirium. "Blood in the stools will arise from a wound in the in- testine, and according to the intestine wounded it will be more or less pure ; if the blood is from a high part of an intestine, it will be mixed with fceces and of a dark co- lour ; if low as the colon, the blood will be less mixed and give the tinge of blood; and the pain or sensation will be more or less acute, according to the intestine wounded, more of the sickly pain the higher the intes- tine, and more acute the lower. " There will be bloody urine from a wound of the kidnies or bladder, and if made by a shot or ball and a lodgment made, these bodies will sometimes become the cause of a stone. The sensation will be trifling. " A wound of the spleen will produce no particular symptoms, excepting probably sickness, from its con- nexion with the nerves of the stomach." (Hunter.) ELEMENTS OF SURGERY. 89 In the treatment of wounds in the stomach or intestines, it must be evident that many cases occur where the part wounded cannot be exposed, or indeed known, and here nothing is to be done but to combat the inflammatory symptoms.* When a wound in the stomach can be seen, a number of stitches proportioned to its extent must be used, the ligatures cut off close, and the parts returned. In transverse wounds of the intestine, in which the great- er part of the canal remains entire, the experiments of Mr. Astly Cooper and other surgeons have proved the safety of closing the wound by the interrupted suture, and returning the gut into the belly. The stitches are separated by the actions of the absorbents, and pass readily through the intestinal canal, a coating of coagu- lating lymph being formed over them, which prevents their falling into the cavity of the peritoneum, and ex- citing inflammation there. A single stitch is generally sufficient to close a wound not extending more than half round the intestine, and it should be made with a com- mon round sewing needle armed with waxed thread. Longitudinal wounds of the intestine, it has been believ- ed, do not heal so readily as those which are transverse. There is probably more danger of the escape of fceces from them, and they are not so readily closed. From some experiments of I)rf T. Smith, performed in this city, and published in his inaugural thesis in 1805, it appears that in dogs even extensive longitudinal wounds may be reunited. It is proper in many such cases to cut out completely the wounded portion and unite the cut extremities toge- ther, because the longitudinal is thus converted into a transverse wound. When the intestine is cut completely through, either by • The propriety of dilating the external wound to search for the wounded intestine is very doubtful; 1st, from the danger attending an enlargement of the wound, and 2dly,from the uncertainty of finding the injured viscus. VOL. i. N 90 ELEMENTS OF SURGERY. a removal of a mortified portion, or by the original wound, the divided extremities are to be secured by four stitches; the ligatures are to be left out at the external wound, and in a short time they unite, and an adhesion takes place connecting the intestine to the peritoneum at the wound- ed part. After five or six days, the threads, if loose, may be removed, as they become useless after adhesions take place. The practice of Mr. John Bell in these cases, of trusting to a single stitch, is full of danger, and ought never to be adopted. Mr. Cooper's remarks on the treatment of mortified intestine in his work on hernia are entirely applicable to the present subject. In most instances of wounded intestine the canal is diminished at the injured part, and cholicy pains are an occasional consequence. A great degree of constriction has in some cases resulted and terminated fatally, but in general the bowel regains its usual volume, and performs its functions as well as before the injury. In all cases where there is reason to believe that the bowels are wounded, it is important to prohibit the use of solid food, and confine the patient to barley water ex- clusively, or some mild drink. Wounds of the omentum or mesentery seldom occa- sion trouble, except from their bleeding; when practica- ble, the bleeding vessels are to be secured by ligature, and the ligature in every instance left out at the external wound. Wounds of the gall bladder are, in the opinion of most surgeons, necessarily fatal. A case is related in the Edinburgh Medical Essays, in which the patient survived this accident a week. Before death the abdo- men became extremely tense; a rumbling noise was heard in it. The patient had no stools, notwithstanding the use of purgatives and glisters. Sleep could not be procured, although anodynes were exhibited. No fever appeared. The pulse was natural till the last day, when ELEMENTS OF SURGERY. 91 it became intermittent. Upon dissection the intestines were found much distended, the gall bladder quite empty, and a large quantity of bile, extravasated in the abdomen. Sabatier relates a case in which bile was drawn off by a trochar from the cavity of the belly; but no advantage resulted, and the patient died a few hours after it was performed, viz. on the third day. Wounds of the liver call for no particular treatment. They are generally, when extensive, fatal from hemor- rhage, owing to its great vascularity ; and if any of the branches of its excretory duct are punctured, the bile escapes and occasions inflammation of the peritoneum. Small incised wounds of the liver often heal without difficulty. Wounds of the kidneys are not fatal unless the urine escapes into the cavity of the abdomen. They call for no particular treatment. The patient generally voids bloody urine at first, but the part soon heals. 93 elements of surgery. CHAPTER XVI. Wounds of Joints. In these, as in other wounds penetrating cavities, it is of great importance to guard against inflammation, as the effects of violent inflammation in the larger joints, upon the constitution are very serious. In all cases of wounded joints it is important to place the limb in such a posture as to favour the approximation of the sides of the wound. Absolute rest is to be enjoin- ed, and a rigid adherence to the antiphlogistic treatment. Sutures are never to be used in these cases, if it be possi- ble to dispense with them, and when it is not, they must never be passed into the cavity of the joint, but only through the cellular membrane on the outside of it, for very obvious reasons. Treated in this manner, incised wounds of the larger joints very readily heal by the first intention, even when the articulating extremity of the bones are injured. When inflammation supervenes in consequence of a wound in a large joint, the constitution suffers severely: fever comes on, generally ushered in with a great degree of nausea. Violent pain takes place in the joint, and an increased secretion of synovia, which is thinner and more watery than usual. The ligaments swell and become thickened by effusions of coagulating lymph. At length suppuration takes place, and pus is secreted from the whole surface of the capsular ligament; ulceration comes on, and openings are formed in various parts of the skin covering the joint. The formation of an abscess in a large joint, as the knee or hip, never takes place without great danger to the life of the patient. I have seen death occur in a very elements of surgery. 93 few days from inflammation of the knee, terminating in suppuration. Extreme pain, fever and delirium, generally precede the fatal event. In those cases where the symptoms of inflammation do not terminate so speedily, ulceration of the ligaments is followed by inflammation of the bone; the cartilage is absorbed, and the whole joint destroyed; granulations arise from the inflamed bones; they unite, and anchylosis is effected; but these processes require a great length of time, and during this time the patient is affected with hectic fever, and great exhaustion from the continued discharge. Abscesses also form in the vicinity of the joint, and portions of carious bone or detached cartilage, are evacuated through them. Before anchylosis can in this manner be accomplished, the patient must inevitably suffer a tedious, painful confinement, under which the constitution often sinks, and a lingering death eventually concludes his sufferings. These terrible consequences sometimes result from simple incisions or punctures into joints, as well as from the more aggravated mischief of lacerated or gun-shot wounds. They are only to be prevented by a most active employment of the remedies for inflammation already enumerated. On the first approach of inflammation, bleeding is to be performed, and carried to as great an extent as the patient's strength will warrant. Topical bleeding, by cupping or leeches, is next to be employed, and after this a blister should be applied large enough to cover the skin over the joint. The blister in these cases should be applied earlier than is recommended by authors. I have seen the best effects from a speedy application of this remedy. In chronic inflammations of joints, either from wounds or other causes, the repeated use of blisters is never to be omitted. Purging is also to be actively employed. 94 ELEMENTS OF SURGERY, In order more effectually to procure absolute rest of the joints, it is advantageous in some cases to apply carved splints to fit the parts, and these being lined with soft materials, occasion no inconvenience. In wounds of the knee, ankle or elbow, these splints are particularly use- ful. ' When in consequence of the violence and continuance of the inflammation, there is reason to apprehend a stiff joint from anchylosis, it is necessary to choose the posi- tion of the limb, in which this stiffness will be least in- convenient to the patient, and to preserve that posture during the cure. If, for example, the elbow were to heal with the arm permanently extended, the limb would be almost useless, whereas an arm flexed at the elbow, even when the joint allows no motion, is extremely useful. In the lower extremity on the contrary, a flexed posture would preclude the patient from walking, while an ex- tended leg, with a stiff knee, would be attended with comparatively little inconvenience. Lacerated and gun-shot wounds of the joints are al- ways attended with more danger than simple incised wounds, because in them the parts cannot unite so speedi- ly, and the cavity remains longer imperfect. So great is the danger to the life of the patient, that it always be- comes a serious question with his surgeon in such wounds of the elbow, knee, or ancle, whether an amputation ought not to be immediately performed. £ In addition to the dangers already enumerated, gangrene from the disor- ganization of the parts may occur, or life may be de- stroyed by tetanus. It is not easy to give any general rules by which to guide our decision of the momentous question of amputa- tion in wounds of joints. Undoubtedly many cases oc- cur, in which the destruction of the surrounding parts, arteries, nerves, tendons, &c. together with the shattered state of the bones forming the articulation, especially ELEMENTS OF SURGERY. 95 when this complicated injury has occurred in the hot , weather of summer, leaves no doubt of the propriety of immediately removing the limb ; but other cases occur in which the main artery of the limb is not destroyed, and in which there is a prospect of saving the limb, provided the patient escape the dangers, of gangrene, of tetanus, of inflammatory fever, of extensive suppurations, of hec- tic fever, &c. In cases of this kind the surgeon feels his responsibility to be great, and it requires an attentive consideration of every circumstance connected with the particular case to confirm his decision. All these cir- cumstances should be stated to the patient and his friends, and they should assume the responsibility and conclude whether to attempt the saving of a limb, by incurring the dangers which must be encountered, or by an amputation to avoid them. The cartilages of a joint never either inflame, suppu- rate or ulcerate ; they are incapable of restoring them- selves when injured, and although flesh in some cases grows over them, they never adhere to it. Mr. John Bell observes, " we amputate a toe at the joint, and the flaps unite in two days, but still they have united with each other only, and not with the cartilage at the joint: and in a luxated limb we find that the bone continues displaced, the cartilage never inflames, nor ever unites with the lacerated parts." 96 ELEMENTS OF SURGERY. CHAPTER XVn. Wounds of JVerves and Tendons. In most of the systems of surgery which have been published, wounds of the nerves have been considered as a subject of great importance, and many terrible con- sequences are attributed to punctures or partial divisions of them. The first symptom indicating a wound of a considera- ble nerve is severe pain, and afterwards a numbness, or diminution in the sensation and powers of the part to which the injured nerve was distributed. These symp- toms in general gradually subside, and no particularly bad consequence results from the wound. The inflammatory symptoms sometimes consequent to the operation of phlebotomy have been ascribed by many surgeons to punctures of a nerve or tendon. The true explanation of these effects we shall presently offer. The operation of cutting down to the nerve and divid- ing it entirely, is very seldom to be performed. The only case in which it is to be recommended is when after venisection, the patient experiences violent pain, follow- ed by numbness of the arm, and where these symptoms, instead of subsiding after a few days, increase in severity. Under such circumstances an incision should be made through the wound, and carried a little below it, by which in all probability any partially divided nerve would be completely cut through, and the symptoms, if derived from this source, would speedily cease. The necessity for this operation is, however, extreme- ly rare. I have never seen or heard of a case in this city (where blood-letting is a very frequent operation) in ELEMENTS OF SURGERY. 97 which the symptoms have been such as to warrant any surgical operation for the division of a nerve. Tendons, when wounded, occasion no pain. There are many proofs that tendons in a healthy state possess little or no sensibility; when inflamed, they are often exquisitely sensible. It occasionally happens, how- ever, in punctured wounds, that certain tendinous fasciae are pierced, and the soft parts below the expansion are also injured ; when these inflame, the stricture formed by the tendon occasions very severe pain, and greatly aggravates the inflammatory symptoms. In these cases a division of the tendinous fasciae procures immediate re- lief. As the fascia attached to the tendon of the biceps flexor cubiti is situated in the vicinity of those veins from which blood is generally drawn, there is reason to be- lieve that in some rare cases this accident has happened in phlebotomy; in such cases a small incision through the fascia could very readily be made. Wounds of tendons are to be treated as wounds in other parts, by keeping them at rest with their divided surfaces in contact. It happens to carpenters and ship joiners, occasionally to divide with a foot adze the tendo achillis. When this accident happens, the foot is to be kept extended by a splint secured by means of a roller in front of the leg, extending from just below the knee to the point of the toe ; compresses being applied to fill up the inequalities of the limb, the divided surfaces of the tendon are to be accurately placed in contact, and kept so six or eight weeks, when union will be effected ; but several months must elapse before the patient attempts to support the weight of the body upon this tendon. The same mode of treatment is to be used in ruptures of the tendon. In wounds, however, the skin is apt to fall into folds, and insinuate itself between the cut surfaces of the tendon. To prevent this inconvenience, adhesive plaster vol. i. o 98 ELEMENTS OF SURGERY. should be applied in such a manner as to keep it pulled back from the wound. Dr. Monro's plan of dressing such an accident is equally successful. It consists in having a strap fastened to the heel of a slipper, and this strap buckled to a ban- dage fixed round the leg just below the knee. The roller on the leg prevents the action of the gastrocnemii muscles, by which the superior portion of the tendon would be pulled up, and the strap on the slipper keeps the foot in an extended position, by which the lower por- tion is prevented from being drawn down. WOUNDS OF VEINS.* These generally occasion very little trouble; the he- morrhage may be commonly stopped by compression. In some cases, however, the cavities of veins, like the other cavities of the body, take^on inflammation, in consequence of the external opening not being united by the first in- tention. Mr. Hunter has published a very valuable pa- per on the inflammation of veins in the Medical and Chi- rurgical Transactions; from this paper it appears that the swelling of the arm consequent to venisection is ge- nerally occasioned by the inflammation of the inner coat of the vein. He has dissected the arm in some cases where patients have died from this disease, and has found in some parts of the vein adhesion, in others suppuration, and in other cases ulceration. In most cases when pus forms in a vein thus circum- stanced, adhesive inflammation having preceded the sup- purative stage, is found to have cut off all communication between the general circulation and the inflamed vein. In other cases, however, the pus is not thus excluded from the mass of blood, but is carried along with it to the heart, and occasions death. • The'principal circumstances demanding attention in cases of wounds o? the arteries have been already noticed in the chapter on hemorrhage. ELEMENTS OF SURGERY. 99 After an abscess is formed by adhesions closing up a portion of the vein, absorption takes place, and the coats of the vein are removed. The abscess then points, and matter appears under the cuticle. Mr. Hunter has seen instances of pus contained in the cavities of veins in many patients who have died after amputation, compound frac- ture, and mortification. It happens as frequently in healthy constitutions as in others, a proof of which is that if a patient with an inflamed vein be bled in the other arm, the wound heals without any such conse- quence. In some cases a considerable portion of the vein takes on inflammation; generally that portion between the wound and the heart, but sometimes the portion next the extremity; a string of abscesses existing throughout its extent. When the parts get well, it is found that the ca- vity of the vein at the inflamed part has been obliterated, and the patient ean never afterwards be bled in that place. Inflammation of a vein is sometimes an effect after bleeding horses, which is usually done in the neck. 66 The operator on this animal does not always take suf- ficient care to close up the external wound, for although the method usually employed would at first sight appear a good one, that is, by a pin passed through the wound from side to side, as in the hare lip, and overtied by a stitch or hair ; yet if not executed with sufficient atten- tion, I am inclined to believe that it is the very worst, as it very readily promotes inflammation in the cavity of the vein, either of the adhesive or suppurative kind, accord- ing as the ligature does or does not communicate with the cavity." (Hunter.) Mr. Hunter has seen in some of these inflammations of horses the jugular vein inflamed through its whole length, the head greatly swelled, and the inflammation carried along the vein quite into the chest. Many horses die of 100 ELEMENTS of surgery. this disease, but what is the particular circumstance which occasions their death is not ascertained. " It may be either that the inflammation extends itself to the heart or that the matter secreted from the inside of the vein passes along that tube in considerable quantity to the heart, and mixes with the blood." In many instances the constitution is affected with vio- lent fever, and in some cases in the human subject death has resulted. Pus passing into the circulation adds, in Mr. Hunter's opinion, to the general disorder, and ren- ders it fatal. " Although the operation, which is the most frequent cause of this complaint, is in appearance trifling, yet, as it is very often of serious consequence both to the life of the patient and the character of the surgeon, it re- quires particular attention in the operator to prevent as much as possible an evil of such magnitude; with this viewr he will be particularly attentive to the mode of closing the wound and binding up the arm: this is to be done by bringing the two sides of the wound together, that they may unite by the first intention. To accomplish this let the surgeon with the thumb of that hand which holds the arm push the skin towards the orifice, while he draws it on the other side to the same point with the compress; thus the skin will be thrown into folds at the wound, over which he is immediately to apply the com- press, which should be broad to keep the skin better to- gether, and thick to make the compression more cer- tain." Mr. Hunter recommends a " compress of linen or lint, in preference to sticking piaster, for the blood drying over the orifice is a kind of bond of union more natural and effectual than any other application, and this conclu- sion is drawn from practice," more sore arms being a consequence of bleeding where plasters have been used than when the arm has buc'A dieted in any other wny. ELEMENTS OF SURGERY. 101 ••' When inflammation takes place beyond the orifice, so as to alarm the surgeon, he should immediately make a compress upon the vein at the inflamed part, to make the two sides adhere together; or if they do not adhere, yet simple contact will be sufficient to prevent suppura- tion in this part; or if inflammation has gone so far as to make the surgeon suspect that suppuration has taken place, then the compress must be put upon that part of the vein just above the suppuration." The remedy for inflammation of the veins consequent to venisection, which answers best, is the application of a blister over the inflamed part. As soon as the inflam- mation commences, a small plaster of simple cerate, spread on linen, should be applied on the orifice, and over this a blister large enough to cover the whole in- flamed part, extending an inch or two from the orifice in every direction. This remedy, I believe, was first intro- duced by Dr. Physick. It has been used by him for many years with constant success, and I have myself employed it repeatedly, and never without advantage. Should fever attend, purging and low diet should be ordered, and bleeding, if the inflammatory symptoms run high. A splint is sometimes useful to keep the arm at rest. The inflammation of a vein consequent to venisection sometimes assumes a chronic form, and continues with a hard swelling and some pain for many weeks. Repeated blisters have been found extremely serviceable in these cases. It is unnecessary particularly to describe the appear- ance of the inflamed arm consequent to venaesection, be- cause it is generally known to medical men. In its com- mencement it resembles somewhat an erysipelatous affec- tion, extending above and below the orifice made by the lancet, a tumor existing, however, at the part w hich is hard and painful; the arm cannot be bent or extended 103 ELEMENTS OF SURGERY. without great pain. In this state the blister very gene- rally prevents the further progress of the inflamma- tion. CHAPTER XVIII. Of Fractures. A fracture is a breach in a bone, (or as it is gene- rally defined, a solution of continuity) produced by exter- nal violence, or by muscular action, or by the conjoint operation of both. The bones most frequently broken are those of the extremities. Bones are broken in one or in several places ; when broken in more than one place, the frac- ture is said to be comminuted. Fractures may occur in the vicinity of joints, or in the middle of the bones of an extremity. In the fore arm and leg, one or both bones may be fractured. The fracture may be directly across the bone in a transverse direction, or it may be oblique, and the degree of obliquity may vary very much. Fractures differ in relation to the form of the bone, its importance, and uses. The broad flat bones, as the scapula or ilium, are rarely fractured. The bones of the scull, however, are more frequently broken than any other flat bones, and the importance of this accident transcends most others, from the effects of the injury upon the brain. The long bones are by far the most frequently fractured. AVhen the long bones are broken, the place of fracture is a subject of some importance to be attended to in judg- ing of the effects of the accident and of the mode of treat- ment. In a fracture of the middle of a bone, the broken ELEMENTS OF SURGERY. 103 surfaces are less extensive, and therefore they move more widely one from the other, yet this kind of fracture is the least dangerous, because in such cases the cause is sel- dom applied to the part fractured, and for that reason the surrounding soft parts are injured equally seldom. A less force suffices to break the bene in its middle than at any other part. It is also certain that inflammation, stiff- ness, and anchylosis are less likely to happen than when the bone is fractured near the articulation. Bones are sometimes broken within a joint; the fractured patella is always an example of this. I have seen a frac- ture through the head of the thigh bone, and also through the head of the humerus. The relative situation of the fractured extremities it is of great importance to ascertain. In some cases of trans- verse fracture no derangement at all takes place, the parts supporting each other as though they were not frac- tured. I had one patient with a transverse fracture of the tibia, who could stand up and bear some of the weight of his body upon the injured leg; and Dr. Physick had a patient who, although the grating of the bones was dis- tinctly heard, before his limb was dressed, took off all the bandages and splints, under an idea that, the doctor was mistaken. After walking, however, once or twice over the floor, and being confirmed in his opinion, an un- wary motion of his leg occasioned a twist, and it bent under him at the place of fracture. Sometimes the frag- ments in a transverse fracture are partially separated, and in the tibia we often find one fragment projecting a quarter of an inch or more above the other, and yet a great part of the fractured surfaces remain in contact. This is less apt to happen when both bones of the leg or fore arm are broken, as in these cases a total separation and distortion of the limb generally takes place. In frac- tures of the thigh and arm the muscles generally draw up 104 ELEMENTS OF SURGERY. the inferior fragment, and thus shorten the limb, even when the fracture is transverse. In some cases a bone is broken in such a manner as to form an angle at the place of fracture. The principal causes of the derangement of the frag- ments are the force which produced the fracture, the weight of the body, or of the fractured limb, and the ac- tion of muscles. The force which produced the fracture will often occasion great derangement of the limb, as the kick of a horse. The weight of the arm in fractures of the humerus, and of the leg in fractures of the thigh bone, occasion a separation of the fragments. The weight of the foot, when the patient lies on his back, will occasion a rotation in a broken thigh or leg ; but the most powerful of these causes is muscular action. 6i Of the muscles which surround a fractured bone, some are attached to that bone in a great part of its length, and therefore in many cases to both portions of the fractured bone. Others extend from the bone which is superior to that fractured, to that which articulates with the lower portion, or to the lower fragment itself; there are still others which terminate in the upper fragment, the other extremity of which may be more or less dis- tant. The muscles of the thigh offer examples of these three different dispositions. The triceps is attached to the whole length of the femur ; the biceps, semimembra- nosus and semitendinosus, descend from the pelvis to the leg, to which the lower part of the femur is articulated, and all the movements of which it obeys ; the great ad- ductor muscle has its insertion in the lower part of the femur itself; finally the psoas, iliacus, pectineus, &c. descend from the loins and the pelvis, and have their insertion near the superior extremity of the femur. " The muscles which are attached to both portions of the fractured bone, contribute very little to their change of ELEMENTS OF SURGERY. 105 situation, but may, however, draw them both to the side on which they are inserted, and thus change the direction of the limb. The triceps, and more particularly its middle part, acts thus on the fractured femur, and ren- ders the thigh convex anteriorly. The brachialis anterior tends to produce the same effect when the humerus is broken below its middle part, but the change from the natural situation is principally owing to the muscles which are inserted into the lower portion of the fractured bone, or the limb with which it articu- lates. Let us suppose the fracture of the humerus be- tween its superior extremity, and the insertion of the great pectoral muscle, this muscle aided by the latissi- mus dorsi and teres major, draws the inferior portion in- ward and upward, and causes it to ascend on the interior side of the upper fragment which rests motionless, on account of its shortness, and because the muscles which are inserted into it are not acted on by any cause that excites them to action. In the fracture of the neck of the femur, the superior fragment has no muscles inserted in- to it, and remains motionless in the articulating cavity ; those muscles which, on the contrary, are attached to the lower portion, draw it upward and backward, and ren- der its being displaced in that direction inevitable. " The lower portion being acted on by the limb to which it is articulated, follows all its motions, and is lia- ble to be displaced by the action of the muscles which are inserted into it. Thus, in fractures of the body of the femur, the biceps, semitendinosus, and other muscles, draw the leg, and with it the inferior portion, upward, inward, and backward, and cause it to ascend on the internal, and a little on the posterior side of the superior portion, the inferior extremity of which projects, in that case, on the anterior and external side. "In the fracture of the leg, the gastrocnemii mus- cles, &c draw the inferior portion upward and back, VOL. i. p 106 ELEMENTS OF SURGERY. ward, with the foot; for in this, as in every similar case, the stronger muscles displace the lower portion of the fractured bone, and draw it in their direction : hence it is, that in this case the portion is drawn backward as well as upward, because the muscles are more numerous and larger on the back part of the leg than on any other. Therefore, when a fracture takes place in any part of a bone, it is easy to determine, from a knowledge of the muscles, what species of derangement will follow, if there be no counteracting cause. Finally, the muscles which have their insertion in a superior fragment, may produce its separation from the inferior. When the femur is fractured immediately below the small trochanter, the iliac and psoas muscles draw forward the inferior extre- mity of the superior fragment, which raises the skin, and projects more or less. It is to be observed, however, that the displacing of this fragment is very rare, whilst the inferior fragment is displaced in almost every case."— (Boyer.) Fractures arc more or less accompanied with lacera- tion and injury of the surrounding soft parts. When the integuments covering the fractured bone remain entire, even although there be a great degree of laceration un- derneath it, the fracture is called simple. A compound fracture is that in which an external opening is formed, communicating with the space between the broken extre- mities of the bone, or as it is commonly called, the cavity of the fracture. Mr. Hunter has applied the appellation of compound simple fractures to those in which a frac- ture originally compound becomes simple by the imme- diate healing of the external wound. It sometimes happens that fractures are accompanied with dislocation, the dislocation probably in every case preceding the fracture. The causes of fracture are the endless varieties of accidental force applied to bones. Certain circumstances elements of surgery. 107 of constitution, however, may be considered as predis- posing causes, such as old age, in which the bones are more brittle than in youth. Any morbid state of the system which occasions absorption of parts of the bony structure. The French surgeons* have recorded cases where bones have been broken by simply turning in bed. Cold weather has been supposed to predis- pose to fractures. Boyer observes, that if these acci- dents are more frequent in winter than in summer, it is because persons are then more liable to injuries from falling. Dr. Physick has offered a much more plausible explanation of the fact, which is, that in walking over frozen pavements and other slippery places, great exer- tions are often made to prevent falling, and this muscular exertion, added to the force of the fall, occasions the fracture. The bones are too well covered to feel much influence from the cold. The symptoms of fractures it is very important to be acquainted with. They are severe sudden pain—an alteration in the form of the part—sometimes a shorten- ing of the limb, if the fracture be in an extremity—an inability to move the limb without severe pain at the in- jured part—an inequality of the skin covering the bone; which renders a fracture of the clavicle, or of the tibia, generally easy to be discovered; crepitation is the most certain of all the symptoms—a grating noise, not to be mistaken for any other sound, which is sometimes very audible. The surgeon should take hold of the limb above and below the fracture, and by moving the fractured ex- tremities of the bone, he produces this noise and de- cides beyond doubt the existence of the fracture. If, however, the surgeon be not called till swelling from ecchymosis, and inflammation have come on, it is not easy always to judge whether a fracture exists ; in thte case he must wait until these symptoms subside. » Louis and Saviard. 108 ELEMENTS OF SURGERY. In judging of the probable event of a fracture, a great variety of circumstances influence the surgeon. The age of the patient is of great consequence ; in young per- sons they heal much more speedily and certainly than in the aged. I have seen several fatal cases of simple frac- ture in old persons. A healthy constitution, not debili- tated by intemperance, is favourable for the healing of broken bones. Drunkards often become delirious and die, in consequence of fractures and other severe acci- dents. The nature of the accident, the degree of vio- lence applied, and the mode of its application, greatly influence the prognosis. Fractures from gun-shot are always dangerous, a portion of bone being destroyed by the force of the ball, which must exfoliate (be separated by the absorbents) before the sound bone can granulate and unite ; a compound is always more dangerous than a simple fracture. A fracture attended with great ecchy- mosis, and extensive injury of the adjacent flesh, is more dangerous than one unattended with these circumstances. An oblique is more difficult to manage than a transverse fracture. Fractures of the lower extremities have more serious consequences than those of the upper. In general those of superficial bones are less important than those in which the fracture is covered by large strong muscles. Fractures in the middle of a bone are less dangerous than at its extremities in the vicinity of joints. The season of the year, and many other circumstances, will no doubt affect the healing of broken bones. The reunion of fractured bones is effected nearly in the same manner as the restoration of soft parts. The inflamed vessels pouring out coagulating lymph, which becomes vascular, and is gradually by a deposition of bony matter and an absorption of the unnecessary parts, converted into a bone. The uniting medium is called callus; it is at first soft, but gradually becomes firmer, and at length completely ossifies. ELEMENTS OF SURGERY. 109 In some cases the bond of union is very slow in form- ing, and then the inflammatory action must be increased by stimulating remedies. In other cases too much inflam- mation exists, and then unless prevented by depletion, suppuration takes place. OF THE TREATMENT OF FRACTURES. To place the fragments as nearly as possible in their original position, and to keep them so until union is effect- ed, are the important indications in the treatment of frac- tures. To effect the replacement of the fragments, extension and counter extension are generally necessary, though in some cases, as in fractures of the olecranon and patella, the fragments are to be pushed together. After the parts are placed in their proper position, the application of bandages and splints becomes necessary to retain them so. Extension signifies the force exerted on the fragment of a limb most remote from the body. Counter extension is the power by which the opposite fragment is prevented from moving with it. The various modes of applying these forces will be most properly considered, when the treatment of particular fractures is described. The constitutional treatment must be regulated by va- rious circumstances. Inflammation frequently attends a fracture, and is an essential part of the process of resto- ration. If it be too violent, the surgeon must restrain it by the usual remedies. Purging in many cases of fracture is extremely inconvenient in consequence of the motion to which it gives occasion. Blood letting is to be preferred, as this mode of evacuation is not liable to any objection, and the bowels are to be kept from costiveness, but no cathartics should be administered, unless in those frac- tures in which absolute rest is not enjoined, and the pa- tient on the contrary is permitted to walk, as fractures of the arm, clavicle, &c. A low diet should be observed. 110 ELEMENTS OF SURGERV. When the soft parts are much injured, the antiphlogis- tic measures are to be carried further than where the only injury is the broken bone. In many cases, by their pow- erful application, we prevent ulceration which would convert a simple into a compound fracture. In cases of extensive ecchymosis, w^here no large artery is wounded, cold applications and copious depletion are generally successful in preventing the formation of an abscess. If any particular artery of considerable magnitude is wounded, it becomes necessary to cut down to it and tie it up; and if possible without cutting into the cavity of fracture. In every case of fracture in which it is necessary for the patient to remain in bed during the cure (and there are very few in which it is not) a proper bed is an object of great convenience. Sir James Earle has published an account of a bedstead and mattress invented by his son, which in fractures and various other accidents and diseases, adds so greatly to the comforts of the patient, that I think the medical world are under great obliga- tions to the inventor.* In private practice, however, and especially in the country, it is extremely difficult to pro- cure such a convenience, and then a firm common mat- tress of hair is to be substituted, or if this cannot be obtained, a few blankets folded and applied over boards. A feather bed and sacking bottom afford so very unequal and unsteady a surface, that it is extremely difficult to keep the patient who lies on them in a proper posture. OF COMPOUND FRACTURES. These have an external wound communicating with the cavity of the fracture. Mr. Pott very judiciously re- marks that, " In this kind of case the first object of con- * In the Pennsylvania Hospital I have constantly used this bed in cases of frac- ture for several years, and have found it extremely convenient in the treatment of a variety of other accidents. - *A +>* /• * "iP %>9fc/F EARLE'S DOUBLE BED. #The contrivance consists of a double bed; the upper one has an opening nvthe sacking, in a suitable place and of the proper size, to which a thin mattress, blanket and sheet are made to correspond with a similar aperture : this, by a very simple piece of mechanism, may be elevated to a sufficient height for the nurse to introduce a proper receptacle between that and the fixed bed. The patient being relieved, the bed is gently let down again upon the under one, a thin cushion being placed on the under bed to fill up the opening, and make the upper bed level." The apparatus for elevating the upper bed may be varied according to cir- cumstances ; or the hands of several assistants may be substituted, especially in cases where the accommodation is not likely to be long wanted. In the adjoining plate, Fig. 1. represents the original bed conti&ved by Mr. Henry Earle, at St. Bartholomew's Hospital. Fig. 2. Shews the improved plan in which the upper bed is made, of suffi- cient width tor one person, but is intended to be placed on, and fixed to, any bed, of any breadth. In both figures " the upper bed is seen lying on the lower one: and also, as it appears when raised up." The mode of elevating the patient is evident, without a description. Ear//-.v /J,(/. #^ %*J, 4999999� �87�163944�914���276�639583�97714686761392�57337 X +m ELEMENTS OF SURGERY. Hi . sideralion is, whether the preservation of the fractured 1j£ limb can, with safety to the patient's life, be attempted; or, in other words, whether the probable chance of de- jm struction, from the nature and circumstances of the acci- dent, is not greater than it would be from the operatkto of amputation. Many things may occur to make this the case ; the bone or bones being broken into many different pieces, and that for a considerable extent, as happens from broad wheels or other heavy bodies passing over, or falling on such limbs, the skin, tendons, muscles/ &c. being so torn, lacerated and destroyed, as to render gan- ^ grene and mortification the most probable and most im- mediate consequence ; the extremities of the bones form- ing a joint being crushed, or as it were, comminuted, and the ligaments connecting such bones being torn and spoil- ed, are, among others, sufficient reasons for proposing and for performing immediate amputation; reasons which, notwithstanding any thing that may have been said to the contrary, long and reiterated experience has approved." " When a surgeon says that a limb which has just suffered a particular kind of compound fracture ought rather to be immediately cut off than that any attempt should be made for its preservation, he does not mean by so saying that it is absolutely impossible for such a limb to be saved at all events ; he is not to be supposed to mean so much in general, though sometimes even that will be obvious ; all that he can truly and justly mean is, that from the experience of time it has been found that the attempts to preserve limbs so circumstanced have most frequently been frustrated by the death of the patients in consequence of such injury, and that from the same ex- perience it has been found that the chance of death from amputation is by no means equal to that arising from such kind of fracture. u Every man knows that apparently desperate cases 112 ELEMENTS OF SURGERY. are sometimes cured, and that limbs so shattered and wounded as to render amputation the only probable means, are sometimes saved. This is an uncontroverted \*&>£act, but a fact which proves very little against the com- mon opinion, because every man of experience also knows that such escapes are very rare, much too rare to admit of being made precedents, and that the majority of such attempts fail. This consideration relative to amputation is of the more importance, because it requires immediate determination ; every minute of delay is in many instan- ces to the patients disadvantage, and a very short space of time indeed makes all the difference between probable safety and fatality." It is not easy to give general rules for practice in these cases, or else Mr. Pott, and other writers of great prac- tical experience, would certainly have expressed them- selves with more precision. One evades the question, another gives it very little attention, and Boyer (inferior to none in a knowledge of the subject) says, " It is im- possible to establish any general rule for cases of this kind. The surgeon-must be directed by his own talents and sagacity in each particular case." There are, how- ever, some cases of compound fracture which so evident- ly call for amputation that no doubt need exist as to the propriety of performing it immediately, if the surgeon is called within a few hours after the accident has happen- ed, and before inflammation has commenced. These are, when a luxation of a large joint, as the knee, ankle, elbow or wrist, accompany the fracture, forming what has been called a compound dislocation; when the prin- cipal blood vessels of the part are destroyed, and thus the danger of gangrene augmented; when a large lace- rated wound exists, the bone being greatly comminuted, part of its substance destroyed, and the weather very hot. In such cases, the dangers are to be stated, and the patient and his friends advised to submit to the operation; ELEMENTS OF SURGERY. 113 a mere compound fracture never calls for it; it is the ad- ditional injuries which may require so terrible a re- source. Mr. John Bell remarks, " I am sorry to observe this the most important question perhaps in surgery, treated as if it were no question, but rather a rule of practice, which might be established on the most absolute grounds. When a surgeon condemns a limb, he does not say that if amputation be not instantly performed the patient will die, nor is he disappointed if the limb be saved; he thinks both more sensibly and more humanely; he knows that there is great danger of losing the patient's life in attempting to save his limb, and reckons it his appointed duty to advise amputation ; but he is still sensible that the limb may possibly be saved, and often after his ho- nest opinion is rejected, contributes, by his attention and kindness, to that most desirable object. Sometimes he feels it his duty to advise amputation, and to represent very strongly the manifold dangers of attempting to save the limb, while yet he rejoices to find his patient willing to hazard all those dangers in favour of an object which it must be the chief honour of the surgeon to accomplish." The wound communicating with the fracture is some- times made by the protrusion of the bone, at other times by the same force which caused the fracture; the latter cases are generally accompanied with the greatest mis- chief. If, however, the injury be not so great as to in- duce amputation, the bone is to be reduced, and proper dressings are to be applied. Sometimes a considerable portion of bone protrudes through the external wound, and cannot readily be re- duced. It has been the custom in these cases to cut off the sharp ends and projecting pieces of bone, but this is almost in every instance unnecessary, and therefore im- proper. By carefully attending to the posture of the limb, and by dilating the wound when the bone becomes VOL. I. Q 114 ELEMENTS OF SURGERY. girded in it, and embraced tightly, we may always suc- ceed in the reduction. The enlargement of the wound thus occasioned does much less mischief than violent at- tempts to reduce the bone, which always occasion bruiz- ing and great pain ; an incision down upon the bone with a scalpel, or from the bone outward with a narrow bis- toury (whichever may in the particular case be found easiest) is to be performed; this incision readily heals, and leaves the wound no larger than it would have been if this had been omitted. Any loose splinters of bone may be removed, and the fragments carefully placed in contact. The wound, if an incision, may be closed w ith adhesive plaster. Mr. Hunter prefers, however, the application of a superficial dry compress, in order to allow the blood to coagulate and form a kind of scab, shutting up the cavity of the fracture. I have found both methods successful, and prefer the latter in all cases except where the wound of the integuments is somewhat extensive, iu which case a strip of adhesive plaster should be applied over the middle of the wound, leaving an opening at each end for the evacuation of effused fluids. We are alw ays to keep in mind the great importance of uniting the wound by the first intention, and thereby con- verting the accident to the state of a simple fracture, by which much danger and suffering will be pre vented. What- ever circumstances, therefore, can keep the parts in a situation favourable for union by the first intention, arc to be strictly observed, of course whatever can prevent the inflammatory action from transcending the adhesive grade; copious blood letting is often necessary in these cases. In fractures occasioned by gun-shot, and in others where union by the first intention is impracticable, and suppuration must take place, from the extensive contu- sion and injury of the surrounding flesh, a soft poultice of bread and milk should be applied. ELEMENTS OF SURGERY. 115 The wound being dressed, the accident is to be treated as a simple fracture, and of the proper dressings we shall speak after describing the fractures of particular bones. When extensive suppurations come on, and exfolia- tions of bone, the state of the patient's constitution will direct the general remedies. If debility be occasioned, bark and tonics must be administered, and a generous diet with fermented liquors allowed. The length of time necessary for the reunion of a bro- ken bone varies at different ages and in different bones. In a healthy adult a broken leg will generally heal in six weeks, a broken rib or clavicle in four. In children they heal in a shorter time. In old persons not so soon. Notwithstanding the use of the proper remedies, cases sometimes occur in which fractures do not heal by form- ing bone, but by a ligamentous union. The patella gene- rally heals in this manner, and no inconvenience results from a deficiency of bone between the fragments in that particular instance; but whenever this happens in one of the long bones, motion is allowed at the place of fracture, and a joint is formed, which destroys in a great measure the use of the limb, and exposes the patient to great inconvenience. In order to obviate this inconvenience, and to occasion bony union, a variety of measures have been resorted to. The physiological account of the formation of callus is a subject foreign from our present purpose; it is still, however, necessary to keep in view, that inflammation is essential to the restoration of a fractured bone, as well as of a wounded muscle. Whenever, therefore, two months or more have elapsed, without solid union being effected, it becomes necessary to excite inflammation by rubbing forcibly the fractured ends against each other ; after which the dressings are to be re-applied, and the part kept still. If this fail of procuring the desired event (and it sometimes does fail) other measures of a mach 116 ELEMENTS OF SURGERY. more active nature become necessary. Mr. Boyer, and most writers who have preceded him, recommend the cutting off of the extremities of the bone, and placing them again in contact. '< This operation," he observes, " is painful, terrifying, and of dubious event. Its suc- cess, however, has been frequent enough to warrant the trial. It would be impracticable in fractures of the leg or fore arm, on account of the difficulty of separating from the integuments the two bones of which each of these parts is formed, and on account of the numerous nerves and arteries which would be in danger of being wounded by the large incisions, it is therefore practicable only in the femur and humerus, especially in the latter." Mr. Boyer describes an operation of this kind which he once performed in the middle of the humerus ; the limb mortified, and the patient died on the sixth day ! In many other cases amputation has been performed. I saw an arm cut off in one of the largest hospitals in Europe in consequence of an " artificial joint" in the middle of the radius. It must be stated, however, that in this case there was a great deal of pain experienced in the part, but I do not consider this by any means an excuse for such an operation, because there is every reason to be- lieve that had the firm reunion of the fragments been effected, this pain would have .subsided. Mr. John Hunter suggested the propriety of exposing the cavity by an incision, under an idea that the " sti- mulus of imperfection" would excite a sufficiency of in- flammation to effect a union of the fragments. Dr. Physick has the credit of having proposed and practiced a mode of cure in these cases more eligible and successful than any heretofore in use, and one which pro- mises to supersede the cruel and fatal operations which have been mentioned. It consists in passing a seton be- tween the fragments, and suffering it to remain until bony ELEMENTS OF SURGERY. 11/ union commences. The first case in which this plan was carried into effect, occurred in the year 1802. The os humeri had been fractured many months before, and a joint was formed in its middle, which rendered the arm useless. A seton needle armed with a n»ki« of silk wras passed through the limb (extension being made at the time by two assistants) between the fractured en ;%■ of (he bone, a pledgit was applied on each orifice made by the needle, which was cut off, leaving the silk in the wound. The operation occasioned very little pain, and the subse- quent inflammation was by no means violent, and was followed by moderate suppuration ; the arm was in v few days after the operation placed in splints ; the dressings were renewed daily for twelve weeks, during which i rue no amendment was perceived; but soon after, the L iting of the arm at the fracture was observed to be more diffi- cult, and the patient complained of more pain when it was moved. From this time the bony union went on ga- dually, and in about five months the cure wras completed, leaving the arm as well and strong as it ever had been. Several cures of the os humeri and tibia have since been made in the same manner. It is important to be recollected that a long continued inflammation must be kept up in these cases, and therefore the seton should not be withdrawn for four or five months unless bony union is found commencing. I am sorry to state that the re- medy has been applied to two cases of fractured os feino- ris without effect; the occasion of the failure was, how- ever, very obvious in both cases ; it was found impossible to place the fractured extremities nearly together. They had passed each other to a considerable distance, an* the adjacent lacerated flesh had healed around them such a manner, that a great intervention of soft parts - isted, and precluded completely all contact of the f« ments. lis ELEMENTS OF SURGERY. It is probable that the remedy will be found effectual in most other cases of artificial joints, but not often in those situated in the os femoris. Much of the substance of the bone is absorbed in cases of artificial joints, so that the fragments are rounded, or rather pointed, and terminate in a kind of cartilage or ligament.* CHAPTER XIX. Particular Fractures FRACTURES OF THE OSSA NASI. The ossa nasi, in consequence of their exposed situa- tion, are often fractured. u The cause of the fracture is always applied to that part immediately where the solu- tion of continuity takes place, and the fracture may be oblique, longitudinal, or transverse, without derangement of the fragments ; but it more frequently happens that the bones are splintered and crushed into the cavity of the nostril; the nose loses its natural form, and the neighbouring soft parts are much bruised by being crush- ed between the bones and the cause of the fracture, whe- ther tlus be a body against which the nose has been for- cibly struck, or one which may have been strongly im- pelled against it. * In a thesis publishedat Paris, by J. B. La Roche, in 1805, the seton, as proposed by Dr. P. S. Physick, is recommended as preferable to all other means heretofore ised in such cases; but the writer being unacquainted with the English lan« -uage, has supposed the family name of Dr. Physick to be that of his profes- ->n, and consequently ascribes the honour of the invention to Monsieur P. S. .-----, Physician. The writer of the thesis alluded to, having seen setons ufter gun-shot fractures to facilitate the discharge of dead bone, won- .at the thought never occurred to himself nor his master, of applying the • to cure artificial joirtfs. ELEMENTS OF SURGERY. 119 " If the soft parts have suffered no solution of conti- nuity, and if the fragments have not been displaced, the fracture may not be discovered, because the form of the nose does not change. An oversight in this case is not dangerous, as the use of emollients and resolvents is all that is required. If the fracture be comminutive, not only the inflammatory symptoms ought to be combatted by blood letting and other antiphlogistic means, but further, the fragments ought to be replaced, as they strain and irritate the soft parts, already contused, by their unnatural situation. For that purpose the surgeon takes a grooved sound, a female catheter, a ringhandled forceps, or any such instrument, introduces it into the nostrils, and by using it as a lever, pushes the fragments outwards; at the same time with the index of the left hand applied to the ringe of the nose, he prevents them from being push- ed out too far, and from lacerating the integuments. Sometimes the bones continue in the situation in which they have been thus placed; but it may happen, that from being much fractured, and badly supported by the soft parts, they fall again inwards: in which case a ca- nula of elastic gum should be directed along the inferior surface of each nostril, which ought then to be stuffed with lint, and gently thrust in, lest the pituitary mem- brane should be hurt. " In cases of comminuted fracture, with depression of the splinters, it would be imprudent to wait the disap- pearance of the inflammatory symptoms, before making an attempt to raise and adjust the fragments; because, during the interval, the portions of bone might reunite in an unnatural situation, and produce deformity of the nose. " Fracture of the nasal bones is sometimes attended with very dangerous symptoms, whether produced by a violent commotion given to the head, by the cause of the fracture, or by a co-existing fracture of the bones of the 120 ELEMENTS OF SURGERY. skull; or, as some authors think, by the concussion communicated to the perpendicular part of the ethmoidal bone, and thence to its cribriform part, which would, in that case, be fractured, on account of its great tenuity. The laceration of the dura mater and its vessels, caused by the fracture of the cribriform lamella of the ethmoidal bone, would produce effusion, and thus give rise to all the symptoms. It is certain that cases have occurred where blows on the root of the nose have produced coma, convulsions and death; particularly when the nasal bones were not fractured." (Boyer.) A piece of leather spread with adhesive plaster assists by gentle compression in preventing the tlisplacement of the fragments, and as there is no danger of displacement from muscular action, no other dressing is necessary. I have seen a fracture of these bones in which one of the fragments punctured the facial artery as it passes over the nose. The hemorrhage at first was very profuse, but ceased after the fragments were reduced. ELEMENTS of surgery. 121 CHAPTER XX. Fractures of the Lower Jaw. Tins bone from its moving freely when struck, and also from its strength of texture is not very often frac- tured. It sometimes however is broken, and no part of it is secure from fracture. Mr. Boyer declares that its "symphysis at the chin is very rarely fractured though it is not impossible:" I once saw an instance of fracture at this place. Sometimes it is broken in several places. I have known the jaw bone broken by a fall, into five dif- ferent fragments. The middle piece in these cases is most difficult to be kept fixed, because of the muscles in- serted into it which tend to draw it downwards. It is liable to fracture in every part, from the condyles to the chin. The coronoid process is not often fractured except by gun-shot wounds. The condyles are oftener broken. The fracture may vary greatly in its direc- tion ;—it is sometimes transverse, sometimes oblique, sometimes in the direction of the bone, or longitudiual, separating the alveolar portion from the basis. It is generally simple, but sometimes compound. The symptoms of a fractured jaw are very obvious a severe pain at the part is felt at the time of the accident and an inequality is perceived on passing the fingers along the basis of the jawr, upon examining the teeth they are found unequal, those situated upon one fragment being elevaled above those of the other; when the two sides are taken in the hands it is easy to reduce the teeth to their proper level and in doing so crepitation is perceived. These symptoms exist when the fracture is situated an- teriorly to the angle of the jaw, when the condyles are broken, the fracture is not so very obvious, but may be VOL. F. R 123 ELEMENTS OF SURGERY. ascertained by pain near the ear when the jaw is moved, and by crepitation occasioned by these motions. If con- siderable swelling occur before the surgeon is called, greater difficulty is experienced in determining the na- ture of the accident, and in these cases it becomes neces- sary to wait until the inflammatory symptoms subside. The greatest danger attending a simple fracture of the lower jaw is that of consequent deformity, and this is very readily obviated by proper arrangement. Compound fractures, however, are more dangerous and are often followed by tedious exfoliations, and in some instances do not unite. To reduce the fracture, nothing more is necessary than to shut the mouth, and forcibly push upwards the infe- rior fragment, until the teeth contained in it come in con- tact with those in the upper jaw. When all the teeth are upon a level, the fragments are to be supposed in apposi- tion. It is not easy in all cases to keep them at rest in this position:—A variety of means have been contrived to effect this purpose, such as fastening the pieces togeth- er by passing wire around some of the teeth in each— forming a mould of moistened pasteboard to fit the chin, and binding this fast upon it The simplest and best plan is to avail ourselves of the support given by the teeth in the upper jawr, by binding the fragments firmly against them, and this can be very conveniently done by means of a simple roller of muslin passed repeatedly round the top of the head and under the chin. It may be further secured by passing a few turns of it round the back of the neck and in front of the chin. The four-headed and double-headed bandage formerly used for this purpose, have no advantage over the roller, and it is by no means so easy to apply them neatly. The patient should be nourished fifteen or twenty days on spoon victuals, sucked between the teeth for which there is generally space enough, and this space is often ELEMENTS OF SURGERY. 1S3 augmented by the w.tnl of a tooth at some part of one of the jaws.— Lt has been proposed in comminuted and compound fractures, where the slightest motion is pro- ductive of great pain, to pass a catheter through the nos- tril, and inject the fluid aliment through it. If a case re- quiring such treatment should occur, no difficulty would be found in effecting it. In fractures of the condyles of the jaw, that process is drawn forwards by the pterigoideus externus muscle; as it is very short there is no means of obviating this, and it becomes necessary therefore to push forward and keep in that situation the inferior fragment; in order to effect which, before applying the bandage as has been di- rected, a compress is to be applied behind the angle of the jaw extending nearly up to the ear, this compress when the roller presses tightly on it will keep the infe- rior fragment advanced sufficiently to come and remain in contact with the upper.—In fractures of the condyles it is particularly necessary for the parts to remain at rest, as motion has sometimes prevented the reunion of the fragments and the condyle has exfoliated. Boyer relates a case in which this* unpleasant event occurred: he ex- tracted the condyle seven months after the accident through a fistulous ulcer. Compound fractures of the lower jaw, are very fre- quently attended with exfoliation, by which the cure is much protracted. It often happens that one or more of the teeth are loosened at the fractured part; it has been advised to extract all loosened teeth, as extraneous matter. It is a fact, however, that the teeth under these circumstances very readily become fixed, and it is extremely improper to remove them, because the accident is thus converted into a compound fracture. 124 ELEMENTS OF SURGERY. CHAPTER XXI. Fractures of the Vertebra?. The spinal column moves readily in every direction, and being composed of a great number of separate pieces, of small size, is not very liable to fracture. The spinous processes are sometimes broken, because they are more slender and brittle than the other parts of the bone, pro- ject considerably backwards and are more superficial. Whenever the vertebrae are fractured, the force w hich produces this effect occasions also concussion of the spi- nal marrow, which is the only circumstance rendering the accident important, for the mere fracture of the ver- tebrae would heal as readily as that of any other bone. A palsy of all those parts which derive their nerves from below the fractured spot is the immediate consequence of every fracture of the spine which produces compres- sion on the spinal marrow; whether this be by the pres- sure of bone or effused fluids. When this happens, therefore, in either of the three superior cervical verte- brae, immediate death ensues, from palsy of the fourth and fifth pair of cervical nerves, which chiefly supply the diaphragm, aud which originate in the spinal mar- row, a little higher than the place of their exit. Although death does not instantaneously follow the fracture of the fourth cervical vertebra, yet it very soon occurs. "The variety of causes which may give rise to symp- toms analagous to those of fracture of the vertebrae ren- der it difficult to establish a diagnosis. Yet when a per- son has fallen on his back from an elevated situation, or when a body very forcibly impelled, as a bullet dis- charged from a musket, has struck that part, if a fracture has taken place, some derangement of the spinal process ELEMENTS OF SURGERY. ±25 of the fractured vertebrae may be observed, by an atten- tive examination of the part affected. Much pain is caused by pressing on that process; the inferior extremi- ties are paralyzed, as also the rectum and bladder; the patient is afflicted with a retention of urine and faeces, or with an involuntary discharge of the latter. " This paralysis of the inferior extremities, the neces- sary concomitant of the fracture of the vertebrae is not in itself a mortal affection; but the patient losing the power of locomotion, and being obliged to lie perpetually on his back, soon feels a troublesome itching in the region of the sacrum on which the pressure of the body is princi- pally concentrated. The skin of this part becomes in- flamed and gangrene to a greater or less degree ensues, because the pressure on that part intercepts the course of the humours. The bone is quickly denuded, the ulcer extends rapidly and consumes the patients strength, the dissolution is accelerated by the retention of excrements, from the paralysis of the rectum and bladder. The ca- theter which must be introduced into this latter organ for the purpose of evacuating the urine gives admission to the airy* " Its mucus secretion becomes more abundant and its substance thickened. A slimy matter flow s out with the urine, and the penis and scrotum become cede- matous, a slow fever succeeds these symptoms, and the patient however robust he may be, falls in a few weeks. We have known, however, a man of very vigorous con- stitution to have survived for six months an accident of this nature. Examples of recovery are recorded, but they are extremely rare, and to be ascribed to the secret operations of nature rather than to the efforts of art, and we repeat that scarcely one in thirty recovers ; almost all " The inflammation thus occasioned, is probably not excited, as Mr. Hoyer supposes, by Uie admission of air, since there is no reason for supposing this fluid a powerful irritant, except when it produces fermentation, in the contents of a cavitv. 126 ELEMENTS OF SURGERY. die from the exhaustion of their strength, by slow fever, colliquative diarrhoea, &c. " Any attempt at setting these fractures would be not only useless but dangerous, by the straining which it would occasion. General treatment alone can be had re- course to." (Boyer.) In all cases of injury of the spine it is of extreme im- portance to introduce a catheter into the bladder and to leave it in with a cork in the orifice, or to introduce it and evacuate the urine three or four times every twenty four hours. As the patient in these cases feels no pain and is not conscious of the distention of his bladder, it is necessary for the surgeon to be aware of the importance of attending to this circumstance. A patient was brought into the Pennsylvania hospital in the summer of 1S12, who had been wounded in the spine, by a musket-ball two weeks before in a naval engagement. He had re- ceived very little attention after the accident; immediate- ly on his admission I ordered the catheter to be intro- duced, when nearly three quarts of urine were drawn off; he had voided none for two weeks. It has been recommended to trepan the spine in cases of paralysis from fracture, and to remove the depressed bone or effused fluids, as in cases of fractured cranium. This operation could not be performed without extreme difficulty, and the greatest uncertainty of relieving the compression. The inflammation likely to follow the ope- ration, would probably occasion a repetition of the pres- sure from distention of the vessels within the spinal ca- vity. Dr. Physick has attempted to relieve the effects of frac- tures of the vertebrae, by making extension and counter extension from the head and feet of the patient, the head being secured to the upper and the feet to the lower part of the bedstead. In the first case in which it was used, the fracture was situated in the fifth and sixth cervical ELEMENTS OF SURGERY. 127 vertebrae; the patient regained after the extension, the use of his arms which had been paralytic, but expired shortly after, apparently from a collection of mucus in the trachea which he was unable to cough up, from palsy of the expiratory muscles. Perhaps as some relief was in this case experienced the remedy may be worthy of trial.* In examining patients with fractures of the spine it is of extreme importance not to turn them on their faces, but to conduct the examination whilst they lie on one side—suffocation has resulted and instant death from ne- glecting this caution. CHAPTER XXII. Fractures of the Ribs. The ribs in consequence of the elastic cartilages in which they terminate, and of the strength derived from their arched form, are not very often fractured. Tho first rib is very seldom broken, as the shoulder and cla- vicle protect it greatly from accidental violence. .The ribs are most commonly broken by falls from a conside- rable height, and sometimes by violent blows. They are generally broken near their midde, by a transverse fracture; sometimes the fracture is oblique and inconve- niences result from the sharp extremities of the frag- ments ; sometimes these penetrate the external integu- ments, forming a compound fracture, and sometimes they pierce the pleura and lung, and thus occasion emphy- sema. * An account of this case may be seen in Dr. Hartshorne's edition of Bover. 123 ELEMENTS OF SURGERY. The fracture is ascertained by an acute pain in breath- ing and by careful examination with the hand, and op- pressing the rib in different parts a crepitus may some- times be felt. To assist in the investigation the patient should be desired to cough whilst the surgeon's hand is kept on the part injured, if any fracture exist the act of coughing will generally produce crepitation. In many cases, especially in very corpulent subjects, there is great difficulty in ascertaining the existence of the accident, and in all these cases the dressings should be applied as if a rib actually were fractured. From the articulation of the ribs to the sternum before, and the vertebrae behind, no diminution of length can take place : no lateral derangement of the fragments can happen, because the intercostal muscles act equally on both fragments, and tie them to the uninjured ribs above and below. The only derangement which can happen, is by an angular projection internally at the place of fracture. The only treatment necessary in simple fractures of the ribs whether one or several be broken, is to keep the parts at rest as much as possible during their reunion, and this is done by counteracting in great measure their motions in respiration. To effect this, a bandage six inches wide is to be passed repeatedly round the chest as tight as the patient can suffer it to be drawn. Its des- cent may be prevented by a shoulder strap. When this is done respiration U performed, principally by the ac- tion of the diaphragm, and the ribs remain, comparatively at rest. Instead of the roller, a jacket of strons linen may be used capable of being laced very tight by means of tapes. When the lungs have been wounded by a fragment of the bone, the patient generally spits blood and coughs violently—The lungs inflame, and violent fever comes on, attended with difficult respiration and other symp- ELEMENTS OF SURGERY. 129 toms of pneumonia. Copious blood-letting, and the usual remedies for inflammation must in such cases be em- ployed. When emphysema occurs from a fractured rib, it is to be treated in the same manner as has been recom- mended when this affection is consequent to a wound of the thorax. If the complaint proceed to any consider- able extent an incision is to be made into the thorax; it is, however, a very rare occurrence: to prevent it, it has been recommended to bind a compress very firmly over the fracture. When the cartilages of the ribs become ossified, as they often do in advanced life, they are also liable to fracture, the accident is to be treated just as a broken rib. CHAPTER XXIII. Fractures of the bones of the Pelvis. The os sacrum is not often fractured—A carriage passing over it, or a heavy weight falling on it, may oc- casion a fracture: no muscles are inserted into it which have any agency in moving the fragments, and the only remedy is rest in a horizontal posture. If extensive inflam- mation result from the contusion accompanying the frac- ture, it is to be treated as usual. If suppuration take place, and abscesses form, they must be opened as soon as pos- sible, to prevent the formation of fistulous ulcers. When large extravasation takes place within the pelvis, bleed- ing and lowr diet are to be ordered, with a view to pre- vent suppuration, which in this situation would prove a very serious evil. The os coccygis is sometimes broken, though very vol. i. s 130 ELEMENTS OF SURGERY. rarely—The existence of this fracture is ascertained by pain in the part, and in every attempt to walk this pain is augmented : by introducing the finger into the anus, the fragments may be felt.—The only remedy necessary is rest and gentle compression, by means of a compress supported by a T bandage. The ossa innominata are occasionally broken by a variety of accidents; the fracture occurs in different si- tuations. Mr. S. Cooper has seen instances of fracture in the ilium, the ischium, and the os pubis. I have seen the acetabulum fractured in such a,manner as to occasion incurable lameness. The ilium, however, is more fre- quently broken than either the ischium or pubis. The fracture of these bones, is in itself of less consequence than the mischief occasioned by the force which pro- duced it. The contents of the pelvis must be contused severely by any force great enough to fracture the bones which form it, and generally extravasations of blood take place into the cellular texture, which intervenes between the viscera of the pelvis. A fracture of the os innominatum, is to be known by the usual symptoms of pain and crepitation upon moving the fragments; an inability to walk also occurs, but any severe injury to the pelvis produces this: fractures of these bones have often been found after death, when their existence has been unsuspected. The treatment consists chiefly in obviating inflammation by the usual remedies, as no displacement of the fragments is likely to occur. The inconveniences of discharging the urine and faeces, are sometimes very great in these ac- cidents, but they are much diminished by the use of sir James Earl's bed. In some cases suppuration takes place, notwithstanding the free use of evacuating remedies, and large abseesses form: splinters of bone have been found to occasion these collections of matter.—"Desault in giving an. exit to a collection of urine which had taken ELEMENTS OF SURGERY. 131 place from a fracture of the pelvis found a splinter which he extracted from the bottom of the wound. If the bladder be perforated by a splinter, this should be ex- tracted, and a catheter introduced, in order to prevent the accumulation of urine and its consequent effusion into the cavity of the abdomen;" an accident which has oc- curred. CHAPTER XXIV. Fractures of the Scapula. The mass of muscular flesh which surrounds the sca- pula, and its great mobility, protect it in great measure from fracture; some parts of it, however, are more ex- posed than others. The acromion process forms the most projecting part of the shoulder, and is oftener fractured than any other part of the scapula; the inferior angle is the part next in frequency found broken. The coracoid process has seldom been known fractured: a gun-shot wound, and the falling of a heavy body directly upon it, have sometimes, however, occasioned this accident. The force which produces the fracture generally occa- sions much contusidn of the adjacent flesh. When the scapula is broken longitudinally, the muscles on its sur- faces prevent a displacement of the fragments, transverse fractures are more apt to be accompanied with a derange- ment of them. The serratus major anticus muscle, draws forward the lower portion to which it is principal- ly attached. The inequality is evidently perceived by passing the fingers along the base of the scapula. To ascertain the existence of the fracture, it is neces- sary to examine particularly whether any derangement is evident, and whether any crepitation can be produced 132 ELEMENTS OF SURGEK.Y. by pressing the bone in different places. The only frac- tures which are not easily discoverable in this way are the longitudinal. The lower angle when broken off moves easily under the fingers, whilst the rest of the bone is stationary. When the fracture is longitudinal, or transverse through the scapula, a roller is to be applied round the chest and arm, so as to confine the arm close to the side; this roller should cover the arm down to the elbow. " As the inferior angle when separated by fracture from the rest of the bone, is like the condyloid process of the jaw, little susceptible of being acted on by any means in our power, it will be necessary to act on the scapula itself, to push it downwards and forwards, to- wards the inferior fragment which the serratus major anticus has drawn in that direction. In this case too it is on the arm that it will be necessary to act, in order to move the scapula. The arm is to be pushed inward, forward, and downward, the fore arm being half bent. It must be kept in this position by a circular bandage seven yards long. It will be proper at the same time to act on the angular detached portion by means of com- presses, which may be pressed backward by some rounds of a bandage, and thus brought in contact with the rest of the bone. The arm may be supported in a sling tied on the opposite shoulder." (Boyer.) "The accromion when fractured is drawn outward and downward by the action of the deltoid muscle, at the same time that the rest of the bone is drawn upward and backward by the trapezius and levator scapulae. This fracture is set, by raising the arm in such a manner as that the head of the humerus may push upward the ac- cromion, which has descended, and which naturally co- vers it like an arched roof, at the same time an assistant pushes the scapula forward and downward, in a direc- tion opposed to that which is given to the arm"—In ELEMENTS OF SURGERY. 138 order that the parts may remain in this situation, banda- ges are to be applied—"A circular bandage is to be applied round the trunk and arm, and afterwards made to ascend from the elbow to the shoulder, and vice versa." "This bandage like all those of the thorax is very liable to be displaced, and therefore to be frequently reapplied, never forgetting on these occasions to have the elbow rais- ed and the shoulder pressed down." (Boyer.) Although fractures of the scapula consolidate in the ordinary time of thirty-five or forty days, yet in those of the accromion it will be necessary to continue the band- age a little longer; not that the generation of callus is slower in that part than in any other, but because the accromion, is acted on by strong muscles, which might rupture the callus if exposed to their action before it had acquired a great degree of solidity. CHAPTER XXIV. Fractures of the Clavicle. The clavicle is perhaps as often broken as any bone of the body. Its exposed situation at the upper part of the trunk, its long slender shape, and its being covered only by the common integuments, expose it to frequent accidents. The fracture commonly occurs near the middle of the bone, as it is here most prominent, it is also occasionally broken near the sternal, and humeral extremities. When fractured by the falling upon it of a heavy body, the nerves of the arm become paralyzed by the contusion. In general the fragments are displaced, unless it is broken near the shoulder, in which case its firm con- nection by ligaments with the scapula prevent the dis- 134 ELEMENTS OF SURGERY. placement. The external fragment, or that nearest the. shoulder, is drawn downwards by the weight of the arm, and the action of those fibres of the deltoid muscle, which are inserted into it, and also by the pectoralis major, which when it is depressed draws it forwards, or in- wards towards the sternum; so that the sternal portion is always found riding over the humeral; the arm of the affected side falls over upon the breast, and the patient is unable to rotate the humerus, so that it is impossible for him to raise his hand upon his head. He leans to the fractured side, and the attitude is so remarkable, that the celebrated Desault it is said, was never deceived in deciding from this circumstance alone, the existence of the fracture. Crepitation may easily be produced by moving the arm, and the finger passed over the clavicle readily detects the place of fracture. This accident in itself is not dangerous, but becomes so when accompanied with great contusion or laceration of the neighbouring soft parts. The treatment of this fracture has been the source of much difficulty among surgeons, a vast variety of ma- chinery has been contrived for the purpose of keeping the fragments together, and lately a surgeon of great and deserved celebrity* has renounced all applications and trusts to rest in a horizontal posture, as the only neces- sary remedy. 1 refer to Mr. Boyer for a concise ac- count of the discarded apparatus of the older surgeons. Mr. Desault was the first who properly contemplated the difficulties to be surmounted, and constructed an appara- tus, which better than any before in use, removes them. His plan with different modifications has been very ge- nerally used in this country, and continues to be pre- ferred to all others, I shall therefore describe it. It is not the smallest advantage of his dressings that they are always at hand. " The pieces of which this apparatus is composed are, • Mr. Pelletan, surgeon in chief to (he Hotel Lieu, &c. &c. &c. Missing pages 135-136 Missing pages 135-136 ELEMENTS OF SURGERY. 137 extent of about the third part of its breadth. It is ne- cessary that these turns be applied in such a way as to bind but very gently above, and to increase in tightness, as they descend nearer to the lower extremity of the hu- merus. The use of the second roller is to supply the place of the hand of the assistant in pressing the arm against the side of the thorax, its effect evidently is to draw the up- per extremity of the arm outwards and as it is already directed backwards, to retain it in that position. The compression of the circular turns on the arm, being thus gradually augmented, becomes on the one hand more ef- ficacious, because it acts on a greater surface; and on the other less troublesome, because being more divided it is less felt at the lower extremity of the arm, where it bears with most force. A third indication remains to be fulfilled, namely, to retain the shoulder in its elevated position, and by that means to assist in the extension of the fragments, which already has some effect in preventing a depression. To fulfil this indication, an assistant sustains th© elbow in its elevated position with one hand, and with the other supports the patients hand before his breast, whilst the surgeon fills with lint the hollow spaces around the clavicle. He then applies on the clavicle at the place where it is fractured, the two long compresses, wet with vegeto mineral water, a solution of sugar of lead, or some other cooling liquid. Taking now the last rol- ler, he fixes the end of it under the sound shoulder, from thence he brings it obliquely across the breast, over the long compresses, and carries it down behind the shoulder along the posterior part of the arm, till it passes undej? the elbow. From this point he again carries it obliquely upwrards across the breast to the arm pit, then across the back over the compresses, and brings it down again be- fore the shoulder along the front of the humerus, till it VOL. F. T 138 ELEMENTS OF SURGERY. again reaches the elbow. From thence the roller again ascends obliquely behind the thorax, passing under the arm-pit where the first coat of the roller is covered, and from whence it again starts to. run the same course we have just described. This constitutes a second round, which covers in part the first, and forms a kind of double triangle, e,f, d, situated before the breast, and over the circular turns of the other rollers (c, c Fig. 4.). The re- maining part of the roller brought from behind forward, is employed in circular turns over the arm, and round the thorax for the purpose of preventing, the displace- ment of the first part. To make it the more secure it is fastened with pins or stitches at its different places of crossing. The sling (Fig. 4.), is next passed under the hand, and fastened above to the ascending turns (d) and not to the circular (c c), which the weight of the hand would be likely to draw downward. It is only necessary to examine the course of this third roller to see that united to the sling; it is well cal- culated to support the external fragment, which the weight of the shoulder, has a tendency to depress on a level with the internal one. It supplies the place of the assistant who raises the elbow, and supports the hand of the patient, in like manner as the second roller performs the office of the assistant who presses the lower part of the humerus against the side of the thorax. On the other hand, the circular turns by which the ap- plication of the third roller is finished, being directed from before backwards, push in the same direction the arm and shoulder, which have been already carried that way, by the process of reduction, and thus retain them in their proper places." (Desault.) By this apparatus the shoulder is kept, upward, back- ward, aud outward; the weight of the arm and the ac- tion of the muscles, are thus effectually prevented from drawing the humeral fragment inward, and downwards. ELEMENTS OF SURGERY. 139 <( The coats of the rollers thus surrounding the thorax, however well they may be secured, are yet liable to be displaced, particularly when the patient is in bed. This inconvenience may be obviated by surrounding the whole with a piece of linen, leaving nothing uncovered but the sound arm, which is at liberty to perform its usual mo- tions." It is better, however, to add to the firmness of the dress- ingsr by connecting them together with several rows of stitches in different places. This mode of treating fractured clavicle, has been found extremely successful, but it has its inconveniences; the principal one that I have experienced in its use, is the numbness of the arm, and stoppage of the circulation, which occur in consequence of the pressure of the bol- ster in the axilla, upon the vessels and nerves of the arm. Great attention is necessary to obviate this by diminish* ing when it occurs, the tightness of the bandage, which passes round the arm near the elbow; to judge whether the pressure be too great the pulsations of the radial ar- tery at the wrist should be attended to; if they be inter- rupted, the bandage must be loosened. Another incon- venience results from the slipping down of the pad in the axilla; I have in some cases, with advantage, attached a piece of tape to it, and tied this on the opposite shoul- der. Whenever the dressings become slack they must be tightened; without attending to this circumstance they are useless. Mr. Boyer availing himself of the principles of De- sault has constructed a very simple apparatus which acts in the same manner, and is very easily applied. It consists of a girdle of linen cloth quilted, and six inches broad, which passes round the trunk on a level with the elbow. It is fixed on by three straps, and as many buckles fastened to its extremities. At an equal 140 ELEMENTS OF SURGERY. distance from its extremities, on each side, are placed two buckles, that is, two anterior, and two posterior to the arm. A bracelet of quilted linen cloth five or six fingers broad, is placed on the lower part of the arm of the side affected, and laced on the outside of the arm ; four straps fixed to this bracelet, that is two behind and two before, correspond to the buckles on the outside of the girdle al- ready described, and answer the purpose of drawing the lower part of the arm close to the trunk, the more so, as the straps by being two before, and two behind, prevent the arm from moving either backwards or forwards. With this apparatus, as well as the preceding, the cush- ion must be applied under the arm. I have never seen this plan used, but have no doubt it would answer very well. It cannot, however, be free from those inconveniences of Desault's which result from pressure in the axilla, and the weight of the arm, appears to be less completely supported. In about four or five weeks the fracture will generally unite, and no particular attention is necessary to diet or regimen; the patient may be allowed to walk about du- ring the cure. riq.2. Sngrmt tyWlJitafi ELEMENTS OF SURGERY. lit CHAPTER XXVI. Fractures of the Os Humeri. The os humeri is fractured most frequently near its middle; occasionally, however, in all its parts. I have known it fractured in one case within the capsular liga- ment, the fracture extending through the head of the bone. Fractures above the insertion of the pectoral and latissi- mus dorsi muscles, are called fractures of the neck of the bone. The lower extremity is also broken, and in some instances, the condyles are detached from the rest of the bone, and from each other. When the fracture is transverse, and is situated near the middle of the bone, no great derangement takes place, the fragments supporting each other, and the limb pre- serving its length, and unless moved, its form. In ob- lique fractures, the limb is shortened by the action of the muscles, and considerable alteration in its shape is per- ceived. When the bone is fractured at its upper end, or neck, there is some difficulty in distinguishing the accident from a dislocation of the head of the bone into the axilla. It can always, however, be known, by a depression at the upper and external side of the arm, very different from that depression which occurs in dislocations, and which is situated immediately under the accromion sca- pulae. In the present instance, the shoulder retains its natural rotundity, and no depression exists directly un- der the accromion. The axilla being examined with the fingers, the fractured unequal surface is readily felt; whereas, in dislocations, the round head of the bone is felt high up in the arm-pit. By moving the arm the grat- ing of the fractured surfaces can be distinctly perceived. 14S ELEMENTS of surgery. The best manner of treating this accident, is that des- cribed by Desault. " The patient is to be seated on a chair, or on the side of a bed, the arm is slightly separated from the body and carried a little forward. One assistant is directed to fix and secure the trunk in a proper manner; this he does by pulling the arm of the sound side, taking hold of it near to the hand, and extending it in a direction perpen- dicular to the axis of the body. This mode of counter- extension, is preferable to that commonly employed, which consists in applying the hands to the upper part of the patients shoulder; because on the one hand, the power being farther removed from the resisting force need not be so great, and on the other, the body being entirely unincumbered renders it easy for the surgeon to apply the roller, without discontinuing, or in any way disturbing the extension. Another assistant makes ex- tension on the fore arm, which serves him as a lever, where one hand being placed behind, or on the back of the wrist, forms the point of support, or fulcrum, while the other applied to the anterior and middle part of the fore arm, on whieh it makes pressure from above down- ward, constitutes the power, and the fragments to be brought into contact, the resistance. The relaxation of the muscles produced by this semi- flexion of the fore-arm, and the separation of the arm from the trunk, greatly favours this mode of extension; a mode, recommended by the ancients, adhered to by the English, and which possesses the advantage of leaving uncovered all that portion of the limb on which the ap- paratus is to be applied, and by that means of allowing the hands of the assistant to keep the same position du- ring the whole time of the application. A small degree of force directed according as the displacement is inward or outward, is sufficient to effect the reduction, which even takes place of its own accord under this process. elements of surgery. 143 If the surgeon lays his hands on the place of fracture, it is rather to examine the state of the fragments, than to assist in bringing them into apposition." In order to keep the parts in this state of reduction, the surgeon takes a roller, fixes one end of it by two cir- cular turns, on the upper part of the fore arm, and car- ries it up along the arm by oblique turns moderately tight, and overlapping each other about two thirds of their breadth. Having reached the upper part of the limb, he makes some reversed turns to prevent the wrin- kles, which would otherwise be caused by the uneven- ness at this place. He then passes two casts of the rol- ler under the opposite arm-pit, and brings it to the top of the shoulder again; a splint* is then placed before, which reaches from the fold of the arm to a level with the accromion ; another on the outside reaching from the external condyle to the same level; a third reaching from the olecranon to the fold of the arm-pit. f These splints* are to be secured in their situation by the roller brought down over them and secured at the elbow*. A bolster is now applied between the arm and side; Desault advises this bolster "to be made of linen from three to four inches thick at one end, tapering like a wedge to the other, and of a sufficient length to reach from the arm-pit to the elbow." If the displacement be in an inward direction, the thick end is to be placed uppermost, and if outward, which is commonly the case, the thin end. This bolster is to be pinned to the roller, and the arm then secured against it, by a roller passed round the arm and body, (as in cases of fractured clavicle), sufficiently tight to*keep the arm firmly fixed against the bolster. Instead of the cushion or bolster recommended by Desault, compresses of fold- ed flannel or linen may be substituted, and they can be * Firm pasteboard answers very well for this purpose. f Two splints, each two inches wide, are generally sufficient in this fracture 144 ELEMENTS OF SURGERY. made thicker at one place than another, according as the displacement inward, or outward, may require. The fore-arm is to be suspended in a sling. From twenty-six to thirty days are required for the reunion of the fragments. It is of consequence in this accident, from the vicinity to the joint, to prevent any displacement of the fragments, as their union under such circumstances would greatly impede the motions of the limb. The apparatus just described, which varies in nothing important from that of Desault, will effectually prevent this inconvenience. Fractures occurring in the middle of the bone, or in any situation between the immediate vicinity of the el- bow and shoulder joints, are very easily dressed. Coun- ter extension is to be made by an assistant with his arms round the chest; extension is to be made by another as- sistant who draws down the arm, taking hold below the elbow. The surgeon readily places the fragments in contact, when the arm will be found to have its proper length and shape; the external condyle corresponding with the most prominent part of the shoulder. A roller is now to be applied, extending from the wrist to the shoulder (to prevent tumefaction of the fore-arm); the fore- arm is to be bent to a right angle with the arm; when the roller reaches the elbow, three or four splints ac- cording to the bulk of the arm, (I have never, however, seen more than three necessary,) are to be applied to the outer, inner, and back part of the arm, and secured by bringing down the roller over them : these splints should be two and a half inches broad, long enough to extend from the shoulder to the elbow, the inner one will be se- veral inches shorter than the two others, to allow the flexion of the fore arm, and to prevent excoriation at the axilla. They may be made of thin wood, or strips of wood glued upon leather, or tin, or what I have always pre- ferred to every other material, thick pasteboard, such as h employed for the covers of books. When pasteboard ELEMENTS OF SURGERY. 145 is used in this case, it need not be soaked in water, but bent so as to fit the arm. The roller must never be bound so tight as to cause pain. The arm must be supported in a sling, and the patient, in general walks about during the cure which is commonly completed in four weeks. At the expiration of a week (Sid in most other fractures the same thing should be done) the dressings are to be removed and the part examined, and any displacement rectified before they are reapplied. When the fracture is situated near the condyles, or at the condyles, a very different mode of treatment is to be adopted. A deformity is extremely apt to occur after this accident, and the motion of the elbow is much im- peded. To obviate this, Dr. Physick has for many years been in the habit of applying two angular splints, which keep the fore arm flexed at a right angle upon the arm. The fracture being reduced, and the parts placed in their proper situation, a roller is to be applied as usual, from the wrist to the shoulder, and brought down over the angular splints: these splints are made of pasteboard or wood, an inch and a half wide; the part applied to the arm, extends from near the shoulder to the elbow, and the part applied to the fore arm, should be long enough to reach to the ends of the fingers, to obviate the motions of the hand; a handkerchief passed round the neck, supports the weight of the arm. After a week has elapsed, the dressings are to be re- moved, and the joint carefully and gently flexed, and extended several times to prevent stiffness ; after which they are to be carefully reapplied, and this is to be repeat- ed once in every forty eight hours, increasing as the cure advances, the motion of the joint. At the end of three weeks the mode of dressing is to be altered, and splints forming an obtuse angle are to be substituted for the rec- tangular, which had been first employed. The object of this change, is to prevent a kind of deformity, which vol. i. CJ 146 ELEMENTS OF SURGERY. though not very important in man, as it does not interfere with the motions of the joint, is however, of more conse- quence to females. The deformity alluded to, consists, in an angular projection of the elbow, outwards. It is most evident when the whole arm is placed at right an- gles to the body, with the thumb upwards, the patient standing erect. In that case, instead of a gentle curve downwards at the elbow*, which is natural, the curve is directly reversed. I have attempted to represent it in the annexed sketch, in which the natural and the de- formed appearances, are contrasted. The effect is par- ticularly apt to occur, when the condyles are broken off directly at the joint, and when in addition to this trans- verse fracture they are also separated from each other, which sometimes happens, from the extreme thinness of the bone between the two condyles, occasioned by the space for receiving the olecranon behind, and the coro- noid process of the ulna before. The mode of treatment just described, has in several instances, been completely successful in preventing deformity, and preserving the perfect motions of the elbow. Plate v. s 5 V/ { Page 146 M^ ,4\ :0 $. '€* i H \ * ELEMENTS OF SURGERY. 14? CHAPTER XXVII. Fractures of the Fore-arm. These are very frequent accidents, and are produced by a variety of causes. Sometimes both bones are bro- ken, sometimes the radius only, and sometimes the ulna« When both bones of the fore-arm are fractured by the same force, the fracture in each bone is generally on the same level; but sometimes one bone is broken higher up than the other. The interosseous ligament which connects the bones of the fore-arm together, generally prevents a separation of the fragments in the longitudinal direction ; the derangement is most commonly in a trans- verse direction, the four fragments approaching each other at the injured part, and a considerable change in the shape of the arm is perceived. The symptoms of the fracture are very obvious ; great pain at the time of the accident, which is augmented by every motion of the hand; an inability to pronate or supi- nate the hand; mobility at the place of fracture ; crepi- tus when the fragments are moved, and deformity of the member. These symptoms are not so obvious when the fracture occurs near the wrist; the accident lias in such cases, been mistaken for a dislocation. Boyer mentions as the best diagnostic symptom that, when the fracture exists, the styloid processes of the radius and ulna fol- low* the motion of the hand when the wrist is flexed; whereas, in cases of dislocation they remain fixed. The dislocation is a very rare accident, and the fracture a very frequent one; in most cases, the crepitus when the fragments are moved decides the nature of the injury. To reduce the fracture, the fore-arm is bent to a right- angle with the os humeri. An assistant takes firm hold 148 ELEMENTS OF SURGERY. of the arm just above the elbow, another grasps the pa- tient's hand, and the necessary extension is then made. The surgeon very readily adjusts the fragments. To dress the fracture, a roller is applied, commencing at the hand and extending a little above the elbow; two firm splints of pasteboard (not soaked in water), arc to be next applied ; compresses of linen, flannel, or tow, being interposed, to fill up the spaces between the splint and arm: the roller being brought down over these splints secures them in their situation; the thumb being upper- most may be left projecting out between the splints, as an indication that no rotatory motion has displaced the fragments. The splints used in dressing all fractures of the fore-arm, should be long enough to extend from the elbow to the extremities of the fingers, and a little wider than the broadest part of the arm. They should be long, in order to confine the fingers from moving, by which irritation would be occasioned, and possibly a displace- ment of the fragments, because the muscles moving the fingers, are situated on the fore-arm; and they should be broad, because the roller passed round narrow splints would press the fragments together, and thus by dimin- ishing the interosseous space, greatly impede the motions of the limb: for the same reason the roller first passed round the arm should not be drawn tight over the place of fracture. The compresses placed on each side of the arm, being pressed by the splints upon the soft parts si- tuated between the bones, force them between the two bones and thus obviate the inconvenience alluded to: All that remains, is to place the arm in a sling. After a week or ten days, the dressings should be removed and the part examined ; any deviation from the proper position can at this period be remedied. In thirty or for- ty days the cure will generally be completed. If much contusion be occasioned by the cause of the accident, the patient is to be confined to his bed and the inflammation combatted by the usual remedies. ELEMENTS OF SURGERY. 149 A compound fracture requires the confinement of the arm upon a pillow, and instead of the roller a bandage of strips is to be applied (called Scultets, from its inventor Scultetus); the wound is to be dressed in such a manner a3 to promote its speedy union : if it be small and not greatly contused, it may be allowed to scab, and dry lint is to be applied over it: if great laceration exist, a poul- tice will be found necessary. 2. When the Radius only, is broken, which is most frequently the case in fractures of the fore-arm, the mem- ber cannot be bent at the place of fracture, as the ulna being uninjured, preserves its firmness. The existence of the accident is discovered by drawing the hand along the edge of the radius firmly when the fracture can be felt by the angle of one of the fragments ; great pain is experienced in attempts to rotate the hand, and the cre- pitus can generally be heard. When the radius is broken near its upper extremity, the depth of muscle in which it is imbedded, renders the diagnosis more difficult. In these cases Mr. Boyer recommends that "the thumb be placed under the external condyle of the os humeri, and on the superior extremity of the radius, and at the same time, the hand is to be brought to the prone and supine positions. If in these trials, always painful, the head of the bone rests motionless, there can be no doubt of its being fractured." There can be no derangement of the fragments in fractures of the radius, except what the muscles occasion by draw ing one or both fragments to- wards the ulna; and the pronators principally effect this. The treatment of this accident is similar to that recom- mended when both bones are broken; the ulna, however, acts as a splint in the present case, and aids in keeping the fragments at rest; but it has no effect in pre venting their lateral displacement, and therefore compresses 150 ELEMENTS OF SURGERY. must be applied between the splints and the fore-arm, to keep up pressure upon the interosseous muscles, and thereby preclude the approximation of the fragments, to the ulna. 3. When the ulna is alone broken the fracture is easi- ly discovered by passing the hand along it, as it is su- perficial, and easily felt from the olecranon to the wrist. The treatmeut is the same as in fracture of both bones, unless the fracture happens high up, near the joint. When the olecranon is fractured, no difficulty is expe- rienced in detecting it. The fracture is generally trans- verse, and as the triceps extensor cubiti, is inserted into it, the upper fragment is generally separated consider- ably from the lower, and the patient loses the power of extending the fore-arm: a widt> space is generally felt and seen between the fragments, and they readily move upon each other producing crepitus. The proper treatment of the accident is wrell described by Boyer. " The divided parts, are brought into contact by extend- ing the fore-arm, and pushing down the olecranon from the place to which it had been drawn up by the action of the triceps. The principal object is to counteract the action of this muscle, which tends incessantly to sepa- rate the detached olecranon from the ulna. To effect this purpose, a circular bandage moderately broad, is passed on the fore-arm fully extended, this being done the olecranon is pushed down into contact with the ul- na, and the middle part of a long compress placed be- hind it, the extremities of which are brought downward, and crossed on the anterior part of the fore-arm, after which several turns of the bandage made so as to cross one another, are carried round the articulation of the el bow; the bandage should then be rolled up on the hu- merus, in order to diminish by pressure the irritability of the triceps, which is relaxed by extension of the fore- arm. This bandage being applied, the bend of the fore- ELEMENTS OF SURGERY. 13& arm is filled with lint, and a long splint applied on it an. teriorly, by which the flexion of the arm is prevented. The splint is fixed by the same bandage, rolled on down- ward from the shoulder to the wrist. The oblique casts of the roller which cross one another on the articulation, forming a kind of figure of 8, ought to be nicely applied and drawn very tight; because if but slightly braced, their action, which is oblique, will not be sufficient to confine the olecranon in its situation. Previous to the application of these oblique casts, the skin of the olecra- non should be drawn up by an assistant, for if this pre- caution be not taken, it may sink between the divided portions and prevent their contact. Though the contact be exact, immediately after the application of the bandage, yet if, as is apt to happen, the bandage become relaxed, or if the patient inadver- tantly contract the triceps, the olecranon ascends; be- cause the bandage acting perpendicularly to its direction, can but feebly oppose the ascent of this process: an interval will therefore exist between the ulna, and olecranon, which will be filled up by granulations, and by the thickening of the periosteum, or tendinous expansion of triceps which covers that bone, and the re- union of the parts will be effected by means of an inter- mediate ligamentous substance, the length of which will depend on the careful application, and frequent renewal of the bandage. In forty or forty-five days the liga- mentous substance acquires its greatest consistence, but the articulation should not be kept motionless so long; gentle motion may be commenced on the twenty-fifth or thirtieth day. The object of these motions is to prevent a false anchylosis of the articulation. In cases of recovery obtained by these means, the ole- cranon adheres to the ulna firmly enough to transmit to it the action of the triceps muscle, and to moderate the extension of the fore-arm. 153 ELEMENTS OF SURGERY. Compound fracture of the olecranon is an accident of the most grievous nature, on account of the great number of nerves which pass in the neighbourhood of that part. It should, therefore, be treated with the greatest care. The inflammatory symptoms are to be treated by copious and repeated bleedings; the arm is to be placed half bent on a pillow and dressed with Scultets bandage. In these cases the intermediate ligamentous substance is always greater than in simple fracture, and consequently the force of the arm is much diminished. If a false anchy- losis be prevented by judiciously exercising the articula- tion as soon as the state of the parts will permit, the pa- tient may think himself fortunate. If the inflammatory swelling &c, be not dissipated be- fore the twenty-fifth or twenty-sixth day, the application of the apparatus we have just described will be useless, because it will be necessary at that time to begin to exer- cise the articulation, the formation of the ligamentous substance being then considerably advanced." (Boyer.) The coronoid process of the ulna, Dr. Physick has once seen broken. The symptoms resembled a disloca- tion of the humerus forward, or rather a luxation of the fore-arm backward, except that when the reduction was affected, the dislocation was repeated, and by careful examination, the crepitation was discovered. The fore- arm was kept flexed at a right angle with the humerus. The tendency of the brachieus internus to draw up the superior fragment, was counteracted in some measure, by the pressure of the roller above the elbow. A perfect cure was readily obtained. ELEMENTS OF bi&ucni. 153 CHAPTER XXVIII. Fractures of the Wrist and Hand. Fractures of the bones of the carpus very rarely occur, except in gun-shot wounds, or by a heavy body falling upon them. In every case of this accident which I have seen, the fracture has been an object of secondary importance, and amputation has in general been necessary from the nature of the injury. Where the limb is to be preserved, the hand is to be placed in a straight position and kept at rest by splints and ban- dages. Tlie bones of the metacarpus are sometimes broken. I have known them fractured in pugillistic contests. The accident is readily known from the crepitation per- ceived at the place of fracture by careful examination. The treatment consists in filling the palm of the hand with a compress, and applying a straight splint in front, extending from just below the elbow to the ends of the fingers. The bones of the fingers are also sometimes broken. All the different phalanges are liable to, fracture. The accident is known by the change of shape in the finger, and by the motion at the fractured part, which is attended with evident crepitation. The reduction is easily effected, and is to be maintained by a narrow rol- ler passed round the finger, and by two firm pasteboard splints, one before, and one behind wider than the fin- ger and bent a little round it, which are to be secured by the same roller. I have found it useful to prevent the motion of the fingers and hand by a firm splint, long enough to reach from the middle of the fore-arm to the vol. r x 154s ELEMENTS OF SURGERY. finger ends. In about four weeks the union is generally completed. "When a very heavy body has crushed the extremi- ties of the fingers, or when they have been bruised by a folding door, the soft parts are generally lacerated, the nail torn off, and the last phalanx fractured and denu- dated. If in such cases, the parts hold together by a shred of a certain thickness, and which contains vessels enough for the nourishment of the phalanx, the reunion of the parts should be attempted. The prospect of suc- cess it is true, is not great in most cases, but if our en- deavours to save the finger fail, amputation is still as much in our power, as in the commencement. " If the last phalanx alone is crushed, it will be better to amputate at once, than attempt to save the joint. The cure would be difficult and tedious, on account of the ex- foliation that would take place. i'< sides the part being deformed, instead of being useful, would be troublesome. By amputating at the articulation with the second pha- lanx, a simple wound is substituted to the ragged and lacerated wound, produced by the cause of fracture. This will heal in a very short time, if care be taken to preserve a sufficiency of skin to cover the surface of the articulation." (I>oyer.) ELEMENTS OF SURGERY. 155 CHAPTER XXIX. Fractures of the Thigh. The os femoris is very frequently broken, and it is of great importance to treat the accident in such a manner as to prevent deformity and lameness, which are often its consequences. The thigh bone may be broken at the head, even with- in the acetabulum; at the neck; at the condyles, and at any part between the neck and condyles. The great trochanter is in some cases, knocked off from the rest of the bone. The fracture is sometimes transverse, some- times oblique, sometimes comminuted, sometimes com- pound; but most commonly we find it, a simple oblique fracture. A fracture of the os femoris is attended with a mobility at the fractured part, an inability to stand on the limb, or to move it without extreme pain at the fracture; gene- rally with a very distinct crepitation when the fragments are moved against each other, and almost in every in- stance with deformity and shortening of the member. Mr. Boyer observes, that " the numerous muscles of the thigh by means of which derangement may be effect- ed, are divisible into three classes, relative to the manner in which they tend to effect it. The three portions of the triceps femoris are attached to both pieces, and tend to produce the angular derangement by drawing the two fractured portions to a salient angle on the outside, where their fibres are strongest and most numerous. The bi- ceps femoris, semitendinosus, semimembranosus, sarto- rius, rectus internus, and third adductor, all those in short, which extend from the pelvis to the inferior por- tion, or to the leg with which it articulates, tend to draw 156 ELEMENTS OF SURGERY. the inferior portion upward, on the internal side of the superior, the extremity of which forms a tumour on the external side of the thigh. The inferior portion is that which is always displaced, except when the fracture takes place immediately under the small trochanter, to which process are attached, by a common insertion, the psoas and iliacus muscles; which muscles would, in such a case, draw the superior portion upward and for- ward, producing by that means a tumour in the groin. When the femur is fractured immediately above the condyles, the inferior piece is drawn backward, and its superior surface turned downward by the action of the gastrocnemius externus, plantaris, and popliteus mus- cles. When the great trochanter is detached from the rest of the bone, it is drawn upward by the muscles which are inserted into it, but without producing any change in the direction or form of the thigh. The angular derangement in which the foot inclines. either inward or outward, is the effect of the weight of the foot or of the bed-clothes, rather than of muscular contraction." Transverse fractures are less liable to displacement, and are more easily retained in their natural position than oblique, for very obvious reasons, the opposing sur- faces supporting each other to a certain extent. Fractures of the os femoris are more difficult of cure than those of any other limb ; and such was formerly the want of success in preventing deformity that the ancients considered it impossible to cure them without shortening of the thigh, and Mr. John Bell, notwithstanding his high notions of modern surgery declares, that " the ma- chine is not yet invented, by which a fractured thigh bone can be perfectly secured." A position which, though entirely false, proves that surgeons consider the fracture of a very serious nature. Before proceeding to detail the practice I wish to re- ELEMENTS OF SURGERY. 157 commend in the treatment of fractures of the os femoris, it may not be amiss to premise, that surgeons have been greatly divided in their opinions respecting the posture in which the patient should be placed during the cure. The celebrated Mr. Percival Pott was a warm advo- cate for a bent position, and recommended the thigh to be bent upon the pelvis, and the leg upon the thigh, and the patient to be laid upon his side, under an idea, that in this manner the muscles would be most completely re- laxed, and thus the great cause of deformity obviated. The British surgeons have pretty generally followed this practice. The late French writers and particularly Desault and Boyer, have strenuously recommended, a contrary prac- tice, placing the patient on the back and extending the lower extremity; the reasons which induced them to re- ject Mr. Pott's plan, Desault states to be "the difficulty of making extension, and counter-extension, with the limb thus situated; the necessity of making them on the fractured bone itself, and not on a part remote from the fracture, such as the lower part of the leg; the impossi- bility of comparing the broken with the sound limb; the uneasiness occasioned by this position if long continued, though at first it may appear most natural; the trouble- some and painful pressure on the great trochanter of the affected side; the derangements to which the fragments are exposed when the patient goes to stool; the difficulty of fixing the leg with sufficient steadiness, to prevent it from affecting the os femoris by its motions; the evident impracticability of this method when both thighs are broken, and finally experience, which in France has been by no means favourable to the position recommend- ed by Pott." Mr. John Bell, with all that copia verborum which characterizes his truly peculiar style, and with all that violence, with which he opposes every thing he fancies 159 ELEMENTS OF SURGERY. wrong, has devoted several quarto pages of his princi- ples of surgery to an abusive opposition of the practice of Desault, whose theory he pronounces " unworthy his high character," and asserts that "his intentions, and in- deed his very words, are anticipated not merely by old surgeons whose works he might have neglected to read, but by his immediate predecessors and cotemporaries, Pettit, Sabatier, and Duverney." Mr. Bell declares, that Desault's plan "is neither original nor successful;" and that " the napkin round the thorax produces op- pression and insufferable distress which no one can pos- sibly bear." Mr. Bell in this and many other passages proves incontestibly that he never saw Desault's appara- tus applied; that he is entirely ignorant of it, and that in this, as in several other instances, he writes and rails on a subject he does not comprehend. In proof of this, 1 shall quote the following passage, which strongly evinces his want of candour, and his want of correct in- formation. " To judge of the merits of these methods, imagine to yourselves the condition of a patient under Desault's discipline; first laid dozen on one side and bound to the long splint of Duverney that the body and the limb were as one piece; next a great napkin put round the thorax with all the firmness of a bandage; straps going round the thorax, passing under the arm-pits fixed to this cir- cular, and the patient drawn up by these straps to the head of the bed. Next imagine, two lacs or long ban- dages, fixed one round the knee the other round the an kle, one tightened when the other had caused excoria- tion; imagine the patient, extended like a malefactor drawn by horses, bound so down to the bed, that even a cloth or flat dish, could not be slipped in under him; the bauds assiduously tightened the moment they seemed to relax, and the thorax so bound and compressed that he could not breathe; think of all this apparatus of bandage ELEMENTS OF SURGERY. 159 if you can, without holding in your breath, as if trying whether such oppression could be endured. I think for my share, I could as well undertake to live under water, as in Desault's, I might say Damien's bed." When the reader has finished this rhapsody, let him ima- gine something precisely opposite to what Mr. Bell has imagined, and he will have some idea of Desault's ap- paratus. How far Desault or Damien, are to be considered as authors of this imaginary apparatus of Mr. Bell, a perusal of their writings will show; but it is truly as- tonishing that after such gross perversions, Mr. Bell should have the effrontery to add, that he has quoted his histories of the various machines " in the very words of the inventors, because it is the only fair and impartial representation."* Mr. Bell knew what would have been impartial; and yet far from quoting Desault's "very ivords" his whole object has been to misrepresent them. I should owe an apology for this digression if the ob- ject were less important, but I am solicitous that students of surgery should not consider the sophistries of John Bell as logical arguments. I should next proceed to state the advantages of the straight position in fractured thigh, but having quoted them from Desault, I shall simply detail the mode of treatment which I consider best adapted to the accident, and which is a modification of that proposed by Desault, just premising that although volumes have been writ- ten on the action of the muscles in occasioning derange- ments of the fragments, it is a certai» truth which has been too much overlooked by all writers, that the mus- cles, very speedily accomodate themselves to any pos- ture, and that therefore, that one should be chosen, which is most favourable to the healing of the fracture • John Bell—Principles of Surgery, Vol. I 166 ELEMENTS OF SURGERY. and the convenience of the patient, and this for many rea- sons which I shall not detail in this place (but the chief of which is the experience of the surgeons in the Penn- sylvania hospital and in the French hospitals), I believe to be the straight position. The bed should be prepared and the dressings dis- posed on it before the patient is placed upon it. If sir James Earl's bed, cannot be procured, a hair mattress may be placed upon a common bedstead, but boards or strips of wood should be substituted for the sacking bot- tom ; across this mattress, five or six pieces of tape should be laid; over the tapes a piece of muslin a yard in width, and a yard and a half long (if the patient be an adult); over this "splint cloth" a splint of pasteboard nine inches long and two wide is to be placed at its upper end, and a bandage of strips long enough to extend from the knee to the groin, is to be laid over this splint; each strip should be of muslin, two inches wide, and long enough to pass round the thigh, and overlap several inches. In arranging these strips, the one which is to be last applied to the thigh, must be the first laid down, and this will be the upper one, which should be rather longer than the rest, because the thigh is thickest at its upper part; each succeeding strip is to cover one third part or half of that which preceded it. The next things to be provided, are two bags of chaff, or finely cut straw, four inches wide and long enough to extend from the hip to the foot; if these cannot be obtained, flannel or tow may be used as compresses, in lieu of them. A silk hand- kerchief, or a strong band of soft linen, is to be placed at the top of the splint cloth for counter-extension, and a similar one is to be provided for making extension at the ankle. Two long splints are to be procured, made of light wood. The first which is that of Desault, improved by Dr. Physick and Dr. Hutchinson, should be so long as to extend from the axilla six inches below the foot, ELEMENTS OF SURGERY. 161 it is formed like a crutch at its upper extremity, and a block projects from near its lower end, the use of which will be presently noticed ; two holes are formed near the upper extremity, and one near the lower, through which the counter-extending and extending bands are passed ; the second long splint is three inches wide above, and tapers to two and a half below, and long enough to reach from the perineum to the end of the longest splint; a fourth splint, of the same dimensions and materials as the first, completes the apparatus. The patient is now to be placed carefully on his back on the mattress, in such a manner that the injured thigh may be situated upon the bandage of strips. The band for counter-extension is now passed along the perineum, and between the scrotum (or labium pudendi) and the affected thigh, and is delivered to an assistant. The band for extension is passed round the ankle, tied under the foot and delivered to another assistant; by pulling these bands extension is made, and the surgeon replaces carefully the fragments in apposition, and then applies the bandage of strips, beginning at the knee and pro- ceeding upward, to the groin. The two long splints are now folded up in the splint cloth so that both splints may apply neatly to the sides of the limb; the bags of chaff, or compresses are interposed to fill up the spaces occasioned by the inequalities of the leg and thigh, and the two extremities of the bands for counter-extension are passed through the two holes near the upper end of the splint and tied firmly; care being taken not to permit the displacement of the fragments whilst this is done. The band for extension is next passed through the hole at the lower end of the splint, and tied; but great caution is to be used in this stage of the business, to avoid, on the one hand, drawing the bandage too tight, and on the other, relaxing it so as to suffer the fragments to pass each other. All that now remains is to apply the fourth splint vol. I. y 162 ELEMENTS OF SURGERY. on top of the thigh, and secure it by three tapes, which will bind all four of the splints moderately tight upon the thigh, and to secure the lower extremities of the two long splints by two or three tapes between the knee and ankle. A bandage or handkerchief may now be passed round the pelvis, to assist in fixing the patient at rest, and this ban- dage will certainly be found to exert no mischievous ef- fects on the organs of respiration. The use of the posterior pasteboard splint, is chiefly to prevent the tape passed round the thigh from irri- tating the skin, and also to assist in gently compress- ing the muscles of the thigh and supporting equably the fragments of the bone behind. The principal difference between the mode of dress- ing a fractured thigh, just described, and that recom- mended by Desault, consists in the increased length of the splint by which the permanent extension is kept up; an improvement which was first made by Dr. Physick. In the first of the annexed engravings Desault's appa- ratus is represented, and in the second the improvements that have been introduced by Dr. Physick, which cer- tainly give to the apparatus some important advantages. In the first place, the splint of Desault being but little lon- ger than the limb, the strap or band for counter-extension passes over the upper part of the os femoris at an oblique angle, and has a strong tendency to draw the superior frag- ment of the bone outwards; whereas in the splint contrived by Dr. Physick, the mortise hole being cut high up near the axilla, the band for counter-extension acts upon the pelvis, in a line nearly parallel with the natural direction of the limb, and has no tendency to any lateral displace- ment of either fragment. In the next place, by extend- ing the splint as high as the axilla, part of the counter- extension can be sustained at that place, although the chief dependence is to be placed on the pelvis. The crutch like form is intended to prevent the extremity ELEMENTS OF SURGERY. 16-3 from rubbing against the patient's side, and it is to be covered with soft flannel or linen, to defend the axilla. Dr. Physick having in some cases found that when considerable force was applied to the extending band, the foot was pulled outward and pressed against the splint so as to occasion excoriation, and finding the use of compresses and the chaff bags inefficient in pre- venting this inconvenience, suggested to Dr. Hutchinson, then a student at the Pennsylvania Hospital, the advan- tage of some contrivance to obviate it. He accordingly attached to the lower end of the splint a block, project- ing two or three inches from the inside of the splint, across which the band for extension is carried to the mortise hole at the lower end of the splint. The splint being thus constructed, the extension is also made more completely in the direction of the limb. By the use of this apparatus there can be no doubt that " permanent extension" of the thigh bone, notwith- standing the cavils of Mr. J. Bell, may be kept up, and that a perfect cure may in m©st cases be effected, with- out the slightest evident deformity, or shortening of the limb. I have for twelve or fourteen years witnessed the effect of this mode of treatment in the Pennsylvania hos- pital, where more accidents are admitted than in any other institution in America, and 1 am safe in asserting, that the success of the practice has been surpassed by that of no other hospital in the world. I have never seen a crooked limb, or a shortened limb, the consequence of a simple fracture of the thigh, unattended by comminu- tion, where Desault's apparatus, modified as above, has been fairly applied. It is proper, however, to remark, that some practitioners have become dissatisfied with this mode of treatment in consequence of the excoriation which they have found to take place at the perineum and at the top of the foot. In answer to this objection it must be stated, that the use of 164 ELEMENTS OF SURGERY. i(permanent extension" does not imply violent extension1, nor sudden extension, but simply a long continued resis- tance to the contraction of muscles which would if unre- sisted, shorten the limb. In order to effect this, after the dressings are applied, it is proper in every instance if any pain is experienced, either at the foot or perineum, to loosen the extending band. Most of the inconveniences attributed to the method of Desault have arisen from its improper application, and nothing is more improper, than to make violent extension, during the existence of the ir- ritation and inflammatory symptoms which succeed to a fracture of the os femoris. The extending bandages ought always to be very moderately tense, during the first three or four days after the accident, and afterwards they should be gradually tightened, the limb being exa- mined from day to day, and its comparative length with its uninjured fellow, distinctly ascertained. If the pa- tient experience any difficulty in bearing pressure upon the top of the foot, a piece of buckskin with holes in front may be laced round the ankle, and straps attached to this afford a very convenient substitute for the handker- chief with which the extension is made. In warm weather, and in emaciated persons this gaiter of buck- skin is extremely useful. By observing these precautions, very little difficulty will be experienced in the treatment of fractures of the thigh bone near its middle. Six or eight weeks are ge- nerally necessary for the reunion of a fractured thigh bone. Compound fractures of the body of the os femoris re- quire no difference of treatment from other compound fractures, but the dressings necessary for the external wound may be very conveniently applied, without inter- fering with the long splints. When both thighs are broken, or when one thigh is fractured in several parts, no plan of treatment is coinpa- ELEMENTS OF SURGERY. 165 rable with that by permanent extension. I have had oc- casion to apply it in the case of a miller's wife who was caught in some machinery; which fractured both her thighs and one leg below the knee. She was placed on her back, and the dressings which have been recommended, were applied; she recovered as happily as if only one fracture had existed, experiencing very little more pain, fever, or inconvenience, than is usual in simple fractures of the thigh or leg. It has been proposed among other methods of preserv- ing a bent position, to place the patient on his back with an angular box under the knee. I have known this plan used, and much difficulty was experienced in pre- venting the rotation of the limb, every motion of the pel- vis, occasioned motion at the fracture, and the surgeon who attempted it, laid it aside.* Fractures of the great trochanter are the effect either of falls on that protuberance, or of the action of bo- dies striking against it. They are either oblique, or trans- verse, situated sometimes at its summit, and sometimes at its base. This accident may be distinguished, by a facility of moving the great trochanter in every direction, while"the pelvis and the thigh remain without motion; by a crepi- tation, arising from the friction of the divided surfaces against each other; by their being no shortening of the limb, when the fracture exists alone : by the fragments being brought together in abduction, and separated in adduction ; by the position of the great trochanter bein°- higher and more anterior than natural. The presence of these signs are more readily perceived, because, bein°- superficially situated, this protuberance can be easily felt, and yields to the motions impressed on it. The reduction is effected, by pushing the separated fragment in the direction opposite to that of its displace- • Something of this kind has been recommended by Mr. Charles Bell Ooera tive Surgery, Vol. 2. Page 190. ' ; 166 ELEMENTS of surgery. ment, by bringing it to its natural level, and, in certain cases, by moving the thigh a little outwards; it is re- tained by means of some compresses placed by its sides, and secured by a roller directed obliquely from the sound hip towards that part of the thigh corresponding to the fracture. Fractures of the neck of the os femoris are not so frequent as those of the body of the bone, but they do oc- casionally occur; the fracture is generally transverse, oc- curs at every part of the neck of the bone, sometimes com- pletely within the capsular ligament, so that the round ligament, constitutes the only connection which the up- per fragment has with the body. As this accident has some symptoms in common with certain dislocations of the os femoris, it is of great importance to discriminate this accident from all others. Desault states the follow- ing as the best diagnostic symptoms. " At the time of the fall a sharp pain is felt, sometimes a noise is distinct- ly heard, a sudden inability to move the limb occurs, and in general the patient cannot rise, this last circumstance, however, is not uniform; a case is recorded in the fourth volume of the Mem. Acad. Surg, where the patient walked home, after the fall, and even rose up the follow- ing day. Desault also saw examples of this peculiaritv. The interlocking of the fragments is the cause of it. A shortening of the limb almost always occurs, more or less perceptible, according as the extremity of the frag- ments are retained by the capsule, or as the division, being without the cavity, no resistance is made to their displacement. The muscular action drawing the lower fragment upwards, and the weight of the trunk, pushing the pelvis and superior fragment downward, are the causes of this shortening. A slight effort is in general sufficient to remove this shortening, which, however, soon returns when the effort ceases. A tumefaction ap- pears in the anterior and upper part of the thigh, almost elements of surgery. 167 always proportioned to its shortening, of which it appears to be the effect. The projection of the great trochanter is almost entire- ly removed. That protuberance being directed upward and backward, is approximated to the spine of the ilium. But if it be pushed in the opposite direction, it readily yields, and then returning to its proper level, allows the patient to move the thigh. "The knee is a little bent. A severe pain always ac- companies the motions of abduction, when they are com- municated to the limb. If, while the hand is applied to the great trochanter, the limb be made to rotate on its axis, this bony protuberance is perceived to turn on it- self as on a pivot, instead of describing, as it does in its natural state, the arch of a circle, of which the neck of the os femoris is the radius. This sign, which was first observed by Desault, is very perceptible, when the fracture is at the root of the neck; less, when it is in the middle, and very little, when it exists towards the head of the bone: these are circumstances the cause of which it is unnecessary to unfold. In rotatory motions, the lower fragment, rubbing against the upper one, produces a distinct crepitation, a phenomenon which does not al- ways occur. " The point of the foot is usually turned outwards ; a position which Sabatier, Bruninghausen, and most other practitioners, regard as a necessary effect of the fracture; although Ambrose Parey and Petit, have borne witness that it does not always exist. Two cases, reported on this subject, by celebrated surgeons, have been thought unfounded by Louis, who has attributed them either to an error in language, or a mistake of the transcriber. But the practice of Desault has fully confirmed their pos- sibility. The firstpatient whom he had under his care, at the hospital of Charity, after he was appointed sur- geon in chief, laboured under a fracture which presented 168 ELEMENTS OF SURGERY. this phenomenon. Many other examples occurred to him afterwards, and he believed it might be laid down as an established principle, that, in fractures of the neck of the os femoris, the direction of the foot outwards is to that inwards as eight to two. "The common opinion is, that this direction outwards, is to be attributed to the muscles that perform rotation. But, were that the case, 1st, it is evident that it would always exist: 2dly, all the muscles running from the pelvis towards the trochanter, except the quadra- tus, are in a state of relaxation, in consequence of the approximation of the os femoris to their points of inser- tion : 3dly, muscles in a state of contraction would not allow the point of the foot to be drawn so easily inwards. Is it not more probable, that the weight of the part draws it in the direction in which it is usually found. "From the foregoing considerations, it follows, that none of the signs of a fracture of the neck of the os femoris, is exclusively characteristic, that the whole of them, taken separately, would be insufficient, and that it is their as- semblage alone, which can throw on the diagnosis that light wiiich is oftentimes wanting to it, even in the view of able practitioners. But after all, in the present case, as in every other one, should any doubt exist, it is right to take the safe side, and apply the apparatus, which is indeed useless, but not dangerous, if the fracture does not exist, but indispensably necessary if it does." (Desault) xV concise abstract of the symptoms enumerated by Bover will aid the student in distinguishing this fracture. A fall or blow on the trochanter or feet, is generally the cause; it is followed by pain in the articulation, an im- possibility to bend the thigh; shortness of the limb, which is easily removed, but returns when the extension is discontinued ; an inclination of the foot and knee out- ward, with great facility of moving these parts to their natural situation ; crepitation produced in different move- elements of surgery. 169 ments; and the smallness of the circle in which the great trochanter moves in a rotatory motion. We can seldom be mistaken as to the existence of this fracture, if we at- tend to all these circumstances. Of all fractures of the os femoris those of the neck are most tedious in healing, and attended with most danger of lameness and deformity. Some surgeons imagine, that bony union never forms between the fragments; but many proofs exist that this opinion is erroneous, and prepara- tions in different anatomical collections shew instances of bony reunion of the neck of the thigh bone. It is al- ways however slower in its formation, and in many instances does not at all take place, the patient remain- ing incurably lame. Instances of recovery in old persons are not frequent, and Boyer considers the fracture "after a certain age" incurable; but he adds "it is not in our power to mark precisely the period beyond which a cure is not to be hoped for. To be able to settle this, it would be neces- sary that the effects of old age were uniform in every in- dividual, and that the degree of senility were always- commensnrate with the number of years. Lesne shewed at the Academy of Surgery, the femur of a woman aged eighty-nine, with evident marks of a consolidated frac- ture of its neck." Boyer himself, saw a patient in which the consolidation of a double fracture was considerably advanced in a man eighty-three years old. Numerous facts of this nature, authorize and require the application of the apparatus in all cases, except where the patient reduced to the last stage of decrepitude and debility can- not support its weight, or is attacked by some mortal dis- ease. But at the same time the surgeon should for his own sake, acquaint the patient and his friends with the uncertainty of the cure, in order to ward off any imputa- tion that might be made in case of failure. Many respectable surgeons have positively asserted vol. i. z 170 ELEMENTS OF SURGERY. that a recovery without lameness and shortening is impos- sible. Desault and Boyer on the contrary, both relate instances in which they were completely successful. The fracture is easily reduced by making counter-ex tension at the arm-pits, an assistant holding the patient under the arms, and extension by drawing down the foot until the limb resumes its natural length and appearance, it is not easy, however, to secure the fragments in con- tact, but the apparatus of Desault promises to be more successful than any other plan heretofore in use for that purpose. The long splints are to be applied precisely as in fractures of the body of the os femoris, but no ban- dages of strips, or pasteboard splints are required in this ease, as the permanent extension is alone necessary, and they would be useless as they would act only on the infe- rior fragment. The fracture healed in one case recorded by Desault in sixty days, but generally three months are required for the consolidation. During this time the apparatus should be examined daily, and tightened from time to time, if any shortening of the limb is observed. Stiff- ness of the joint is not a frequent consequence of this ac- cident. When the permanent extension cannot be applied, from the extreme age of the patient, or any other cause, great care should be taken to prevent the motions of the fragments, by long stiff splints bound firmly on the pel- vis, and extending below the foot. In this manner a cure will be effected, but probably the detached neck of the bene will adhere to a portion, considerably below the trochanter, and thus the limb will be shortened. In a case of fracture of the head of the os femoris which occurred in a gentleman of Philadelphia perma- nent lameness ensued, and no union of the fragments took place, he died some years after, and upon examin- ing the hip joint, a singular instance of the resources of ELEMENTS OF SURGERY. 1/1 nature was presented to view. The detached portion of the head of the bone, was diminished considerably and rounded smoothly by absorption, as was also the oppo- site fragment. A ledge of bone was observed projecting from the trochanter, and upon this the acetabulum rest- ed, and thus some weight was sustained by the os femo- ris—it was in fact, an attempt to regenerate a neck and head for the bone in a situation where it would have been useful, and have enabled the patient to walk, Jiad he lived until it was completed. He never was aide' after the accident to bear much weight on the affected side. The bone is now in Dr. Physick's possession. Fractures of the lower extremity of the os femorntun- less ihey are situated within the joint, eall £&n%pSpllj- liarity of treatment, but are to be managed jijfewv^jen they occur higher up in the bone. jt Sometimes, however, the fracture detaches a portion of one condyle from the rest of the bone (Fig. 5.) Some- times a fracture separates the condyles from each other, and both from the rest of the bone by a double fracture, analagous to that which occurs in the lower end of the humerus, as in Fig. 4. The fracture in which the condyles are thus separated from the os femoris may be known, by a perceptible se- paration, increasing the width of the knee. The patella sinking into the chasm between the condyles, renders the part flatter than natural: if the patella be pressed back- wards the condyles are still further separated : if on the contrary, pressure be made on the sides of the knee, the knee resumes its usual breadth and appearance: by mov- ing the fragments, crepitation may be heard. Where only one condyle is detached, it can be felt moving under the fingers, and producing crepitus when rubbed against its fellow. Sometimes this accident is complicated with a lace- rated wound, from the bone being forced through the 173 ELEMENTS OF SURGERY. skin, or from the cause of the accident penetrating to the cavity of the fracture, and of the joint, thus produc- ing a compound fracture, with an exposure of the joint: a terrible accident, attended with all the dangers result- ing from lacerated wounds of the larger joints, and de- manding the same mode of treatment, with the additional measures necessary for maintaining in contact the frag- ments of the bone. The treatment necessary in these cases, varies accord- ing to their circumstances. If a fracture exist an,inch above the knee joint, and this fracture be attended with a shortening of the limb, (which will be the case if it be an oblique fracture.) and if in addition to this, a second fracture separates the condyles extending to the first, as in Fig. 4. In this case the permanent extension is to be applied, as in fractures of the body of the thigh bone with the omission of the pasteboard splints, this will pre- vent the upper fracture from displacement, and in order to keep the condyles in contact at their fractured sur- faces a roller or bandage of strips must be applied, reach- ing from the ankle to the middle or upper part of .the thigh, and applied pretty tight at the knee. If the upper fracture be transverse, no necessity exists for permanent extension, and therefore simple pasteboard splints may be applied, or the long splints as in the pre- ceding case, omitting to apply the extending force. The lateral pressure is in these cases the chief indica- tion, and to prevent the foot and leg from swelling, a roller should be applied from the foot to the knee. The usual antiphlogistic remedies are to be employed if in- flammation run high, and the apparatus must be kept on eight weeks before any motion is attempted ; as soon as the parts have united firmly, the limb must be gently and repeatedly moved, to prevent false anchylosis, or stiff- ness of the joint. The patella should be moved frequent- ly, and the posture of the leg whilst at rest, often varied plate vi. Frac/r/rvs of th* Y/(7/j7t I-'iq.l. Faqt 173 WWW- 2 \ LS-Dorstj deLVSt ELEMENTS OF SURGERY. 173 EXPLANATION of the plate. Fig. 1. Represents a fracture of the head of the os femo- ris. Fig. 2. A fracture of its neck. Fig. 3. A common oblique fracture near the middle of the bone. Fig. 4. A fracture at the lower extremity of the bone, in which the condyles are detached from the body of the os femoris and from each other. Fig. 5. Shews several directions a, b, c, d, in which the different condyles are occasionally fractured. Fig. 6. Represents the relative situation of the frac- tured ends of the bone in the cases mentioned in page 117, in which the seton was unsuccessfully tried for the cure of an artificial joint. The dot- ted line shews the course of the seton, which passed through an indurated mass of flesh, and did not come in contact with the bone. From this view7 it is evident, that in such cases, the seton cannot be successfully used. 1/1 ELEMENTS OF SURGERY-* EXPLANATION OF THE PLATE. The opposite engraving represents the apparatus for permanent extension, employed by Desault in oblique fractures of the os femoris. A A. The external splint, with a notch and a mortise at the lower end to fix the inferior extending roller. BB. A bandage passing round the body, intended to se- cure this splint against the pelvis. CC. The anterior splint, reaching only to the knee. d. d. d. d. The anterior bolster, extending along the whole limb, and secured by pieces of strong tape. EE. A portion of the bandmge of strips, seen between the anterior and the external lateral bolsters. FF. The junk-cloth intended to be folded round the two lateral splints. g. g. The superior extending roller, passing round the end of the external splint, and fixed underneath on the tuberosity of the ischium. H. The sub-femoral roller or strap, intended to prevent the bandage BB, which passes round the body, from slipping upwards. K k. A roller usually passed round the foot, to prevent it from turning. L. The inferior extending roller, fixed in the mortise and the notch of the external splint, Page 147 Pawl/* ELEMENTS OF SURGERY. t7^ EXPLANATION OF THE PLATE Representing Dr. Physick's modification of Desault's apparatus. AA. Dr. Physick's long splint. B. A block fastened near its lower end, projecting at right angles from the splint, over which the extending band passes and is tied at the mortise C. D. The crutch like extremity fitted to the axilla. E. The edge of the inner splint which extends from the perineum below the foot. F. The splint cloth wrapped round the external and in- ternal splints. ff Gr. The counter-extending band passing under the tube- rosity of the ischium and secured at the mortise, at the upper end of the splint. H. The anterior splint of pasteboard (a similar one is placed on the back part of the thigh). The bandage round the pelvis is omitted to prevent con- fusion. 176 ELEMENTS OF SURGERY. CHAPTER XXX. Fractures of the Patella. These may be longitudinal, transverse, or oblique - but in general, they are transverse. They are occasion- ed by falls, blows, and accidental violence, and also in some cases by the exclusive action of the extensor mus- cles of the leg: of this many instances, are recorded. I have myself met with two, one of which occurred in a rider at the circus, who in vaulting into his saddle from the ground whilst his horse was in full speed, suddenly fell, without knowing the cause; a sharp pain at the knee informed him of the seat offthe injury. Upon exa- mination, I found the patella fractured transversely, and the upper half, drawn to a considerable distance from the lower. It sometimes, though very rarely happens, that the tendon above or below the patella is fractured, and not the bone. The mode of treatment arc in both cases pre- cisely similar. A fracture of the patella is readily distinguished. If it be transverse, the patient cannot extend the leg, he generally falls and is unable to rise; though sometimes he gets up, and by dragging the limb sideways, is even able to walk, taking great care not to bend the knee. A depression at the place of fracture is nerceived, and commonly, the superior fragment is found at a consider- able distance from the inferior, which being tied firmly to the tibia, cannot move upwards. The longitudinal and oblique fractures can be known by examination with the fingers, as the bone is very thinly covered. It has been a matter of doubt among surgeons whether bony reunion ever takes place betw'een the fragments X ELEMENTS OF SURGERY. 177 a broken patella. When the distance between them is considerable, a firm ligamentous or tendinous matter con- nects them, and the motion of the joint after a time is regained. When on the contrary, they are kept in close contact, the union is hard, firm, and unyielding; whether it is bone, iendon, cartilage or ligament, is an object of more curiosity than utility* The great object to be attended to in the treatment of fractures of the patella, is to preserve the fragments as nearly as possible, in apposition, so that the substance connecting them may be rendered as short as possible, and the motions of the joint be perfectly preserved. Whenever the fracture is occasioned by a violent blow, and great contusion is produced by it, there is reason to apprehend inflammation and swelling of the knee, in which case breeding and the usual remedies for inflammation are to be employed. The local treatment consists in keeping the limb at rest in an extended pos- ture, and by a splint and bandages preserving the con- tact of the fragments. The chief obstacle to be encoun- tered, is the action of the extensor muscles; and this is easily overcome, by the application of a stiff splint be- hind the limb secured by a roller. A variety of machines have been constructed for the purpose of preserving the permanent extension of the leg and most of them answer very well. I have always em- ployed a very simple one. It consists of a piece of wood half an inch thick, two or three inches wide, and long enough to extend from the buttock to the heel; near the middle of this splint, two bands of strong doubled muslin a yard long, are nailed, at a distance of six inches from each other. Upon this splint, covered with compresses of soft flannel or linen, so as to fill up the inequalities of the limb, the patient's leg and thigh are placed. An assistant now raises the heel, and the surgeon applies a bandage (a common muslin roller, two inches wide, and eight or vol. i. a a 178 ELEMENTS OF SURGERY. ten yards long,) commencing at the ankle, and proceeding to the knee ; he carefully draws down the upper fragment of the bone as nearly as possible to the lower one, and places a compress of folded linen above it; several turns of the bandage are now made over this compress and oblique- ly under the knee, in such a manner as to cross below the lower and above the upper fragment alternately, in the form of the figure 8; the bandage is then carried on to the top of the thigh and brought down over the splint, leaving the band attached to it, free. Care must be taken to cover every part of the skin with the roller because any part which is not thus supported will swell and inflame. After the dressing has proceeded thus far, the bands of muslin are to be used for the purpose of more completely fixing the fragments; the lower one is to be passed round the thigh above the upper fragment, and vice versa, the upper strap passed below the lower and secured by a pin or knot. These bands will thus enable the surgeon to ex- ert any requisite compression upon the fragments without the inconvenience of moving the bandage or splint. It is evident that this apparatus is in principle the same as Boyer's. I claim no merit for its construction, but one advantage it certainly possesses ; it may always be pro- cured in a few minutes, as a shingle or strip of wood and a couple of nails are the only materials necessary for its formation; and this in country practice is an ob- ject of no small importance. I have never employed any other mode of treatment, in the cases of this accident which have fallen under my care, and in all these, it has completely answered my expectations; the union of the fragments has taken place very quickly and in two cases * without any perceptible interval or motion between them. The patient must be kept lying on his back on a mattress and from day to day the bands are to be examined, and tightened if necessary. Boyer directs the joint to be moved after the twenty-fifth day, to prevent stiffness. ELEMENTS OF SURGERY. 179 These motions, if commenced so early, should be very gentle, but they may safely be delayed until the fourth or fifth week. In six or seven weeks the union is gene- rally completed. CHAPTER XXXI. Fractures of the Leg. The tibia and fibula are sometimes broken singly and sometimes both are fractured. The fracture may hap- pen at any part between the knee and ankle. The frac- ture of both bones is most frequent; it may be transverse or oblique, simple or compound, comminuted or single. The fragments, are occasionally, displaced in every di- rection. In transverse fractures, there is generally no shortening of the limb, but in those which are oblique, the leg is generally shortened : patients have been known to walk many steps without great inconvenience, after having fractured the tibia transversely, in consequence of the want of derangement. Fractures of the leg are characterized by the general symptoms of fracture. Deformity of the member; loss of power to move the limb ; great pain at the time of frac- ture, and on every motion of the part; crepitation, &c. The higher up the fracture is situated, in general, the more favourably does it terminate : very little danger of derangement exists when the upper extremity of the bones are broken, as the bulk of the tibia at this part, affords large opposing surfaces, which support each other, and prevent displacement. Oblique fractures of both bones of the leg it is sometimes very difficult to ISO ELEMENTS OF SURGERY. manage; they are attended with great inflammation from the irritation of the sharp fragments. The treatment varies according as the fracture is trans- verse or oblique. A transverse fracture, is very easily reduced and maintained in its proper situation. One as- sistant grasps the knee, and another the foot, extension and counter-extension being made, the surgeon replaces the fragments, and judges of this by the deformity ceas- ing, and by the regularity of the anterior edge of the ti- bia, which is so thinly covered as to be easily felt. A roller is now to be applied, (or a bandage of strips,) very neatly from the ankle to the knee; two pasteboard splints soaked in water, are placed one on each side of the leg, they should extend from the knee to the sole of the foot, in order to confine and prevent the lateral mo- tions of the foot at the ankle joint. Over these splints a second roller or bandage of strips is to be applied ; the splints soon become dry and form a solid case for the limb which supports sufficiently the fractured bones. It is necessary to avoid bandaging too tight, and to loos- en the dressings if inflammation render them so, by augmenting the volume of the limb; an observation which is applicable to most fractures and should never be ne- glected. The limb is now laid on a pillow the patient being placed on a mattress on his back, two strips of wood as long as the pillow, and three or four inches wide, may be tied with tapes on the outside of the pillow and answer the purpose of a fracture box; the weight of the foot should be supported by a bandage passed round the toes, and fastened to the boards on the outside of the pillow. The weight of the bed clothes should be sus- tained by some simple contrivance, as the segments of two hoops tied together. At the end of six or seven weeks the fracture generally unites. When instead of a transverse direction, the fracture has taken a very oblique one, the mode of treatment is PLA TE TX .ELEMENTS OF SURGERY. 181 very different, and permanent extension becomes neces- sary : a very convenient mode of applying this was con- trived by the late Dr. James Hutchinson. Two splints of wood are made, long enough to extend from the knee six or eight inches below the sole of the foot; a mortise hole is cut near the lower end of both these splints, and the upper extremity of each is perforated with four small holes. A piece of wood fitted to the mortise holes of the splints, eight inches long, is to be provided. In applying this simple apparatus, the patient is to be laid on his back, and extension and counter-extension made as usual; a pillow is placed under the leg upon which is arranged a bandage of strips; two pieces of tape are next to be secured by numerous turns of a roller, on each side of the leg below the knee : these tapes are to be passed through the four holes in the upper end of the splint, and tied, a silk handkerchief is next to be passed round the ankle, crossed on top of the foot, and tied un- der the sole. The fracture being reduced, the bandage of strips is applied neatly to the leg, and the silk hand- kerchief next tied over the cross piece connecting the two splints ; by which any necessary degree of extension may be permanently applied. The annexed plate represents the apparatus and its mode of application, very intelligibly. It is particularly convenient in compound fractures, because the external wound can be dressed daily, without disturbing in the slightest degree, the fragments of the bone; but it cannot be used in fractures near the knee or ankle joints. Be- cause the bands for extension and counter-extension would irritate the inflamed parts and could not be borne. Excoriation must be guarded against by apply. ing soft compresses wherever the skin is irritated by the extending forces; it is convenient to interpose a small compress of folded linen with this view, between the 185 ELEMENTS OF SURGERY. tapes and skin, or what is equally effectual, to pass the roller once or twice round the limb before they are applied. In some cases the irritation at the knee is very great, and the leg swells from the pressure of the circular ban- dage below it: when this happens in oblique fractures of the leg, the long splint of Desault must be substituted, and the counter-extension made against the pelvis. It is to be applied in the same manner as to a fractured thigh, excepting that the leg must be dressed with the bandage of strips; the two long splints are all that will be found necessary. It is of great consequence in all oblique fractures of the leg to attend particularly from day to day, to the form of the limb, and the position of the foot, which should be supported by a bandage, as before directed, or by a prop of wood attached to the splints or bedstead. If the heel sinks too low, so as to cause the lower frag- ment to fall downwards, a piece of folded linen or flan- nel must be placed under it. The general treatment of the patient is of great impor- tance in these cases, and bloodletting is to be performed as often as the degree of fever and inflammation may in- dicate. It is by far the most convenient mode of deple- tion, and the most efficacious. Compound fractures of the leg, are from the thin covering of the tibia, and its exposure to accidents, more frequent than any other compound fracture. The general directions for their treatment have already been detailed. But it may not be improper to remark in this place, that the permanent extension kept up, either by Desault's or Hutchinson's splints, enable the practitioner to dress the fracture, as often as necessary, without any pain, or in- convenience to the patient, and without retarding the progress of the cure by moving the fragments of bone— circumstances of great importance at all times, but par- ticularly in warm weather when the dressings must be ELEMENTS OF SURGERY. 183 very frequently changed. Should the discharge be very copious from a compound fracture of the leg, the pillow upon which it rests should be covered with thin oiled silk, to prevent its imbibing the offensive matter, and great cleanliness should be observed. Fractures of the tibia alone, sometimes happen: the fracture is generally transverse and attended with but little derangement of the fragments. The fibula being uninjured, prevents the shortening of the limb, and as no great pain or inconvenience is experienced, the case is sometimes not discovered until a considerable time has elapsed. A careful examination with the fin- gers will in general, from the thinness of the covering over the tibia, enable the surgeon to detect an inequality at the place of fracture. Crepitation may also in general, be occasioned, by forcibly pressing the fragments in op- posite directions. The treatment of the case is extremely simple ; rest on a pillow, is all that is essential, but it is most prudent to apply the dressings recommended for transverse frac- tures of both bones of the leg, and to keep the patient in bed until the cure is effected, viz. forty or forty-five days. Fractures of the fibula are less frequent than those of the tibia, notwithstanding its slender size, owing in great measure to the circumstance that it is not concerned in supporting the weight of the body. Tha chief causes of fractures of the fibula, are a vio- lent blow on the outside of the leg, or a forcible abduc- tion of the foot. There is reason to believe that in many cases of sprained ankle this fracture exists without being known. No shortening of the limb takes place, and the only displacement observed, is the fragments being pushed inwards towards the tibia. To ascertaiu the existence of the accident, the bone should be pressed inwards, and crepitation will generally 184 ELEMENTS OF SURGERY. be perceived, or at least a motion of the bone at the place of fracture. The mode of treatment, consists, in an attempt to force the fragments outward by abduction of the foot, and by pressure upon the interosseous muscles after which two pasteboard splints are to be applied, as in transverse fractures of both bones of the leg, and the patient must be kept at rest thirty or forty days. The splints are chiefly useful by keeping the ankle joint at rest. The approximation of the fibula to the tibia, is not so important as that of the radius and ulna, because no ro- tatory motion exists between the bones of the leg. A slight stiffness of the ankle joint is commonly a conse- quence of fractures of the fibula, but it soon subsides without any remedy but exercise. CHAPTER XXXII. Fractures of the bones of the Foot. Fractures of the os calcis are very rare but occasion- ally happen. The accident may be detected by a crack at the moment attended with severe pain at the part, and great difficulty in standing upright, a swelling of the heel and mobility of the fragments attended with crepi- tation. To reduce the fracture, the leg must be flexed upon the thigh, and the foot extended on the leg. In which situation the fragments can readily be reduced. Boyer directs in order to retain the fragments, the slipper in- vented by Petit, for a rupture of the tendo achillis, or if that cannot be procured, the uniting bandage used for transverse wounds, modified as follows. The end ELEMENTS OF SURGERY. 185 of a bandage is placed on the superior surface of the foot, whence the bandage is reverted on the sole, and the end is made fast by circular casts around the foot; this ban- dage is then drawn along the posterior side of the leg to the ham, the foot being previously extended, on which part it is fixed by other circular casts, it is thence brought downward forcibly, and the application terminated by rolling along the leg what remains. To this bandage may be added a long compress, the middle part of which should be applied above the posterior portion of the os calcis, and the extremities crossed on the superior sur- face of the foot, and turned under the sole ; this compress may be fixed by a bandage rolled on the foot in the shape of the figure 8. The union of the fracture is effected in thirty or forty days, at the end of which time the patient may be allowed to bend his foot. He must, however, for some days, avoid any forced flexion of the foot, as also any excessive extension by rising on his toes." "The other bones of the tarsus, as the astragalus, cu- boides, scaphoides, and three ossa cuneiformia, are sus- ceptible only of comminutive fracture. The same may be said of the bones of the metatarsus and phalanges of the toes." The treatment of these fractures can be very suf- ficiently understood from what has been said of fractures of the bones of the hand, to which they are analagous. VOL. I. Mb 186 ELEMENTS OF SURGERY. CHAPTER XXXIIr. Of Wounds of Bones. In the following observations on the denudation and wounds of bones, 1 shall avail myself chiefly of the la- bours of Boyer and Hunter. The bones may be stripped, not only of the integu- ments, muscles, &c. by which they are naturally covered, but also of the periosteum, which is their intimate and appropriate covering. Cutting or contunding instruments may produce this denudation of the bone, without injuring its substance, or they may cut or contuse its external fibres. These two cases must be carefully distinguished, as the contu- sion of the bone is attended w ith consequences much more serious than those of a simple denudation. If the bone has been merely stripped of its perios- teum and integuments, and those parts are immediately replaced, so as to exclude the contact of the air and ban- dages, the reunion of the periosteum is found to take place in a very short time. But if the external lamina of the bone has been contused, or if its surface has been left a long time exposed to the actiou of the air, or to the friction of bandages, exfoliation becomes a natural conse- quence. All the external lamina must separate; and be- fore this separation is effected, the cicatrization of the external wound would be rather injurious. Should the wound in the integuments be prematurely closed, puru- lent matter will continue to form underneath, the con- tused lamina will exfoliate, an abscess w ill point exter- nally and burst spontaneously, and the matter that escapes from it will contain small splinters of bone. ELEMENTS OF SURGERY. 187 Old age is unfavourable to the healing of wounds and contusion of the bones; because, as the cure can be ef- fected only by means of the vascular texture of the bone and periosteum, the turgescence and expansion of this must be slow and difficult in proportion to the person's age. The treatment adapted to the different cases is as follows. If the bone be simply laid bare, the integuments, if not completely separated, should be instantly replaced. This precept holds good in all cases, whatever may be the patient's age, if the bone has not been already ex- posed to the contact of the air. At the same time it must be allowed, that it is very difficult to know by mere in- spection, whether the bone be contused or not; but should that be the case, and even should suppuration and exfo- liation be inevitable, no bad consequences can result from the attempt to produce an immediate cicatrization ; whereas, in the contrary event, the duration of the treat- ment will be much abridged. If it be possible to unite the wound by the first intention, its lips are to be kept separate by lint interposed, and the whole is to be light- ly covered. In a short time granulations appear, and the external lamina of the bone exfoliates. Sometimes, how- ever, and particularly in young persons, the bone be- comes soft and red, and granulations arise from it, which bleed from the slightest cause. It has been said, that the bone exfoliates insensibly in this case; but this ob- servation is not found to be true : the laminae of the bone are not broken down, dissolved, and carried off by sup- puration. The change consists of a softening of the bone, and conversion of it into a fleshy substance, which unites with the soft parts. In this last mentioned case, the cure is much more prompt than when a real exfoliation takes place. The process of exfoliation resembles that of the separation of gangrenous eschars : the mode in which the separation 188 ELEMENTS OF SURGERY. is effected, is equally unknown in both cases.* In exfo- liation, it is merely known that the subjacent vessels grow turgid, expand, and pullulate, and that a line of separa- tion is observed between the contused lamina and the sound part of the bone. The former are undetermined, as it were, and their connexion shaken by the purulent matter formed under them, and at length are entirely de- tached, and may be easily removed by the fingers or a forceps. When the bottom of the wound is entirely freed, the granulations that arise from it, unite with the soft parts, and in a short time the wound is cicatrized. Various processes have been employed for expedi- ting the exfoliation. Thus the ancients covered the bone with pledgits of lint impregnated with spirits, or with a tincture of myrrh and aloes ; but it is found, that these applications retard the exfoliation by opposing the expansion of the vessels ; for which reason they have been laid aside, and oily relaxing applications have been substituted for them. It has been proposed to perforate in different parts the laminse which are to exfoliate, on the supposition that this practice facilitates the growth of the granulations. The perforations certainly have this effect, but the granu- lations by shooting up through them, retain the laminse rather than aid their exfoliation : each vessel spreading as it rises, and assuming in some respect the shape of a broad-headed nail. It will then be more prudent to limit the treatment to the use of unctuous or emollient ap- plications. By means of these remedies, the texture of the part will be sufficiently relaxed, and the develope- ment of the vessels facilitated. But if the portion of the bone to be exfoliated be very considerable and deep seated, these applications are nearly useless, at least their effect must be vqry trifling; then we must content • Mr. Hunter has fully explained this formerly unintelligible process. See page 190 of the present volume. ELEMENTS OF SURGERY. 189 ourselves with covering the part with lint, and trusting to time and nature for effecting the separation. Though the exfoliation be complete, as may be known by the motion of the piece, it may still happen that the circumference of the detached portion may be encroached on by the growth of the soft parts, and thus prevented from separating. In this case it w ill be ne- cessary to disengage it by making an incision in some point of the circumference of the wound, after which it may be drawn out by the fingers or a forceps. In gene- ral there is but very little difficulty in removing it. The action of cutting instruments is not always limit- ed to the mere denudation of the bone ; they sometimes completely divide it: this, however, is but a rare occur- rence. It sometimes happens that a part of the bone is cut off, of which there are numerous instances in wounds of the head, where a part of the parietal bone, with its pericranium, a portion of the occipito-frontalis muscle and hairy scalp, have been entirely separated by a blow of a sword. When a wound of the soft parts is accompanied by a similar affection of the subjacent bone, an immediate re- union of the soft parts must not be attempted. Lint is to be gently introduced into the fissure, and the wound healed from the bottom ; for a solid cicatrix of the soft parts cannot be expected until the wound in the bone is first cicatrized. If the bone in one of our limbs be cut quite through, as in the cases mentioned by La Peyronie, Warner, and others; and if a piece of flesh remain undivided, which contains the principal vessels of the limb, it will be pru- dent to reunite the parts, and place the limb in the appa- ratus used in cases of fracture of the part. The time necessary for the reunion of the parts in cases of this nature, is full as long as that in those of fracture, 190 ELEMENTS OF SURGERY. and the consolidation is effected in the same manner as in the former case. In the preceding remarks, Mr. Boyer has not attempt- ed to explain the manner, in which bone that has been contused and suffers death, in consequence of a blow, separates from the living bone with which it is in con- tact. I shall therefore state in this place the opinion on the subject, taught by Mr. Hunter, and now generally adopted. Exfoliation is the separation of dead from living bone, as sloughing is the separation of dead from living flesh, and the process in both cases, is effected in the same manner, by the action of the absorbent vessels. There is nothing like a melting down of the bone; no solution takes place; the bone separated is solid and in texture unchanged, and the term exfoliation was derived from the scales or leaves of bone thus detached. In bones which are most solid, and have few est cells, the separation takes place most rapidly. 1 have know n a portion of the radius exfoliate in a few days, and I have known the os calcis, several years in casting off* a por- tion of dead bone. The entire death of a portion of bone, is necessary to its exfoliation, and hence, in some cases, the hot iron may be used with advantage in expediting the process, by destroying the life of diseased bone. According to Mr. Hunter, caustics and hot irons may ex- pedite exfoliation in two ways, first by killing the bone, and secondly by inflaming the adjacent bone, and thus increasing its vascularity and its actions. Dead boue like all other extraneous matter, stimulates the adja- cent parts, in consequence of which they become more vascular. The bone is composed of animal gluten, and earth; the earthy portion of the living bone, is removed by the action of the absorbents ; just as in health these vessels perform the process of interstitial absorbtion, re. ELEMENTS OF SURGERY. 191 moving from time to time the solid parts of the body. The consequence of this absorption of the earthy parti- cles from the bone, must necessarily be, that the bone is converted into a soft matter, which is interposed be- tween the living solid bone, and the dead solid bone. The soft substance thus interposed, is last of all absorb- ed, and the dead bone left without any connection with the living. We are, therefore, to consider the living bone as effecting the whole business of exfoliation, through the agency of its absorbing vessels, and these vessels act on the living matter, and perhaps also, on the dead part immediately in contact w ith it. The process of exfoliation begins at the surface of the bone, and proceeds irregularly, not progressing uni- formly, in the same direction, or with the same celerity in every part; circumstances not easy of explanation. During the continuance of this absorption of the bone, granulations of a fungous nature, shoot out from the sur- rounding parts, and by pressing on the loosened bone, push it outwards towards the surface of the body, in the same manner as any other loose extraneous matter would be cast off, by the ulcerative process. The edge of dead bone, presents an unequal ragged surface, " a groove or worm eaten canal" being inter- posed between it and the sound bone. The highly interesting physiology of the absorbent vessels, and their agency in this process, have been most ably developed by the late John Hunter, the first writer who threw any light on the subject. 193 ELEMENTS OF SURGERY. CHAPTER XXXIV. Of Dislocations. A Dislocation or Luxation signifies the escape of the articulating surface of a bone, from its natural situa- tion ; as of the head of the thigh bone from the acetabu- lum. A knowledge of anatomy is essential to the compre- hension of all surgical cases, but the reduction of dislo- cated hones in some instances occasions great difficulty, and calls for a complete and accurate knowledge of the parts concerned in forming the joints, and of the effects of the muscles acting upon the displaced bone ; a kind of knowledge not to be obtained simply from osteology or a study of the skeleton, but demanding a frequent inspec- tion of the fresh joints, covered with cartilage and sur- rounded with ligaments, &e. Some bones in consequence of the structure of their joints and their exposure to accidental violence, are very frequently luxated, as the os humeri at the shoulder; others from opppsite circumstances, are very rarely dis- located, as the vertebrae. In general the liability to luxa- tion is proportionate to the degree of motion which the joint possesses, and hence the ball and socket joint al- lowing motion in all directions, is the seat of dislocation most frequently. In the joints possessing a hinge like, or ginglimus motion, the accident is proportionally rare; in consequence of the greater extent of the opposing sur- faces forming the joint, and of the strength of the liga- ments which surround them, added to which, they are less frequently exposed to force in a direction proper for separating their articulating extremities. ELEMENTS OF SURGERY. 193 Luxations are said to be complete, when the bones of the joint are entirely separated; incomplete, when some portion of the articulating bones remain in contact. The only instances of incomplete luxation occur in the articu- lations by ginglimus ; as the knee, elbow, or foot; and here a complete luxation is very rare, from circumstances obvious to every one who is conversant with the struc- ture of these joints. The longer a bone is suffered to remain in the new situation into which it has been forced, the more diffi- cult will it be found to reduce it to its natural place. The soft parts having accommodated themselves to the new position; the muscles being shortened; after a lon- ger time, adhesions forming; and lastly, actual concre- tion of the dislocated bones in a situation remote from the joint, or the formation of a new moveable joint; these are circumstances which increase the difficulty of re- placing the luxated bone, in proportion to the length of time which has elapsed after the accident. Luxations like fractures, have been divided into sim- ple and compound. The simple being accompanied with no external wound, the compound having a wound commuuicating with the cavity of the joint, formed either by the protrusion of the bone through the integuments, or by the cause of the luxation dividing them at the time of the accident. Luxations may be complicated with va- rious other mischief, by the injury of blood vessels, nerves, &c. The immediate causes of the luxation of a bone are violence applied to the joint, and the action of muscles. In an enarthrosis joint (ball and socket) if the direction be not oblique, it is impossible for the bone to be dislo- cated. Boyer has illustrated this by the example of the os humeri. If this bone " hang exactly along side of the body, or perpendicularly with respect to the glenoid ca- vity of the scapula, no force is capable of luxating it. If vol. i. c c 194 ELEMENTS OF SURGERY. a person fall on the elbow while the fore-arm is in this position, the head of the humerus will be forced against the eavity formed to receive it; but if the arm be removed from the body, the axis of the os humeri will fall ob- liquely on the surface of the glenoid cavity, which will favour its passing out of the socket; and this disposition to luxate, will be encreased in proportion as the angle formed by the axis of the bone with the surface of the cavity deviates from a right angle. The action of muscles probably very often assists in dislocating bones ; sometimes no other cause exists. 1 have known the patella dislocated laterally, by a lady in dancing, and in convulsions different bones are occa- sionally luxated. Some joints we have already noticed, are more liable to dislocations than others. This predisposition may depend on great latitude of motion; on the small ex- tent of articulating surfaces in contact; the laxity and small number of the ligaments uniting them; paralysis of the muscles surrounding a joint; and whatever has a tendency to weaken the different connections between the bones. In some instances the soft parts connecting the bones, are so relaxed that a very slight force suffices to dislo- cate them. I have known a woman whose shoulder was liable to luxation from exertions of the most trifling force, and Boyer relates the case of a patient who could not yawn even moderately without dislocating her jaw. These luxations are, from the same relaxation which gives rise to them, very readily reduced, unless this pro- cess be too long delayed. Boyer declares, that " whatever may be the manner in which the causes act, luxations are always accompanied with more or less laceration of the ligaments surround- ing the joint; and in the round articulations, as those of the shoulder and hip, the fibrous capsules are always ELEMENTS OF SURGERY. 195 torn.*' He ought to have excepted cases similar to those noticed in the last paragraph. The symptoms which distinguish luxations, are pain and inability to move the member, a change in the ap- pearance of the joint, an elongation or shortening of the limb, an impossibility of performing certain motions. By careful examination the displaced bones may often be felt in their new situations ; producing eminences where there are naturally depressions, and vice versa; but a more explicit account of these symptoms will be de- livered when the different luxations are particularly de- scribed. The treatment of dislocations consists in replac- ing the bones, and retaining them in their natural situa- tion. The reduction is to be effected as in fractures, by extension and counter-extension. There is in general no difficulty in keeping the bones in their natural posi- tion when they have once regained it. The principal obstacle to the replacement of a bone, recently dislocated, is the action of muscles drawing its articulating surface into a situation remote from that, which it ought to occupy. It frequently happens, that after the head of a bone has been forced out of its natu- ral place, it passes over certain bony prominences, and then takes a situation in a depression of bone, from which it must be forcibly raised before its reduction can be ef- fected. Instances of these bony resistances to the reduc- tion are found in luxations of the thigh bone; the head of the femur passing over the high margin of the acetabu- lum lodges in the foramen thyroideum, or on the dorsum ilii, and before it can be replaced in its natural socket, it must reascend the prominences over which it has passed. For the purpose of applying extension and counter- extension for the reduction of luxated bones, a variety of machines have been contrived, which it is unnecessary 196 ELEMENTS OF SURGERY. to detail in this place. The only means at present in use, are the hands of assistants, and compound pullies. Whenever we can avail ourselves of the aid of a suffi- cient number of assistants, this mode of applying force is to be preferred, because its direction and degree may be altered instantly by a word. The parts to which force should be applied in reduc- ing luxations, can be better explained by describing the different dislocations, than by any general rules. In most cases the force should be made to act as directly as possible upon the affected joint. Boyer and the gene- rality of French surgeons direct, on the contrary, that " the extending force should be applied not on the luxa- ted bone, but on that with which it is articulated, and as far as possible from it." A rule which can be applied with advantage to very few cases.* The degree of force to be employed can only be esti- mated by the difficulty of the reduction, it should always be sufficient to accomplish that end. Although it is to be constantly recollected, that force alone is never to be re- lied on, but skill in the direction of it is ever to be exert- ed. A force sufficient to tear off a limb has been ap- plied without reducing a dislocation. In estimating the force to be employed, the obstacles to be encountered should be carefully kept in view, and when vthese are clearly understood, the direction of the extending powers and the degree of their violence will be the more easily judged of. It should in every instance be gradually applied: Mr. Pott remarks, that "whatever kind or de- gree of force may be found necessary for the reduction of a luxated joint, that such force be employed gradually; that the lesser degree be first tried, and that it be in- creased gradatim." This important rule if carefully * Mr. Pott advocates the principle I have recommended, and most of the British Surgeons, as usual, oppose the French. ELEMENTS OF SURGERY." 197 observed will prevent all serious mischief from the use of the force necessary even in the most chronic luxa- tions. Napkins and strong bands or girths, fastened upon the limb by means of cotton rollers, enable the requisite number of assistants to act at the same time. To prevent excoriation of the skin where great force is necessary, Dr. Physick has applied a piece of buckskin with ad- vantage, between the cuticle and the extending bands. Counter-extension applied to the bone with which the luxated one was articulated, should always be made at least equal to the extension. If for example, three as- sistants are employed in extending a luxated arm, a force equal to three should be employed in fixing the scapula. Counter-extension may often be made by securing a band to a staple in a wall, or some secure position. In attempting the reduction of difficult luxations the position of the patient should be changed. After an erect posture has been tried, a recumbent one should be sub- stituted ; if this fail, the patient may sometimes with ad- vantage be seated in a chair. In recent luxations it has been already noticed that the principal difficulty experienced, is in overcoming the contraction of the muscles. The fatigue of the mus- cles occasioned by long continued efforts at reduction, often produces a relaxation which permits the bone to return to its natural place. Dr. Physick many years ago employed copious bloodletting with this view. He bled the patient until fainting was produced, and during his continuance in a state of syncope all muscular action being suspended, the reduction was readily accomplish- ed. In a great number of instances which have since occurred, the practice has been found completely suc- cessful. There are several writers who recommend bleeding to diminish the action of the muscles in obsti- nate luxations, but none (so far as I know) who pro- 198 ELEMENTS OF SURGERY. pose bleediug ad deliquium animi, except Dr. A. Mon- ro sen. who suggested in his lectures on surgery co- pious bloodletting from one or both arms in an erect pos- ture, as a probable means of facilitating the reduction of dislocations ; but Dr. Physick I believe was the first who had the boldness to carry the practice to the extent ne- cessary for complete success. The first case in which it succeeded, was a luxated humerus, which had baffled every mode of applying force, and a very great' degree of force had been used. During the fainty state, the hands of the operator were the only means employed, and in a single moment, without the slightest difficulty he re- placed the head of the bone in its socket. In cases where bloodletting to the necessary extent is inadmissible, other means of suspending the action of the muscles are to be used. Perhaps nauseating doses of emetics, or the tobacco glyster, might be employed with advantage. Intoxication has been recommended. I once saw it succeed completely in a case of dislocated jaw, which no previous efforts were effectual in redu- cing. The effects of bloodletting ad deliquium animi in fa- cilitating the reduction of dislocated bones, has been very strikingly exemplified in several chronic luxations, which have occurred in different parts of the United States. Dr. Physick reduced a luxated humerus which had been out of place forty-five days, with very great fa- cility ; and in a case which occurred at Baltimore, the arm had been dislocated five or six months and was re- placed by Dr. M'Kenzie by the aid of the same remedy.* * The following extract of a letter to Dr. Physick, contains the history of this truly remarkable case, of the success of which I believe no parallel is to be found in the records of surgery. " B. J. a seaman aged about thirty-five years, was admitted into the Baltimore hospital in the month of September 1805 with a luxation of the os humeri. The account he gave of his case was, that while on a Voyage to Liverpool, and two weeks after leaving this port, he fell from a considerable height and dislocated ELEMENTS OF SURGERY. 199 An erect posture, as being most favorable to the pro- duction of syncope, should be preferred. It is proper to remark, however, that after a bone has continued several months dislocated, it forms adhesions in its new situation; probably the rent in the capsular ligament contracts, or even heals up. Inflammation pro- duces great changes in the structure of the parts and in- creases greatly the difficulty of reduction. Rotating the bone and moving the joint in all possible directions, are necessary to destroy these adhesions, and long continued efforts sometimes succeed when the surgeon had near- ly despaired of accomplishing his object. Perseve- rance, therefore, is to be strongly recommended in all recent luxations, and even in those which have existed several months. To preserve the bone in its proper place nothing but rest is necessary. Very little bandaging is required for this purpose, but it should be remembered that a joint his shoulder, and that an attempt was made by the Captain of the ship to re- duce it, but without success; that upon his arrival at Liverpool repeated trials were made to effect reduction of the bone, but to no purpose, and he had now remained in this situation between Jive and six months. Upon examining the shoulder, I found the head of the humerus under the pectoral muscles, where it had imbedded itself, and appeared to have formed considerable connexions with the surrounding parts. In this state of things I deferred any attempt to reduce the bone till the fol- lowing day, when in consultation with my friend Dr. Smyth, it was determined at once, to have recourse to bleeding ad deliquium, as the only plan in our view likely to succeed; and having secured our patient in the usual manner, a vein was opened, and nearly Jive founds tif blood were drawn before fainting could be produced; this, however, was at length completely effected, and with (compa- ratively speaking) very little effort the bone was reduced. It is worthy of remark in this case, that neither swelling nor inflammation succeeded the reduction of the bone, and the poor man was dismissed well in the course of two weeks. I am, &c. COLIN My extravasated blood. When the perforation has been made, if the pus exist under the skull it will flow out, if under the dura mater this membrane should be punctured with a sharp lancet, though recoveries under such circumstances are not to be expected. Although inflammation of the brain generally occurs within a few days after the accident which causes it, yet in some cases months elapse before its commencement. I assisted Dr. Physick to trepan a gentleman, whose dura mater we found thickened and in a state of suppu- ration, several years after the occurrence of the accident which occasioned the formation of the abscess. THE OPERATION OF TREPANNING OR TREPHINING. The manner of removing portions of the cranium, when this becomes necessary is next to be described. The various obsolete instruments of the ancients, and many of the useless contrivances of modern surgeons may be dispensed with in proceeding to this operation, for as Mr. Pott remarks " Reduction of the number of instruments to be used in an operation, and an extreme simplicity and plainness in those which may be required, are a part of the merit of modern surgery." The instru- ments w anted, for removing portions of the skull, are 280 ELEMENTS OF SURGERY. a scalpel (with the steel projecting through the handle (Fig. 1.), a trephine with a sliding centre-pin. (Fig. 2.), a saw (commonly called Hey's savy) (Fig. 3.), a quill tooth-pick, needles, and ligatures. The lenticular, the rhaspatory, the brush, and the other instruments com- monly foffhd in the trepanning cases, are quite useless. The hair being previously removed, an incision is to be made through the scalp down to the bone, and if a longitudinal incision should not sufficiently expose the surface, it may be crossed by another, and extended in any necessary directionjJ^The removal of a portion of scalp as practiced by the older surgeons and recom- mended by Mr. Pott should never be performed. In making the incision down to the bone, great caution is in some cases necessary to avoid plunging the knife through the fracture into he brain. After having denuded the bone of its pericranium, by means of the end of the knife handle, the centre-pin of the trephine is to be pro- truded, and fixed on the part of the skull which is to be removed. If in a case of fracture, this centre-pin must always be placed upon a piece of firm solid bone, not detached from the skull, and as near as possible to the • fracture, and therefore more than half the bone included by the crown of the instrument will generally be unin- jured bone. The instrument is to be now freely turned backwards and forwards by the surgeon, who presses It firmly against the skull, until a groove is formed of sufficient depth to allow the retraction of the centre-pin, which must always be carefully withdrawn as soon as this groove is made, to prevent a wound of the dura ma- ter. The action of the circular saw is to be continued and the depth of the groove very frequently examined. The teeth of the instilment are to be wiped from time to time with a towel, and when they have penetrated to the diploe, less resistance is experienced, and now a great PL ATjS XJ Pagt 180. ELEMENTS OF SURGERY. 281 degree of care is necessary on account of the inequalities in the thickness of the inner table of the skull, in conse- quence of which one part may be completely cut through before the other is nearly divided. The tooth-pick is the most convenient probe for ascertaining the depth of the groove, but when the trephine reaches the tabula vitrea and has made some little impression upon it, it is safer to attempt to break out the circular portion of bone by means of the elevator, than to proceed completely through it with the saw. If any part of the bone is en- tirely divided and the tooth-pick is found to touch the dura mater, considerable force should be exerted to separate the section of bone without further sawing, as the dangers of a wounded dura mater, are very great; if this, however, be impracticable, the action of the tre- phine should be directed against the undivided portion of bone exclusively until it is thin enough to be broken off; this can always be done with the common trephine with- out resorting to the old instrument with a file like cir- cumference. If any inequalities of bone remain round the edge of the foramen, they may be broken off by the end of the elevator; the lenticular which has been con- structed for this purpose, is by no means a convenient in- strument. When one perforation has been made, in general the depressed bone may be elevated to the proper level, and any loosened portions maybe entirely removed. If the operation have been performed in order to eva- cuate extravasated blood or pus, one opening is gene- rally sufficient, but if necessary the operation may be repeated. The ancient surgeons were in the habit of applying the trepan very frequently, and in some cases very numerous perforations have been made without fa- tal consequences. Iu one instance, we are assured that twenty-seven perforations were made through the skull vol. I. no 282 ELEMENTS OF SURGERY. of a nobleman in consequence of a fracture, but no one can doubt that the removal of portions of the skull is a very serious evil, and that it should be performed as rarely as possible. The introduction of the straight saw into practice has diminished the frequency of using the trephine, and al- though the instrument is to be found in many old books of surgery, yet until Mr. Hey of Leeds in a publication a few years ago, recommended its use in fractures of the skull, surgeons were ignorant of its great advantages. A va- riety of cases occur in which it may be substituted for the trephine in removing portions of skull, without the additional loss of bone which the latter instrument occa- sions. With respect to the parts of the skull where the tre- phine may properly be applied, I believe the surgeon hesitates at none, to which he can get access, provided the urgency of the symptoms demand the operation. The sutures, offer no barrier and the large blood-vessels none—indeed the basis of the skull is the only part where the operation cannot be performed, and with safe- ty, by a prudent operator. Should the longitudinal si- nus or the great arteries of the dura mater be opened eith- er by a fragment of bone, or by the operator, the bleed- ing is easily arrested by a dossil of lint. I have seen a profuse hemorrhagy from a large opening in the longitu- dinal sinus occasioned by a fragment of bone, immediate- ly stopped by applying lint over the orifice. The mid- dle artery of the dura mater wounded in the same man- ner, is as readily secured. Dr. F. Dorsey of Maryland, once tied up this vessel with a needle and ligature, and no ill consequences resulted. In some cases which 1 have seen this would easily be effected, because the ar- tery could be separated to some distance from the dura mater, with which it is not always intimately connected. I have seen it projecting a quarter of an inch from that membrane in an extensive fracture of the parietal bone, ELEMENTS OF SURGERY. 283 but if the ligature must pass through the dura mater in order to secure it, the operation of tying it up ought never to be performed. If the bleeding from the ves- sels of the scalp should not spontaneously cease, the needle and ligature are most convenient for securing them. The only dressing in general required after tre- phining, is a light poultice of bread and milk; great care should be taken to guard against pressure upon the exposed brain. The remedies proper to prevent and re- lieve inflammation are always to be employed with great activity. In some cases it may be proper after remov- ing the bone, to place the scalp and dura mater in con- tact and to allow them to unite, but in a majority of ca- ses this cannot be effected, and when it is attempted great care should be taken to prevent collections of blood and serum or pus from being confined under the scalp, and thus compressing the brain. Where a small wound of the dura mater exists, I believe its adhesion to the scalp at the wound and around it, would greatly dimi- nish the danger of suppuration in the brain. HERNIA CEREBRI. When ulceration takes place in the dura mater a tu- mour generally rises through it, which has been called hernia cerebri, this tumour in all the cases 1 have seen, consisted evidently of the substance of the brain, and un- der the pia mater in several places clots of blood of a dark colour were observed. These tumours sometimes acquire a large size, and if removed, speedily return. Mr. Abernethy has de- scribed sonic cases which have led him to an opinion that "the disease frequently described by the term her- nia cerebri, consists of a tumour formed by coagulated blood; for an organized fungus could hardly be produ- ced in so short a time as that in which these tumours are usually formed." I have no doubt that the tumour con- 284 ELEMENTS OF SURGERY. sists partly of coagulated blood, but chiefly of the sub- stance of the brain, which is pressed out at the aperture through the dura mater, in consequence of an abscess having formed in the brain, or immediately under the skull, and in consequence of the increased volume of the brain which is greatly swelled by inflammation. Mr. Abernethy is of opinion that extravasated blood pushes out the brain, and that what would be apoplexy, if the cranium were entire, becomes fungus cerebri, in consequence of the deficiency of bone which allows the brain and coagulated blood to protrude. This no doubt occasionally happens, but a considerable quantity of pus was found in two cases which I have dissected, and the protrusion appeared to be caused by the pressure of this pus. Mr. Charles Bell supposes that though Mr. Abernethy's account be correct, yet two other kinds of tumour arise from the brain—the one a fungous ex- crescence from the dura mater, the other a proper orga- nized fungus of the brain, How far these opinions are correct, I shall not decide, but I shall take a greater liberty with his practice than with his opinions, and condemn without hesitation his proposal to cut off' the tumour: this I conceive could not answer any good purpose, and would probably be pro- ductive of very copious hemorrhagy, which in the ex- hausted state of the patient might prove fatal. The best application is a light soft poultice, or a pledgit spread with simple cerate. Should the tumour however acquire a very great size, portions may be separated with the knife, as in some of Mr. Hill's cases. Some rare in- stances are recorded of recoveries from this dangerous affection, but in general it terminates speedily in death. I have endeavoured to avoid confusing the preceding condensed history of the affections of the brain from ex- ternal violence by a detail of opinions, or a quotation of wonderful cases. I may now, however, not improperly ELEMENTS OF SURGERY. 285 remark that although the opinions of our predecessors on the subject, are many of them fanciful and unimpor- tant, yet their histories of cases, merit the greatest atten- tion. One general principle I would inculcate from them, which is, that injuries of the head apparently tri- fling should never be neglected; and on the other hand those which appear most dangerous and alarm- ing, should never be despaired of. In proof of this I could select instances of death from a blow which scarcely exeited attention, and of recovery where the brain had been shot through by a musket-ball. I have myself seen several skulls in an European collection, in which the bony cicatrices demonstrate that large portions of brain and skull had been cut out, and subsequent cures had been effected. I shall now proceed to relate a case, which I think il- lustrates more of the usual circumstances of injury of the brain than any other I have met with. CASE. P. Welch aged about twenty-four years received at midnight June fifteenth, a violent blow from a brick-bat. He instantly fell, and was conveyed home stunned and scarcely breathing; a quack in the neighbourhood was sent for and by the time of his arrival the symptoms of the first stage of concussion had subsided, and the pa- tient's breathing was much improved, his pulse rose. he remained stupid, but moved occasionally, aud when his head was touched appeared to suffer pain and put up his hands, as patients generally do in the second stage of concussion. He remained in this situation till the afternoon of the succeeding day, the Doctor having declared that the skull was not fractured and that he would soon be well. His friends becoming uneasy at the continuance of the stupor had him bled, and sent for 286 ELEMENTS OF SURGERY. surgical aid. I made my visit about twenty hours after the accident, and found him snoring, but if spoken to in a loud tone of voice, he attempted to answer, but could not articulate distinctly. His pulse was full and slow. Over the left ear was a contusion and a small wound which when touched occasioned pain, and the patient moved his head and hands to escape from the examination of it. I made an incision down to the bone and discover- ed that a portion of the squamous plate of the temporal bone was fractured and depressed. During this opera- tion it was with extreme difficulty that the patient could be kept in bed; he screamed, and moved about vio- lently. Under these circumstances I postponed opera- ting and drew from the arm eighteen ounces of blood in addition to several ounces which had flowed from the branches of the temporal artery. The next morning (June seventeenth) no favourable change having taken place but on the contrary the stu- por being increased, I proceeded to remove the depress- ed bone to which the trephine was applied twice, and all the depressed bone as large as a half dollar taken away, a crack extended forwards toward the parietal bone the extent of which appeared considerable, but no cause for tracing itfurther, existed. A little extravasated blood was found under the skull. After the operation the pulse rose and in the evening gxvi of blood were drawn from his arm after which he appeared more sen- sible. On the eighteenth, the day after that on which the operation had been performed he was evidently better, was perfectly rational though still somewhat drowsy,had no recollection of the accident—was bled 5\ii in the morning and 5viii in the evening, drank toast and wa- !er. For several days no particular alteration was observed the wound appeared sloughy, and a portion of the tem- poral muscle which had been cut through sloughed off. . ELEMENTS OF SURGERY. 287 He vomited occasionally and was bled pretty regularly twice a day till the twenty-third. A tumour cover- ed by the dura mater gradually protruded at the wound: this membrane was tense and appeared evidently to con- tain a fluid. His stupor was increased. On the twenty-fifth, ten days after the accident, the nurse informed me he was greatly better and was more rational. I immediately suspected that the dura mater had given way and that pus had been evacuated ; upon in- specting the head this was found to be the case—a large quantity of pus had been discharged during the preceding night and a hole was observed in the dura mater through which it had issued. I anticipated now the formation of a hernia cerebri, which accordingly happened : on the twenty-seventh (twelve days after the accident) a tu- mour began to appear protruding through the aperture in the dura mater which gradually increased to the size of a hen's egg and was evidently covered in some parts bv the pia mater, and in others had ruptured this membrane and appeared to consist of brain aud clotted blood. Du- ring the formation of this tumour, and the discharge of matter which attended it, the patient regained the entire use of his mental faculties, and appeared to his friend* to be getting well, I assured them that these hopes were delusive and that he would not survive many days. He complained of hunger, and his pulse being languid, lie was allowed chicken broth, and a few oysters. On the first of July he had a violent chill, a slouch came away from the dura mater, and the tumour of the brain enlarged very considerably;—On the second, co- pious hemorrhage from the tumour;—On the third at midnight eighteen days after the accident he expired much blood haviug been previously discharged from the tumour. On dissection, the crack noticed during the operation was traced, and I found it to extend completely round 288 ELEMENTS OF SURGERY. the head, having passed through the temporal bone, a small part of the parietal, and separating the os frontis into two portions, by a crack situated immediately above the frontal sinuses parallel to the superciliary ridges. Where the fungous tumour had existed clots of blood only were seen, and on removing these a considerable hole was found in the brain, occasioned by a loss of its sub- stance, the brain to some distance round this vacuity was intermixed with coagula, and completely disorga- nized, a layer of pus, thick and viscid, intervened eve- ry where between the dura and pia mater, and at one place under the fissure in the bone, an extravasation of one half an ounce of blood was found. In this case the effects of concussion were very evi- dent, afterwards those of compression, then the usual effects of inflammation (not so distinctly marked as in some cases, because compression still existed) followed by suppuration and by hernia cerebri. In consequence of gun-shot wounds and other contu- sions of the skull, exfoliations occasionally happen, sometimes of oue and sometimes of both tables of the skull. When the external table is killed, and exfolia- tion commences, the inner table inflames, and the action of the absorbents as described formerly, removes the earthy matter of the bone, granulations shoot out from the inner table and push off the scale of dead bone, after which, these granulations probably secrete and depositos- seous matter and are converted into solid bone. This pro- cess goes on more rapidly in young than in old subjects. In some cases it is performed very slowly in conse- quence of the granulations shooting up into cavities in the dead bone, and thus connected they prevent for some time the separation; where the delay is evidently owing to this cause some force may be used in removing the dead bone. If both tables of the skull are killed as in cases of gun-shot wounds, the symptoms generally ELEMENTS OF SURGERY. 289 call for the trephine, but if this be not applied, the sepa- ration of the dead bone is effected in the usual manner, and granulations arise from the dura mater and fill up the space. The deficiency of bone after portions of the skull have been removed, is supplied by granula- tions from the surrounding bone and from the dura mater. The bone forms first in contact with the re- maining solid bone, and a thin plate afterwards, ex- tends gradually over the aperture. Previously to the formation of this plate of bone, the brain is defended only by a soft cicatrix of skin under which it may be observed pulsating. From this exposed state it is prop- er to defend it, especially when large portions of skull are deficient by means of firm plates of tin, silver, or leather, which may be worn under a wig, or cap, until the bone is replaced. VOL. i. p p 290 ELEMENTS OF SURGERY. CHAPTER LI. Diseases of the Eye and its appendages. Having treated of the most usual accidental injuries to which the body is exposed and of the remedies to be employed, we pass on to describe certain morbid affec- tions submitted to the care of the surgeon. The term disease does not convey a precise and accu- rate notion of many of these affections; in a qualified sense, however, it may be retained and cannot mislead, when the nature of the various cases is understood. Inflammation attacks the eye and its appendages as well as the other parts of the body ; it may be excited by accidental irritations, or by diseases of the constitution. In some cases it makes its approach w ithout any obvious remote cause. Inflammation of the eye-lids occasions some pain but less than when the eye-ball is affected—the lids swell in consequence of an effusion of serum into the cellular texture—the skin becomes red and a burning sensation is felt. In some instances, this inflammatory tumefaction of the eye-lid comes on at night, and as only one eye-lid is generally affected the patient ascribes it to the bite of an insect; the cause is not always easily ascertained. If fever accompany it, as is sometimes the case, the patient should lose blood from the arm, if not, a brisk mercurial cathartic and low diet will generally remove the affection very promptly. A lotion of brandy, or cam- phorated spirit is often found useful. Should it resist these remedies, repeated bloodletting, the application of a dozen leeches, and the usual antiphlogistic measures are to be employed. ELEMENTS 01 SURGERY. 291 A discharge of pus from the edges of the eye-lids, called psorophthalmy often calls for the aid of the sur- geon. The patient waking in the morning finds his eye- lids closed by a secretion of pus which has dried and keeps them in contact. The glands of Meibomius are generally considered as the seat of this affection. Dr. Physick has been led to believe from his own observa- tions, that the inflammation is seated at the roots of the eye-lashes. The affection of the head called tcenia capi- tis is probably of the same nature, ulceration existing in both cases at the roots of the hair. One proof of the cor- rectness of this opinion is, that the hair being pulled out the inflammation often gets well, and another, that the tar ointment and spermaceti oil, remedies very success- ful in tcenia capitis, are advantageous in the present case. The edges of the eye-lids are sometimes ulcerated in this complaint. The most successful application is the citrin ointment, applied to the part: a solution of lunar caustic has also been used with great benefit. Com- mon mercurial ointment is sometimes successful. Lamp oil, and tar ointment I have several times used with ad- vantage. When the inflammation is very great, leech- es should be applied, and purges administered. A chronic inflammation of the eye-lids called lippi- tudo sometimes proves extremely obstinate; the pa- tient's eye appears surrounded with a red circle, and the lids are agglutinated in the morning. The treatment recommended in the last case is sometimes successful in this; but in many cases it is extremely obstinate and re- quires great attention to diet and regimen. I have known instances where it has lasted through life, aud has ap- peared in several members of the same family. The eye-lids are subject to an inflammatory tumour call- ed hordeolum or stye. It resembles at first a small pim- ple situated on the edge of the eye-lid, which augments, 292 ELEMENTS OF SURGERY. becomes painful and suppurates. It is in fact a small boil, or phlegmonous tumour, and in general gets well without any surgical aid, occasionally an induration re- mains after the inflammatory tumour has subsided. If this become troublesome it may be destroyed by lunar caustic. The eye-lids are subject to two very opposite affec- tions which become sources of great trouble and incon- venience, the one an eversion of the lid, called Ectro- pium, the other an inversion called Entropium or Tri- chiasis. ECTROPIUM. The eversion of the eye-lid most frequently occurs in the lower lid, which is turned outwards towards the cheek and does not come into contact with the eye. In- flammation results from the exposure of the eye, and from the unnatural situation of the puncta lachrymalia, the tears cannot pass through them and of course over- flow the cheek, and a very unpleasant tumour of a red, fungous appearance forms in consequence of the disten- tion of the vessels of the conjunctiva. The complaint is occasioned sometimes by the contraction of granula- tions in the healing of burns, wounds, or ulcers, on the cheek, but oftener from a relaxation and elongation of the eye-lid. The only remedy hitherto relied on, is the removal of the everted lining membrane of the eye-lid, which becomes indurated and enlarged; when this is done by a scalpel or scissars, the lid should be support- ed in its natural situation by a compress carefully ap- plied and the wound in healing, generally contracts suf- ficiently to counteract the disease. A more ingenious operation, however, is described by Mr. William Adams in a work published in 1812 at ELEMENTS OF SURGERY. 293 London for the cure of this affection, it consists in cutting out a portion of the lower eye-lid resembling the letter V—the piece thus removed is one-third of an inch wide at its upper part, the sides of the wound are approxi- mated by a stitch, and the diseased conjunctiva cut off— this effects invariably a complete and speedy cure. ENTROPIUM. In the entropium or trichiasis the eye-lid is invert- ed upon the eye, in consequence of which, the cilia irri- tate excessively the surface of the eye and keep up a constant and violent inflammation. According to Scarpa and other writers two species of this disease are met with; in one the cilia are turned inwards without the tarsus having changed its natural position and direction, in the other the tarsus is inverted and consequently all the eye-lashes are in contact with the globe of the eye. The second form is most common and to this only the term Entropium is properly applied. The causes of Trichiasis are by no means well under- stood—ulceration and consequent cicatrices are sup- posed to have produced it in most cases, but of this there is no proof. It seldom occurs in the under eye-lid. The consequence of the inversion of the eye-lids is a constant irritation and inflammation of the eye, from which the cornea becomes opake, but the patients from time to time relieve themselves by pulling out the cilia and then the inflammation abates, it is, however, soon repeated when the eye-lashes begin to grow, and blind- ness sooner or later results, nor is this a termination of the patient's sufferings for the inflammation goes on, and the pain continues. A callosity and complete change in the structure of the eye is the only event which af- fords a complete relief to the unhappy sufferer. 2g4 ELEMENTS of surgery. * A great variety of means have been proposed and adopted for the cure of this disease, which it is unne- necessary here to detail. In reflecting on the nature of the complaint, several years ago, I was induced to think that the eyelid could very readily be cut half off, without much inconvenience, because the orbicularis muscle is capable of contracting in such a degree as to throw the folds of skin into nu- merous wrinkles, thereby demonstrating that much of it could be removed and the eye still be closed. A case of trichiasis came under my care in the Philadelphia Alms-house, in July 1810, in which several operations had been performed, but without effecting a cure: about one third part of the cilia were inverted. In this case I made an incision through the tarsus and cut out com- pletely all that portion of the eye-lid, from which the cilia proceeded. My patient in a few days Was perfect- ly cured, was extremely pleased w ith the operation, and very little disfigured; indeed compared with her infla- med eye, her appearance was improved. Encouraged hy the success of this case I have twice since performed the operation of removing totally the lower half of the tarsus cartilage, together with the skin covering it and the inverted cilia, the success has been complete in both cases, the wound healed up very readily, the inflamma- tion quickly subsided and the opacity of the cornea was soon removed. By one of those coincidences which are often occur- ring, the late Mr. Saunders of London, contrived and performed the same operation and with equal success. A small volume on the diseases of the eyes which for the first time I saw during the present winter, though it was published in 1811, contains an account of this ope- ration. Mr. Saunders remarks "the certainty of its re- lieving the patient, is what I more value than the cred- it if there be any, of having suggested it;" and in this ELEMENTS OF SURGERY. 295 sentiment I heartily join him. I shall therefore proceed to describe the manner of operating proposed by Mr. Saunders, and afterwards relate my own method. Mr. Saunders directs the operation to be performed as follows : " a piece of thin horn or a plate of silver having a curvature corresponding with that of the eye- lid, is to be introduced, and its concavity turned towards the globe within the eye-lid which is to be stretched upon it. Au incision is to be made through the integu- ments, and orbicularis palpebrarum, immediately be- hind the roots of the cilia to the tarsus, and should ex- tend from the punctum lachrymale to the external an- gle. The exterior surface of the tarsus is then to be dissected until the orbital margin is exposed, when the conjunctiva is to be cut through directly by the side of the tarsus which must now be disengaged at each extre- mity; the only caution necessary being to leave the punctum lachrymale uninjured." The manner in which I have performed the operation is extremely simple. A hook is passed through the edge of the eye-lid in order to gain a secure hold of it, and with a pair of sharp scissars the necessary portion of the eye-lid is removed by two or three cuts. "Nothing can be more simple that this piece of dissection." A remark applied by Mr. Saunders to his operation, but which is much more applicable to mine. The punctum lachry- male must be carefully avoided. The wound generally heals in a few days; no dress- ings are necessary, but a soft compress may be lightly boun I over the eye. Mr. Saunders says a fungus arose from the cicatrix in all his cases, which required caus- tic or the knife, ail the cases I have seen, healed imme- diately without any inconvenience, and the deformity is not so great as would be imagined.* The appearance • The operation is I believe new, though Haller in his Bibliotheca Chirurgica stales, that Rimes, recommended cutting and burning the eye-lid, in similar 296 ELEMENTS OF SURGERY. of the eye after the cure, is represented in Fig. 2. of the Plate next succeediug. When the eye-lids are contracted by cicatrices so as no longer to cover the eye, systematic writers have call- ed the affection lagophthalmy, or hare-eye. I have seen it in consequence of burns and there is no remedy but careful dissection of the surrounding parts, by which the skin may be loosened in sufficient quantity to defend and cover the eye; after the dissection care must be taken to prevent by adhesive plaster or even a suture if requisite, the subsequent retraction of the skin. CHAPTER LII. Of Ophthalmia. Inflammation of the eye, or in medical language oph- thalmia, is a frequent, and very distressing complaint. Its symptoms are very well known; they generally com- mence writh a severe pain in the eye, redness of the eye- ball, and a copious secretion of tears—the patient is un- able to bear the light, and keeps his eyes closed—some- times a violent burning is perceived in the eye; head- ache and in general fever attend—the inflammation is either seated in the adnata, or in the globe of the eye, in which latter case there is less external evidence of in- flammation, but the same general symptoms. In some cases an effusion of blood takes place into the cellular tex- ture under the adnata, and occasions a great tumefaction. Coagulating lymph is sometimes pouied out by the in- flamed vessels, and opacity of the cornea is the conse- quence. In some cases a pimple or inflamed speck ap- cases ; the nature of his operation I cannot ascertain, as the only copy of Rhazes which I have been able to seet contains nothing on the subject. It is a black let- ter edition, very ancient in barbarous Latin, belonging to the Loganian library Ln this city. ELEMENTS OF SURGERY. 297 pears, in some part of the adnata, generally in the vici- nity of the cornea. Small red vessels are often seen ra- mifying over the cornea. It is unnecessary to enumerate the various causes of ophthalmia; they are numerous mechanical and chemical irritants, and certain diseases, as small-pox, syphilis, scrofula, catarrh, &c. When the disease occurs in the adnata only, the pain is tolerable, compared with the sufferings of those pa- tients in whom the internal parts of the eye are affected with severe inflammation; in these the pain is excrucia- ting, and if it be not soon relieved blindness is general- ly the result, and death sometimes takes place. The treatment of ophthalmia whether confined to the adnata, or seated more internally, consists in the active employment of the usual remedies for inflammation. Of course the remote causes if they continue to act, should be removed; all extraneous matters which may irritate the eye should be wiped off; this may generally be done by passing a small piece of rag wet with clean water upon the end of a probe, round the eye between the eye and lid, or by injecting a stream of milk and water un- der the eye-lids by means of a syringe. In many cases, however, the foreign substance sticks in the cornea or sclerotica and cannot be thus easily removed. It is very common for blacksmiths in filing iron, to detach small portions of the metal with great force, so that when they strike the eye, they penetrate to some depth. In these cases the point of a lancet, or a cataract knife must be used to detach the foreign body. The remote causes being removed, bloodletting is to be performed, as extensively as the nature of the case may require. After this remedy has been carried as far as may be necessary, topical bleeding by leeches, and cupping in the neighbouring parts is to be next used. The European surgeons do not employ bloodletting so vol. i. Q q 298 ELEMENTS OF SURGERY. extensively in c> iuhalmia, as is necessary in the treat- ment of the complaint in this country. I have known in one case, seventy bleedings required for the cure of an obstinate acute ophthalmia ; the quantity of blood lost at each operation was generally six or eight ounces. In the Pennsylvania hospital, I have generally directed the patients afflicted with acute ophthalmia, to be bled every other day, and on the intermediate day to be purged; to live upon a very abstemious diet, and to remain con- stantly in a dark room. These are in almost every re- cent case, very speedily successful, and active measures ought surely to be preferred to tampering with serious diseases. In some cases after bleeding, and cupping, and leech- es have been tried, if the inflammation continue, scarifi- cations become necessary; the vessels of the adnata may be conveniently divided by the edge of a sharp scalpel, or the shoulder of a lancet. A few drops of blood evacua- ted in this way from the inflamed part, will often prove extremely serviceable. Purges are to be frequently admiuistered, the saline cathartics are generally employed, and antimonial pre- parations in combination with nitre are also useful. Blisters to the back of the neck, or behind the ear. or to the forehead, are in many cases extremely benefi- cial ; but Dr. Physick has introduced a mode of apply- ing blisters in cases of ophthalmia, which is more quickly useful than any other; the plaster is to be spread with the epispastic ointment covered with gauze, and applied directly over the eye, the lids being closed; in this manner the whole surface of the upper and lower eye- lid, and a portion of the cheek are blistered, a copious discharge of serum takes place, and great relief is in ge- neral immediately experienced. I have for several years availed myself of this practice, and have been much pleased with its efficacy. I was formerly in the habit of ELEMENTS OF SURGERY. 299 cutting off the cilia, and applying a strip of adhesive plaster to prevent the flies from coming in contact with the eye, but of this, if the blistering plaster be carefully prepared, there is no risk, and 1 have often omitted the precaution; indeed the copious secretion of tears would wash out any extraneous matter which might be insinua- ted between the eye-lids. When notwithstanding a vigorous perseverance in the use of the preceding remedies, the inflammation conti- nues unabated, and great pain is felt in the ball of the eye, mercury should be administered in such a manner as to excite a speedy salivation, the ointment should be rubbed upon the thighs and calomel administered in doses of two or three grains in the twenty-four hours. No collyrium but of the mildest kind should be em- ployed during the acute stage of ophthalmia. Milk and water answers very well. The pith of sassafras, infused in water forms a mild mucilage, which in these cases is a very pleasant application to the patient; the young twigs of the sassafras split open, afford considerable quanti- ties of pith; a teaspoonful will render eight ounces of water, sufficiently viscid. A soft light poultice of bread and milk sometimes relieves the pain of ophthalmia, but in general compresses of soft linen, wet with cold water or milk and water often changed, give more ease; the poultice keeps the part too hot, and its weight is an in- convenience. After the more active symptoms of inflammation have abated, the employment of gently irritating or astringent collyria, becomes useful; the formula I have found most beneficial is the following: R. Sacchar: saturn: (Acetatis plumbi) gr. v. Vitriol: alb: (Sulphatis zinci) gr. iij. Laud: liquid: 3. ij. Aq: fluvial: ?. iv. M. f. colly r. 300 ELEMENTS OF SURGERY. The addition of 3ij of vinegar sometimes improves the medicine. Dr. Physick employed tar water several years ago in a most obstinate case of ophthalmia, which had resisted all the usual remedies, it proved completely and speedily successful. In the employment of an eye-water, a rag wet with the fluid should be placed over the eye-lids, and occa- sionally they should be opened so as to admit it into con- tact with the ball of the eye. The tar water should in the first instance be diluted, and afterwards applied of the usual strength. Diluted laudanum, and the vinous tincture of opium are in some cases very useful as colly- ria. A great variety of collyria have been contrived ; I have already named those which appear to me most use- ful. In general by these measures the inflammation is re- lieved, but it sometimes terminates in suppuration, and pus is poured out under the cornea, forming the disease called hypopion. In these cases it is proper to make a puncture with a cataract knife through the cornea for the evacuation of the pus, for if this be suffered to re- main until ulceration takes place vision will inevitably be destroyed. It generally happens, however, that brisk purging and a continuance of the antiphlogistic measures produce an absorption of the effused pus and render it unnecessary to puncture the cornea. Confinement to a dark room, and a very abstemious vegetable diet should be enjoined during the whole course of the disease. Setous and issues in chronic cases are sometimes useful, they may be made on the back of the neck. When the inflammation abates, light should gra- dually be admitted to the eye, and a very cautious re turn made to the usual habits of diet and exercise. ELEMENTS OF SURGERY. 301 CHAPTER Lni. Unguis or Pterygium. Unguis or Pterygium, is an affection of the eye, not unfrequently met with ; it consists in an enlargement of the vessels of the adnata proceeding from the inner can- thus of the eye, and at length forming a dense ofkike red membrane of a triangular figure pointing and pro- gressing towards the cornea, over which at length, it gradually spreads and of course impedes vision, in pro- portion to its extent. In some rare cases it proceeds from the external canthus of the eye. Scarpa observes that the unguis in some rare instances proceeds from other parts of the globe of the eye, but always maintains a triangular shape,—the apex of which is presented towards the cornea; occasionally two or three pterygia form upon the same eye; when these unite upon the cornea, a complete obstuction to vision takes place. , Scarpa considers the vessels of the eye in chronic ophthalmia to be in a varicose state, and in the present case in addition to the varicose state of the vessels which are extended over a certain part of the cornea, there is a preternatural thickening of the thin lamina of the con- junctiva which covers it, upon which these small vari cose veins are situated. Hence it seems that the pterygium appears at first, to be a new membrane formed upon the cornea, while it is nothing more than the fine lamina of the conjunctiva, forming its natural external covering, which in conse- quence of chronic ophthalmia has degenerated from a 302 elemensts of surgery. transparent into a thick and opake tunic interwoven with varicose vessels. Scarpa supposes the unguis to be nothing more than an increase of the same affection which forms nebulje, or spots on the cornea. These nebulae consist of dilated knotty vessels upon the cornea, which ought in their forming state to be treated by astringent collyria, and sti- mulating applications, as the citrin ointment, &c. in order to prevent their extending over the lucid cornea and thus impeding vision. A peculiarity of unguis or pterygium is that it appears very loosely connected with the sclero- tica*; if taken hold of by a hook or forceps it moves ea- sily, and seems connected only by loose cellular texture. Scarpa remarks that cancer has sometimes resulted from this complaint. The remedy consists in seizing the thickened mem- brane with a hook or pair of forceps and dissecting it carefully off with a pair of curved • scissars, (Fig. 3.) Where it adheres to the cornea the union is more intimate and here a sharp knife is the most proper instrument for the dissection. It is most convenient lo commence the incision near the canthus and proceed towards the cornea. Scarpa remarks that in some cases after the removal of the pterygium, the cicatrix prevents the freedom of motion outwards, to avoid which inconvenience in the treatment of pterygia which have a very extensive base upon the white of the eye, he has found it convenient to divide them from the apex, only as far as the cornea and sclerotica unite, and then to separate them at their base by a semicircular incision including about a line in breadth of the substance of the conjunctiva, in a di- rection concentric to the margin of the cornea. By ope- rating in this manner, he has found that the after treat- ment is much shorter, than when it is executed after the ELEMENTS OF SURGERY. 303 common method, that the cicatrix does not form a ridge or fraenum, and that the conjunctiva being stretched cir- cularly and equably n^on the white of the eye by the cicatrix, loses that relaxation and varicose state of its vessels which formed the base of the pterygium. This nicety however, is not necessary where the pterygium is small, and does not extend much upon the white of the eye. After the operation no particular dressings are re- quisite, a wet compress should be loosely bound upon the eye and the patient for a few days confined to a low diet. A species of disease very analagous to this is called Encanthis ; it is a tumour of the same texture as the unguis and formed in the same manner, growing from the caruncula lachrymalis and semilunar fold of the ad- nata. It is to be extirpated by sharp scissars. 304 ELEMENTS OF SURGERY. CHAPTER LIV. Opacity of the Cornea and Artificial Pujril. Inflammation of the eye sometimes terminates in opa- city of the cornea. Several distinct appellations have been given to the various forms of opacity in the cornea, as nebula, albugo, leucoma, &c. for an account of these I refer to Scarpa; In some cases the texture of the whole cornea appears to be changed, in others opake spots are visible; some- times the opacity depends on increased vascularity and subsides when the inflammation is over, in others it re- mains permanent. Some practitioners are in the habit of blowing into the eye powdered sugar, molasses, white vitriol, or pulve- rized glass, with a view to grind off this film, as they call it; the practice is extremely pernicions, and ought never to be used; the remedies for inflammation already recited are the only ones in which confidence should be placed. When a portion of the cornea remains lucid, an artificial pupil if necessary, may be made opposite to this lucid spot in the cornea, and thus vision will be restored ; the operation should not be performed unless the patient has lost the sight of both eyes. The same operation may also become necessary, in cases where the pupil has be- come obliterated, from an adhesion of the iris at its margin, in consequence of inflammation. In both these cases Dr. Physick has for many years been in the habit of makiug a section of the cornea, as for the ex- traction of cataract, and afterwards of removin0* a por- tion of the iris, by means of a pair of forceps tormina* ELEMENTS OF SURGERY* 305 ting in narrow extremities upon one of which is fixed a sharp circular punch (Fig. 12.) the iris in cases where the pupil is obliterated, must be punctured by the point of the knife in making the section of the cornea, and then the forceps can readily seize it. A variety of methods have been contriv ed for effecting this purpose. Baron WenzePs I think is preferable to all before de* scribed. The one I have just noticed is an improvement of Baron WenzePs, and only differs from it in the use of the circular punch, instead of the scissars employed by the Baron. This celebrated oculist was in the habit of performing the operation occasionally, by one stroke of the knife, and it is practicable in some cases to do so; to effect it, it is only necessary to introduce the knife in the usual manner through the cornea, and having punc- tured it, to retract the knife a little, so as to permit a portion of the aqueous humour to escape, in consequence of this the iris will fall into folds before the point of the knife, and by passing the knife through one of these folds a portion of iris can be cut out aud it will escape through the wound of the cornea with the aqueous hu- mour. This operation I have seen performed by Dr. Physick, but it is only practicable in particular cases, where the fold of the iris happens to be opposite the lucid part of the cornea. In general the cutting forceps are most convenient. Mr Charles Bell remarks that he had thought it pos- sible to restore sight by making an artificial pupil, in cases of opake cornea; what he considered possible I have seen accomplished in a variety of cases. Indeed the advantages of the operation would be limited to a very narrow boundary if it were only adapted to cases in which the pupil is obliterated, because this is a very rare case in comparison with opacities of the cornea. A portion of iris ought in most instances to be re- vol. i. r r 306 ELEMENTS OF SURGERY. moved, because a simple puncture or incision through it is apt to contract, and of course it becomes necessary to repeat the operation. Professor Scarpa has lately contrived a mode of form- ing artificial pupil which consists, not in making an aper- ture through the iris, but in separating the iris from the ciliary ligament. The patient being seated, and held as in the operation for cataract, a couching needle is to be introduced through the sclerotic coat, about two lines distant from the cornea; the needle enters on the side next to the external canthus, and its point is made to ad- vance as far as the upper and internal part of the mar- gin of the iris, that is, on the side next the nose. The instrument, is then made to pierce the upper part of the internal margin of the iris close to the ciliary ligament, until its point is just perceptible in the anterior chamber of the aqueous humour. As soon as the point of the nee- dle can be seen in the anterior chamber of the aqueous humour, it should be pressed upon the iris from above downwards, and from the internal towards the external angle; by this means a separation will be made of the iris at its margin, from the ciliary ligament and a black spot will be observed. The light can in this manner be transmitted to the retina. I have mentioned the operation, because sometimes the only lucid part of the cornea is its margin, and in such cases, Scarpa's operation would probably answer extremely well, but under common circumstances Dr. Physick's is vastly preferable, because the pupil can be made wherever it is requisite, and with as little pain and difficulty as possible.* • It may not be improper in this place to ascribe the invention of the artifi- cial pupil to Cheselden, his publication on the subject is contained in the Phil. Trans, for 1735. His mode of operating which was very bad, has lately been revived by Mr. Adams, oculist at Exeter in England—for the objections to it see Baron Wenzel. ELEMENTS OF SURGERY. 307 Mr. Saunders has recommended the use of Belladon- na to prevent the obliteration of the pupil, when the iris is inflamed: it produces a great dilatation of the pupil. Stramonium has been employed in this country with the view of dilating the pupil in certain cases, and would probably be equally effectual in this; indeed most of the narcotic plants possess the same property. ^ ULCERS OF THE CORNEA. These sometimes form in consequence of inflamma- tion, and sometimes an accidental injury ends in ulcera- tion. The application of lunar caustic is the proper re- medy. It is to be scraped to a point; secured in a quill, and then applied to the ulcer, and suddenly removed; the slough separates in a day or two, and the operation is to be repeated; the pain and intolerance of light gra- dually diminish, and the ulcer generally fills up and ci- catrizes. For more minute information on ulcers of the cornea, I refer to Wardrop's morbid anatomy of the hu- man eye. 30$ ELEMENTS OF SURGLIii. CHAPTER LV Fistula Lachrymalis. The tears secreted by the lachrymal gland after lu- bricating the eye, are taken up by the puncta lachryma- lia, and conveyed to the lachrymal sac, whence they pass through the ductus ad nasum into the nose. This ductus ad nasum, however, is liable like all other ca- nals in the body to stricture. Whenever in consequence of a stricture in this duct, the course of the tears into the nose is interrupted they accumulate in the sac which be- comes tumid, and upon being pressed they regurgitate and flow partly over the cheek, and partly through the nasal duct. The tumour is situated on one side of the root of the nose below the inner canthus of the eye. The tears are constantly overflowing the eye, because the sac being full the puncta can receive no more. To the dis- ease in this state the term fistula is improperly applied. The patient experiences but little inconvenience from it, except a constant watery eye; no pain and inflamma- mation exist. Eventually, however, the stricture becomes complete, the sac inflames and suppurates, and now a fistulous sore is formed which discharges tears mixed with mucus and pus. It is geuerally accompanied with inflammation of the eye, and often with caries of the os unguis. The puncta, in this stage are often obstructed, and no tears find their way into the sac, but all which are secreted pass over the eye-lids. In the first stage of the disease, which has been call- ed epiphora, and by Scarpa the puriform discharge of the eye-lids, while the lachrymal sac is entire, the only remedy necessary is to inject by means of a fine sy- ringe, called from its inventor AnePs, a stream of wrarm ELEMENTS OF SURGERY. 309 water through the puncta lachrymalia which will wash away any thickened mucus or similar obstruction. The sac should be kept empty by frequent pressure. Scarpa recommends in addition to this washing out of the " via lachrymalia," the use of an astringent ointment, to be ap- plied between the eyelids and upon the ball of the eye. He prefers the celebrated ophthalmic ointment of Janin. It is composed of the following ingredients; hogs-lard half an ounce, prepared tutty and armenian bole of each two drams, white precipitate (calx hydrargyri alba) a dram. Scarpa dilutes the ointment at its first applica- tion by adding hogs-lard. By the use of these remedies the disease has in many cases been prevented from ul- cerating and has been completely cured. Mr. Pott who condemns the use of Mr. Anel's probes which were intended to pass through the lachrymal punc- ta into the nose, recommends the employment of the sy- ringe; he found it, however, sometimes unsuccessful. Air. Ware's testimony is in favour of the syringe of Ancl; he injects warm water through the lower punctum and places a linger upon the upper one to prevent its es- cape. He repeats the operation four or five days in suc- cession. If he is unsuccessful in forcing any of the fluid into the nose, he makes use of lopieal blood-letting, from the angular vein, or by a leech applied near the lachrymal sac. He also varies the injection, aud tries the effect of a weak vitriolic or anodyne lotion. Mr. Ware has in some cases passed a fine gold probe through the punctum, when unable to force the fluid into the nose, and by gently insinuating this, he has over- come the obstruction, and immediately afterwards the injection has readily found its way through the ductus ad nasum. Mr. Ware remarks that " when an epiphora is occa- sioned by an acrimonious discharge from the sebaceous glands on the edges of the eye-lids, it must be evident, 310 ELEMENTS OF SURGEDY. that injections into the sac will be very insufficient to accomplish a cure, because the sac is not the seat of the disorder. The remedies that are employed must be di- rected, on the contrary, to the ciliary glands themselves, in order to correct the morbid secretion that is made by them; and for this purpose, I do not know any applica- tion that is so likely to prove effectual as the unguentum hydrargyri nitrati, of the new London Dispensatory, which should be used here in the same manner in which it is applied in common cases of the psorophthalmy. It will be proper to cleanse the eye-lids every morning, from the gum that collects on their edges during the night, with some soft unctuous application; and I usual- ly advise to apply to them, two or three times in the course of a day, a lotion composed of three grains of white vitriol, in two ounees of rose or elder-flower water." Mr. Ware recommends whenever collyria are applied, to substitute for linen compresses, eye-glasses, or to ap- ply the fluid by camel's hair pencils. In the second stage of the disease, where the fistulous sore exists, or where the inflamed state of the parts pre- cludes the hope of any other termination, a different mode of treatment becomes requisite. When the abscess of the sac has actually formed, it is best to open it with a lancet, because a puncture of this kind leaves a smaller scar than the sore formed by the absorbents. A probe should now be passed if possi- ble into the ductus ad nasum, if it enter readily a bougie should be introduced, of a conical form so as to dilate the canal at the part where the obstruction exists, and this bougie should be suffered to remain, and a superficial mild dressing applied to the sore. In some cases this simple plan succeeds effectually. If, however, a bougie cannot readily be passed, a silver style or short probe is to be substituted; the size and form of this instrument is represented in Fig. 17« The circular button on its ex- ELEMENTS OF SURGERY. 311 tremity may be covered with black sealing wax or court plaster; when this instrument is introduced, the patient must wear it for several months, care being taken to cleanse it twice or thrice a week, and to inject whenev- er it is removed, a stream of tepid water through the ca- nal. It might be supposed that the tears during this time would flow entirely over the cheek; but this is not the case; they pass by the sides of the probe and moisten the nostril. Very little inconvenience is sustained by the patient in wearing the style constructed by Mr. Ware, and it occasions no more deformity than a small black patch. In six weeks sometimes the obstruction will be permanently removed, but as it occasionally re- curs even when the style has been continued a greater length of time, I have been accustomed to direct its use for six months. Some of Mr. Ware's patients have worn it for years, all the tears passing by its side into the nose. Mr. Ware directs, if the disease has not yet occasioned an aperture in the lachrymal sac, or if this aperture be not situated in a right line with the longitudinal direc- tion of the nasal duct, a puncture to be made into the sac at a small distance from the juncture of the palpe- bral, and nearly in a line draw u horizontally from this juncture towards the nose, with a very narrow spear- pointed lancet. The orifice thus formed soon becomes fistulous round the style, and no irritation is experien- ced in the subsequent introductions of this instrument. When the ductus ad nasum is completely obliterated instead of any attempt to form a new passage in the old situation, it is the practice to perforate the os unguis. Mr. Pott used a trochar for this purpose, but an incon- venience occasionally follows the use of the trochar' the aperture closes up by the fragments of bone inflamin"- and reuniting; to obviate this, Mr. Hunter constructed an instrument like a shoemaker's punch, by which a t*1~' ELEMENTS OF SURGERY. circular piece of bone may be cut out completely, and then the aperture cannot again be closed. It is true that a dossil of lint, or a probe of lead, or a bougie, kept in the passage will prevent its reuniting, but if Mr. Hun- ter's plan be adopted there will be no need of this trou- ble. Mr. Ware recommends a nail-headed style to be worn in this case, as well as in those instances where the natural canal is to be dilated, but for this practice I think there can be no necessity. The operation of removing a portion of the os unguis is very readily performed. The only necessary caution says Mr. Pott, "is to apply whatever instrument is used so that it may pierce through that part of the bone which lies immediately behind the sacculus lachrymalis, and not to push too far up into the nose, for fear of injuring the os spongiosum behind, wiiile it breaks its way." Mr. Hunter recommends a piece of thin smooth horn to be passed up the nostril, to receive the circular punch, which is to be passed into the lachrymal sac and forced through the os unguis, till it comes in contact with the horn. When the perforation is completed, air passes out of the nose through the wound, and blood will flowr through the wound into the nostril. The external open- ing may now be dressed with adhesive plaster and suf- fered to heal immediately. If carious bone exist it will be separated by the absorbents, and should fungus arise from the wound it is to be destroyed by caustic. Mr. Ware's plan of introducing the style through the ductus ad nasum, and of continuing its use for a great length of time supercedes the use of this latter operation in all but a few rare instances in which there is complete oblitera- tion of the nasal duct. He is entitled to the greatest credit for his improvements in the treatment of this dis- ease. elements of surgery. 313 CHAPTER LVI. i Of Cataract. By this term is designated an opacity of the chrystal- line lens or its capsule, or of both. The pupil of the eye Which is naturally perfectly black, becomes gray or white, except in some rare cases where it has a clark co- lour; the colour, however, is always distinguishable from the deep black of the pupil in a sound eye. In its commencement it occasions a weakness or dimness of sight, which increases until vision is totally destroyed. In general, cataraet occurs in advanced life, seldom com- mencing before the age of forty; in some cases, how- ever, it begins much sooner, and is in some instances congenital; in congenital cataract the capsule (according to Wenzel and Saunders) is generally opake and the lens fluid and milky. The causes of cataract are not very easily ascertained. Baron Wenzel found it most frequent among persons ex- posed to the light of strong fires, as blacksmiths, glass- blowers, &c. It now and then happens from external violence. The disease generally commences without pain; the first symptom is commonly an appearance of motes, specks, cobwebs, or insects floating before the eye; the patient attempts to remove them, but without effect. The pupil at this time does not generally ev ince any morbid appearance, but as the disease progresses, a settled mist or cloud obscures every object—vision is greatly im- paired and a turbid whitish appearance of the pupil be- gins to be observed. In some cases these symptoms pro- gress very slowly, and in others the entire obfuscation of the lens takes place in a few weeks. When the dis Vol. i. s s 314 elements of surgery. ease is fully formed the patient is generally able to dis • cern the situation of a strong light; can distinguish day from night; or perhaps count the windows in a room, but is unable to discern most objects, and in some cases even this faint degree of vision does not exist. In the incipient stage of the disease it is proper to em- ploy certain remedies which are occasionally useful in preventing its formation. Bleeding, purging, and a low diet, are to be recommended; mercury has been supposed useful; setons, issues, and blisters, are also to be employ- ed. In some cases, more especially where the disease has resulted from external injuries, these remedies have been found successful, and the opacity has been removed by absorption; but in general no such favourable termi- nation is to be expected, and Wenzel declares that " in- ternal remedies either of the mercurial or of any other kind, are inadequate to the cure of this disorder, and equally so whether opacity be in the chrystalline or in the capsule, whether incipient or advanced." This is not quite correct; I have seen one patient in whom the lens or its capsule was universally opake and the pupil perfectly white; and this opacity subsided in the course of four or five months; the chief remedies employed were bleeding, purges, and mercury; how far they were ser- viceable I am not able to determine, for Pott and Hey both remark that cataract from external violence some- times subsides spontaneously—the case alluded to was consequent to a wound of the eye. Mr. Ware believes in the occasional absorption of the opake chrystalline, and recommends to expedite it, by the application of a drop or two of aether to the ball of the eye once or twice a day, together with friction over the eye-lid with a finger smeared with mercurial oint- ment. Little confidence is to be placed in such remedies, and it is now very generally conceded that the only me- thod of restoring sight to persons afflicted with cataract, ELEMENTS OF SURGERY. 315 is to remove the opake chrystalline from the axis of vi- sion ; this may be done either by extracting it, or by depressing it to the bottom of the eye. Both of these operations are performed by surgeons of the present day, and each has powerful advocates among the most re- spectable members of the medical profession. Before comparing the merits of the two operations, it will be proper to enquire what cases of cataract promise to terminate successfully. Scarpa oberves, "It is easy to determine whether an operation can be performed with a prospect of success or not. A favourable issue may be expected whenever the cataract is simple, or without any other disease of the eye-ball; in a subject not quite unhealthy or decrepid, and in whom the opa- city of the chrystalline humour has been gradually form- ed without having originated from any external violence, or habitual ophthalmia, especially the internal; where there has not been frequent pain in the head, eye-ball, and supercilium; where the pupil notwithstanding the cataract, lias preserved its free and quick motion, as well as its circular figure in different degrees of light; and lastly, where notwithstanding the opacity of the chrys- talline lens, the patient retains the powrer, not only of distinguishing light from darkness, but also of perceiv- ing vivid colours, and the principal outlines of bodies which are presented to him, and where the pupil has that degree of dilatation which it is usually found to have in a moderate light." When the pupil does not contract and dilate in va- rious degrees of light, there is reason to apprehend gut- ta serena (paralysis of the optic nerve and retina) but in some cases of gutta serena, even in both eyes this con- tractility of the iris exists, and on the other hand, cases have occurred where no motion could be observed in the pupil, in which, nevertheless, the operation of extraction has proved the retina to possess its power of vision as 316 ELEMENTS OF SURGERY. usual; the probable cause of the immobility of the pupil in these cases, is adhesion between the posterior surface of the iris and the anterior portion of the capsule of the chrystalline lens. These are to be considered however very rare exceptions to a general rule. In distinguishing gutta serena from cataract the co- lour of the pupil is to be considered; it is black in the former disease, and turbid and lighter coloured in cata- ract ; but Wenzel has met w ith black cataracts, in which scarcely any chango could be detected in the colour of the pupil. Both Wenzel and his commentator Mr. Ware believe it possible to distinguish the blackness of a cataract from the natural blackness of the pupil. He Haen and Van Swietcn have been mistaken, yet they wTere not pro- fessing oculists. Mr. Ware decides boldly that " it is a rule as certain as almost any in surgery that when an eye in a state of blindness, is accompanied with a clear black pupil which is incapable of varying its size ac- cording to the degree of light to which the eye is ex- posed ; this blindness is produced by a defect of sensi- bility in the immediate organ of vision, and removable only by the application of proper stimuli to rouse it again to its natural action." To ascertain with precision the nature and consistence of a cataract by examination is perhaps impossible. Scarpa says "all that has been hitherto written and taught upon this subject, has not that degree of certain- ty which can serve as a guide in practice, and the most experienced oculist of the present day is not able to de- termine with precision what the nature and consistence of the cataract is, upon which he proposes to operate, nor whether the capsule be yet transparent or not, although the lens be evidently opake. For it is an indisputable fact, that the capsule sometimes preserves its transpa- rency when the lens does not. The want of accurate ELEMENTS OF SURGERY. 317 notions however, upon this subject does not materially influence the success of the operation, as the surgeon ought in every case to be prepared to employ such means as the particular species of cataract which pre- sents itself to him, may require during the performance of the operation, whether hard or soft, accompanied by opacity of the capsule which invests it, or not. The firm chrystalline cataract undoubtedly admits of being more easily removed by the needle from the axis of vision than any other; and does not rise again to its former place, if the surgeon in removing it from the pupil, use the precaution of burying it in the vitreous humour. The soft, the milky, or the membranous cataract, how- ever, when met with in the operation, may be also re- moved from the pupil, effused or lacerated with the same needle, without the necessity of introducing any other instrument into the eye." In the next place it will be proper to compare the ad- vantages of extraction and depression as remedies for cataract. Scarpa says truly that " in the warmth of dis- cussion the advantages of the one, and the disadvantages of the other, have been exaggerated by both parties." The most ancient of these operations is depression or couching. The extraction was not performed till near the conclusion of the seventeenth century. Freytagius Lotterius, and Wenzel, are the principal surgeons con- cerned in contriving and perfecting the operation of ex- traction. The last named oculist had wonderful suc- cess in the latter part of his life (though he confesses that he spoiled a "hat full of eyes" before he learned how to operate) and his son who succeeded him, was also extremely celebrated. He remarks in his treatise that " the accidents which are charged upon the operation of extraction may be reduced to the eight following ;-first, the staphyloma ;-secondly, pain ;-thirdly, the discharge of the vitreous humour ;-fourthly, the irregularity of the 318 ELEMENTS OF SURGERY. pupil ;-fifthly, the deformity of the cicatrix ;-sixthly, the closure of the pupil ;-seventhly, the secondary cataract; and eightly, the section of the iris. First. With regard to the staphyloma; Wenzel re- marks "that the mode in which the cornea is divided most commonly prevents this accident, by hindering the iris from coming forwards. But if such an accident should at any time happen, notwithstanding this care to prevent it, it may be reduced by merely rubbing the eye- lids; and it does not occasion those ill effects which some authors have dreaded. Secondly. The unavoidable pain that attends the ope- ration of extraction is to be moderated, as in other ope- rations hy general remedies. It is, however, notwith- standing the assertion of a late author, less severe than that which is produced by depression. Much has been said respecting the comparative pain of the two operations: I do not consider it, an object of great magnitude to decide this contest, because it must be conceded on all hands that if an important advantage is to be gained by a temporary addition to the sufferings of the patient, this slight evil should not enter into com- petition with a permanent benefit; and it is notorious to all who are conversant with the subject, that neither couching or extraction, are to be considered as very painful operations. Notwithstanding this, from what I have seen, and I have seen very numerous cases where extraction has been performed, and some cases of couch- in°- I am very decidedly of opinion that couching is the more painful operation. One patient in particular 1 re- collect who had been couched, and whose cataract had resumed its situation, when the operation of extraction was finished (which was performed on the other eye) exclaimed, "is it possible the operation is over? it was not half so severe as the couching." I have never heard a single patient complain of much pain during the ELEMENTS OF SURGERY. 319 extraction of a cataract, but have often heard them ex- press great astonishment at having suffered so little. Thirdly. The escape of the vitreous humour if the operation be properly performed, will seldom take place. In some cases, however, notwithstanding every caution, portions of this fluid will escape. Wenzel thinks that although this is a slight evil, yet the clear perception of objects is sometimes diminished by this accident; but I have known a very considerable quantity of vitreous humour lost in several instances, in which not the slight- est inconvenience resulted, but the cure was perfected as well as in the most successful cases. This is there- fore no objection to the operation of extraction; first, because the escape of vitreous humour can generally be prevented; and secondly, if from its unusual fluidity, or any other cause, a portion of it should escape, no harm results from its loss. Fourthly. An irregularity of the form of the pupil is an occasional consequence of the extraction of a cata- ract,—but I would observe that it is a very rare acci- dent, and of little moment when it occurs. The shape of the pupil is of no great consequence, and though I do not agree with Wenzel that it becomes an advantage by enlarging the aperture through which the rays of light are to pass, yet I do maintain that patients see as well in whom some irregularity of the pupil exists, as they in whose eyes the pupil is a perfect circle. Fifthly. The cicatrix of the cornea. "If the incision be made with one instrument and one stroke, if it be ' near the margin of the sclerotica and large enough to allow the opake chrystalline to pass through it without violence; in this case the cicatrix will be scarcely visi- ble and will not at all obstruct the rays of light in their passage to the retina." When the incision is made ori- ginally too small and is enlarged by means of scissars the cicatrix becomes opake, but if it be near the sclero- 320 ELEMENTS OF SURGERY. tica it does not, even if opake, interfere with vision. lit general it is impossible to discern a vestige of the wound made in the cornea. Sixthly. A total closure of the pupil. This I never saw, and Wenzel asserts that it is much more frequent after couching: certainly the iris is often scratched and injured by the needle used in the latter operation, and of course is liable to inflammation from which this closure generally arises. Seventhly. A secondary cataract, or opacity of the capsule of the lens. This happens both after extraction and couching, and I know not which it most frequently succeeds, Wenzel of course says it is most common af- ter couching. One thing is certain, that if the capsule be found opake it is easily removed at the same time with the lens; if it become opake afterward, a repetition of the section of the cornea will readily enable the sur- geon to extract it. Eighthly. A wound of the iris by the edge of the knife. This accident it is generally in the power of the surgeon to prevent. It commonly arises (except in awk- ward hands) from an escape of a small portion of aque- ous humour at the puncture made by the knife in passing though the cornea; whenever the iris is found floating before the edge of the knife, as in (Fig. 11.) a gentle friction should be made upon the cornea with one finger of the hand which is at liberty, and the iris in this way becomes disengaged from the edge of the knife. Wheth- er the friction acts by stimulating the iris to contract or whether by pressure on the cornea the iris is stretch- ed at its margin, and thus mechanically disengaged, is not easily ascertained. Mr. C. Bell (without much ex- perience in the operation) recommends pressure, and gives what he calls "an intelligible reason" for it. The fact is that friction succeeds immediately in reducing the ELEMENTS OF SURGERY. 321 iris to a situation behind the knife, and how this is ef- fected is of no sort of consequence. Mr. Hey for whose judgment in common with the me- dical world I entertain a very high respect, differs with Ware and Wenzel, and prefers the operation of couch- ing to extraction. Scarpa who has attended with great diligence to the subject, prefers couching; and to such authority great deference is unquestionably to be paid. Kach of these gentlemen has invented a couching needle different from that in common use, and never perform any other operation than depression. Scarpa has entered into no defence of couching but roundly asserts that "observation and experience, the great teachers in all things, seem to have decided in fa- vour of the ancient method of treating the cataract, or that by depression." Mr. Hey on the contrary, enters into a laboured vindication of the operation, against the attack of Baron Wenzel. The Baron alleges against couching many evils which probably in the hands of Scarpa or Hey, never have occurred, and like all other disputants has urged his objections in language too strong and general. The consequences to be dreaded from couching he states under eight distinct heads; first, great pain at the time of the operation and subsequently to it; second, vo- miting from a wound of the ciliary nerves, occasioning collections of matter; third, pain and suppuration of the eye from puncturing the retina; fourth, violent loug con- tinued pain in the eye, sometimes during life; fifth, bleeding into the cavity of the eye occasioning suppura- tion ; sixth, the impossibility of depressing fluid or mil- ky cataracts; seventh, the rising again of the lens; eighth, wounding the ciliary processes. Enlarging on these ideas Wenzel very strongly contends in favour of extraction, and Mr. Hey taking up each of the argu- ments very ingeniously endeavours to refute them, and vol. i. t t 322 ELEMENTS OF SURGERY. states that the pain in couching is very trifling ;—that the vomiting seldom occurs, and when it does, is remov- ed by an opiate;—that suppuration of the eye —that the long continued pain and bleeding within the eye, he ne- ver has met with in his practice. The milky cataract Mr. Hey declares "has in some respects the advantage over a hard one, as the former is less apt to adhere to the iris, and consequently there is less risk of deranging the ciliary processes or their in- vesting membrana nigra, by breaking down a soft cata- ract than by removing a hard one." Mr. Hey confesses, however, that "the softness of the cataract generally re- quires a repetition of the operation but does not prevent the patient from receiving a cure." The objection that the cataract if depressed is liable to rise again Mr. Hey admits to be " true, but of little consequence. A repe- tition of the operation is not in this case always necessa- ry, as the chrystalline will sometimes spontaneously sub- side and disappear, and when it does not, a repetition of the operation has never failed within the compass of his experience of being attended with success." The wound of the ciliary processes Mr Hey prevents by a change in the shape of the needle which instead of being spear-pointed should be square. Mr. Hey further states that the opake capsule though it cannot be depressed may be so lacerated by the nee- dle, as soon to be absorbed. Mr. Hey does not be- lieve with the Baron that a closure of the pupil or an opacity of the capsule of the lens, are to be considered as solid objections against couching. Mr. Hey when he quits his defensive attitude, and at tacks the operation of extraction by replying to JBaron Wenzel and Mr. Ware, in their account of its ad van tages, appears by no means a powerful opponent. Uni- ting with Mr. Hey in the sentiment with which he clo- ses his chapter upon cataract, I can declare with truth ELEMENTS OF SURGERY. 323 my wish "that that mode of operating may prevail which is most beneficial to the afflicted." I have no hesitation in deciding from what I have seen and read, and from having myself performed the operation (though not fre- quently) that extraction in a great majority of cases, ought to be performed in preference to couching, and I have no doubt that its advocates would be much more numerous, if the operation were as easily performed, for the greatest advantage which I conceive couching to possess is the facility with which it is done; it is in fact an operation, requiring very little dexterity or science. I shall describe both operations and endeavour to state the cases in which couching may with propriety be em- ployed. 324 ELEMENTS OF SURGERY. CHAPTER LYI1. Of Extraction. It will generally be proper that the patient for a week before the operation be confined to a low diet—he should be free from catarrh and other diseases—coughing, sneezing, or vomiting would prove extremely pernicious after the operation. The seasons to be preferred are the spring and fall, when the weather is settled and mild. The instruments necessary in the operation of extrac- tion are a knife for dividing the cornea; the one to be preferred is the instrument invented by the elder Wen- zel. "It resembles the common lancet employed in bleeding, except that its blade is a little longer and not quite so broad. Its edges are strait. The blade is an inch and a half long and a quarter of an inch broad, in the widest part of it, which is at the base. From hence it gradually becomes narrower towards the point, so that this breadth of a quarter of an inch extends only to the space of about one third of an inch from the base, and for the space of half an inch from the point, it is no more than one eighth of an inch broad." One edge is sharp through the whole length of the blade, at the distance of a quarter of an inch from the base this lower edge has a slight projection. The up- per edge is divided into three portions for the space of five sixths of an inch from the basis; this edge is blunt and very little flattened. For the space of half an inch or rather six lines and a half* further towards the point it is blunt and rounded, although very thin. The extremity of this edge to the extent of one eighth of an inch from the • A line is the twelfth part of an inch. ELEMENTS OF SURGERY. 325 point, is keen like the lower edge, in order to facilitate ♦ he conveyance of the instrument through the cornea— the handle is octangular. The knife is represented in Fig. 14. I have described it particularly, because much of the success of the operation depends upon the perfection of the instrument. Mr. Ware uses a knife very little dif- ferent from WenzePs; it is rather wider near the point, in order that the edge may quickly get below the infe- rior margin of the pupil and thus avoid wounding the iris. It has been customary in operating on the eye to make use of a contrivance called a speculum to keep the eye motionless ; a variety of specula have been constructed, but in the opinion of Baron Wenzel they are useless. In addition to the knife, a curette, or small scoop of silver or gold, and a curved needle of steel which are gene- rally fixed to one handle (Fig. 15.);—a small steel hook (Fig. 13.);—and a pair of small forceps (Fig. 16.) are all the instruments required for the operation. Instead of the forceps copied from Wenzel, a more convenient form, is that delineated (Fig. 4.) the extremities arc to be flat, and their surfaces of contact when closed about the fourth of an inch. OPERATION. The patient is to be seated in a low chair before a mo- derate light which strikes the eye obliquely. Baron Wenzel directs the operator to proceed in the following manner. " The sound eye being covered with a compress re- tained by a bandage, an assistant, placed behind, must hold the patient's head, and support it on his breast. With the fore-finger of the hand that is at liberty, he is then to raise the upper lid of the eye to be operated upon, 326 ELEMENTS OF SURGERY. and gently to press the tarsus, with the extremity of the finger, against the upper edge of the orbit. In order to assist this arrangement, and properly to fix the upper lid, the assistant should take care to draw up the skin over the orbit, and strongly to fold the teguments that support the eye-browr. By this method, the eye will be entirely uncovered, an undue pressure upon it will be avoided, the fingers of the assistant will not interfere with those of the operator, and the eye-lid will be so fixed as to be incapable of any motion. " The operator is to be seated on a chair, a little higher than that of the patient. The eyes naturally turning towards the light, he is to place the head of the patient obliquely to a window; so that the eye to be operated upon may be inclined towards the outer angle of the orbit. This position of the eye will enable the operator to bring out the knife, on the inner side of the cornea, opposite to the part where it pierces this tunic, more exactly than he would otherwise be able to do. The operator is to rest his right foot on a stool, placed near the patient, that his knee may be raised high enough to support the right elbow, and to bring the hand with which he holds the knife, to a level with the eye on which he is to operate: (this direction I think unne- cessary if the operator have a steady hand.) He is then to take the cornea knife in his right hand, if it be the left eye on which he is to operate, and, vice versa, in the left hand, if it be the right eye. The knife is to be held like a pen in writing, and his hand is to rest stea- dily on the outer side of the eye, with the little finger, separated a little from the rest, on the edge of the orbit. In this position he is to wait, without any hurry to begiu the incision, until the eye w hich is usually very much agitated by the preparations for the operation, becomes perfectly still. This always takes place within a few ELEMENTS OF SURGERY. 327 seconds of time ; and, therefore, as I have already fully expressed myself on this subject, every instrument invent- ed to fix it is useless. " When the eye is still and so turned towards the outer angle of the orbit, that the inner and inferior part of the cornea, through which the point of the instrument is to come out, may be distinctly seen, the operator is to plunge the knife into the upper and outer part of the tunic, a quarter of a line distant from the sclerotica, in such a direction, that it may pass obliquely from above, down- wards, parallel to the plane of the iris.* At the same time, the operator must depress the lower lid with his fore and middle fingers, which are to be kept a little distant one from the other, and must take the greatest care to avoid all pressure on the globe, which is to be left perfectly free, as the surest way to diminish its pow- er of moving.f " When the point of the knife has proceeded so far as to be opposite to the pupil, it is to be dipped into this aperture, by a slight motion of the hand forward, in order to puncture the capsule of the crystalline :$ and then by another slight motion, contrary to the former, it must be withdrawn from the pupil, and, passing through the anterior chamber, must be brought out near the inferior part of the cornea, a little inclined to the inner angle, and at the same distance from the sclerotica, as when it pierced the cornea above. If the knife has been well- directed, and the fore and middle fingers of the hand op- posite to that which holds the instrument, have been pro- • I am convinced that the horizontal section is more convenient!} made .than the oblique one here directed, and is equally proper; Fig-. 1. marks the in- cision made when the upper edge of the knife passes through the centre of the pupil horizontally. | Mr. Ware very properly condemns this direction, and advises the eye at this time to be moderately pressed, which certainly serves to fix it, and prevent its motion. $ Baron Wenzel's practice in this particular, is not to be imitated by any but experienced operators. 328 ELEMENTS OF SURGERY. perly applied, the section of the cornea, thus completed, will be found sufficiently large ; its shape will be semi- circular ; and it will be quite near enough to the margin of the sclerotica." (Wenzel.) When the iris is unusually convex, and, in making the section of the cornea becomes entangled before the knife, the cornea is to be rubbed downward with the finger, which disengages it. A fear of wounding the iris, should never induce the operator to make the section of the cor- nea at too great a distance from the sclerotica, because the section will in that case be too small to allow the lens to escape. While the section of the cornea is progressing, and the point of the knife has passed out at the side opposite to the part at which it entered, the assistant lets the up- per eye-lid drop, and all pressure is immediately taken off. The next part of the operation consists in puncturing the capsule of the chrystalline lens, for I believe few surgeons have dexterity and confidence enough to do it, generally, with the cornea knife. The best mode of ef- fecting this will be to introduce the needle (Fig. 15.) through the wound in the cornea, into the pupil, and move it gently, but freely and quickly, in all directions; by this manoeuvre the anterior portion of the capsule will be lacerated, and a gentle degree of pressure being made upon the eye, the pupil is observed gradually to enlarge, and one edge of the lens is observed escaping through it; all pressure is to be immediately removed, and the opake chrystalline escapes. Sometimes it is necessary to assist its escape through the aperture in the cornea, by the use of the needle, or scoop, and any portion of opake glutinous matter which remains behind are to be carefully removed by the curette. If the capsule be not opake the pupil will now be observed to have regained its natural blackness, ELEMENTS OF SURGERY. 329 and the patient will discover the surrounding objects. In a majority of the cataracts which I have seen extract- ed, the centre has been firm and dense, but portions of the external part have been soft and glutinous, and have remained after the extraction of the central portion. If it be inconvenient to remove them all, it will be bet- ter to wait for their absorption than to augment the danger of inflammation by protracting the operation too long. Sometimes the cataract, according to Wenzel, ad- heres, and must be separated by the needle from its ad- hesions, this is in general readily effected by inserting the needle in the lens, and moving it gently in different directions. If the capsule of the lens be found opake, it may now be extracted, by means of a pair of small forceps; those recommended by Wenzel, (Fig. 16) are much too clumsy, they cannot from their bulk, be readily opened and shut in the wound of the cornea, it is more convenient to have forceps resembling those delineated in Fig. 4. The anterior portion of the capsule is most frequently opake, and sometimes considerably thickened and indu- rated ; when this is the case it comes out at once ; if it be torn however, the fragments are to be removed, and dur- ing this part of the operation, great care must be taken to avoid the escape of the vitreous humour; the eye should not be kept open long at a time, and the attempts to extract the portions of opake capsule, should be repeat- ed as often as necessary, but not continue more than a minute at a time, and the eye in the intervals should be covered with a small compress of fine linen wet with clear cold water. Dr. Physick, has in some cases w here the capsule was evidently opake extracted it first with the forceps ; when this is done the lens descends below its usual situation, but its falling to the bottom of the eye " does not appear vol. I. u n 330 ELEMENTS OF SURGERY. to be quite correct; it was in the cases alluded to, very easily extracted with a curved needle, or small hook, (Fig. 13.) this hook is occasionally useful in removing portions of the capsule as well as of the lens and should always be at hand. The lens does, however, in a diseased state of the vitreous humour, descend in some cases to the inferior part of the eye, and in these cases pressure can not be used, and it must be extracted with the hook. If the capsule though lucid at the time of the opera- tion should become subsequently opake, forming what is called secondary cataract, the section of the cornea is to be repeated and the opake membrane removed. The subsequent treatment consists in preventing inflammation. The patient should lie on his back for eight or ten days, the room being somewhat darkened: the eye requires no dressing but a compress loosely applied : the hands ought in every instance to be secured to the sides of the bed by means of tapes, in such a manner as to prevent their reaching so high as the head, persons waking, are very apt to rub their eyes, and sight has been destroy- ed by such accidents, the caution just given ought there- fore never to be neglected; a low diet, and if necessary from the accession of fever, bleeding and purging ought to be directed. For much useful information on the present subject, the reader is referred to the writings of Mr. Ware, and Baron Wenzel. ELEMENTS OF SURGERY. 331 CHAPTER LVIII. Of Couching. It has already been mentioned, that this operation consists in depressing the opake chrystalline lens, and removing it from the axis of vision. The couching needles generally employed are those of Saunders, fig. 5; of Scarpa, fig. 6; and of Hey, fig. 7- No very particu- lar description need be given. Scarpa's needle is, in my opinion, to be preferred; it possesses firmness enough to enter the eye without danger of its breaking, and has a point somewhat curved. The curved extremity is sharp at the edges, and polished and flat upon its convex dor- sum ; there is a mark on the side of the handle which cor- responds to the convexity of the point. It should be made rather shorter than Scarpa directs. I shall quote the description given by this celebrated oculist of his operation. OPERATION. "Every thing being arranged for performing the ope- ration, the surgeon should place his patient on a low seat, on the side of a window which has a northern as- pect, so that the light coming from it may only fall upon the eye which is to be operated on laterally. The pa- tient's other eye being covered, although affected with cataract, the surgeon ought to place himself directly op- posite the patient, upon a seat of such a height, that when he is prepared to operate, his mouth shall be on a level with the patient's eye. And, in order to give his hand a greater degree of steadiness in the several mo- tions which the depressions of the cataract require, the elbow corresponding to this hand should be supported 33aJ ELEMENTS OF SURGERY. upon the knee of the same side, which for this purpose he should raise sufficiently by resting his foot upon a stool, and according to circumstances also, by placing a small hard pillow upon his knee. An able assistant si- tuated behind the patient, with one hand fixed upon the chin, should support the patient's head against his breast, and with the other placed on the forehead, gently raise the upper eye-lid by means of Pellier's elevator, careful- ly observing to gather the eye-lid against the arch of the orbit, without pressing upon the globe of the eye. "Supposing then the eye to be operated on is the left, the surgeon taking the curved needle in his right hand, as he would a writing pen, with the convexity of the hook forwards, the point back, and the handle in a di- rection parallel to the patient's left temple ; should rest his fingers upon the temple, and boldly perforate the eye- ball in its external angle, at rather more than a line from the union of the cornea and sclerotica, a little below the transverse diameter of the pupil, gradually moving the extremity of the handle of the needle from behind for- wards from the patient's left temple, and consequently giving the whole instrument a curved motion, until its bent point has entirely penetrated the eye-ball; which is effected with the greatest readiness and ease. The ope- rator should then conduct the convexity of the needle upon the summit of the opake crystalline, and by pressing upon it from above downwards, cause it to descend a lit- tle, carefully passing the curved point at the same time be- tween the corpus eiliare and the capsule of the crystalline lens, until it be visible before the pupil, between the an- terior convexity of the capsule of the lens and the iris. Having done this he should cautiously push the hook with its point turned backwards towards the internal angle of the eye, passing it horizontally between the posterior surface of the iris, and the anterior convexity of the capsule, until the point of the needle has arrived ELEMENTS OF SURGERY. 333 as near the margin of the crystalline and capsule as pos- sible, which is next the internal angle of the eye, and consequently beyond the centre of the opake lens. The operator then inclining the handle of the instrument more towards himself, should press the curved point of it deep- ly into the anterior convexity of the capsule, and sub- stance of the opake crystalline, and by moving it in the arc of a circle, should lacerate the anterior convexity of the capsule extensively, remove the cataract from the axis of vision, and lodge it deeply in the v itreous humour, leav- ing the pupil perfectly round, black, and free from every obstacle to the vision. The needle being retained in this position for a short time, if no portion of opake mem- brane appear behind the pupil, which would require the point of the instrument to be turned towards it, in order to remove such obstacle, (for with respect to the crystal- line, depressed in the manner now described, it never rises again)' the surgeon should give the instrument a small degree of rotatory motion, in order to disentangle it easily from the depressed cataract, and should with- draw it from the eye in a direction opposite to that in which it had been introduced, that is greatly inclining and turning the handle towards the patient's left tem- ple. " In every species of cataract, with considerable opa- city and density of the anterifor hemisphere of the cap- sule of the crystalline, the surgeon may very easily know during the operation, whether the curved point of the needle, insinuated between the corpus ciliare and the cap- sule, is exposed between the pupil and the anterior he- misphere of that membrane; or, whether having pene- trated into the membranous sac of the crystalline, it has only advanced between the anterior hemisphere of the capsule and the opake lens. But when the capsule, not- withstanding the opacity of the crystalline lens, pre- serves in a great measure, or entirely, its transparency, 334 ELEMENTS OF SURGERY. it is an easy matter for a young surgeon, not sufficiently conversant with this operation, to commit an error, and one of great importance, that is, to remove the cataract from the axis of vision, and lodge it in the vitreous hu- mour, leaving the anterior convexity of the capsule un- touched, which afterwards gives rise to the secondary membranous cataract. "To avoid this serious inconvenience, every operator should be particularly careful to satisfy himself before making any movement with the point of the needle for depressing the cataract, that the curved extremity of the instrument is really, and not apparently, situated between the pupil and the anterior portion of the capsule, of which he will be convinced by the degree of light which the convexity of the hook presents to him, and the faci- lity which he finds in pushing it forwards through the pupil towards the anterior chamber of the aqueous hu- mour, and in moving it horizontally between the iris and and anterior hemisphere of the capsule. In the oppo- site case he may be certain that the curved point is with- in the membranous sac of the chrystalline, by observing that the extremity of the needle is obscured and covered by a more or less transparent veil; that he meets with some resistance in pushing it through the pupil into the anterior chamber of the aqueous humour; and that in doing it, this membranous veil which covers the hook is elevated towards the pupil, and lastly, that the point of the needle is with difficulty conducted horizontally be- tween the iris and the cataract, from the external to- wards the internal angle of the eye. "The surgeon will remedy this inconvenience, by giving a slight rotatory motion to the needle, by which the point being forwards will pass through the anterior convexity of the capsule opposite the pupil; the point of the instrument being then turned backw ards again, should be passed horizontally between the iris and the anterior ELEMENTS OF SURGERY. 339 hemisphere of the capsule towards the internal angle of the eye, and having reached this part should be boldly plunged into the capsule, and the substance of the opake lens, in order to lacerate the former extensively, and to carry the latter deeply into the vitreous humour out of the axis of vision, and thus complete the operation. "When, without observing this precept, the opake lens is removed, or, more strictly speaking, enucleated from its capsule and lodged in the vitreous humour; and the anterior convexity of this membrane being left en- tire, is slightly opake, the pupil will appear black, and so free from obstruction to the light as easily to deceive the young surgeon, and induce him to believe that the operation has been properly executed. But persons ex- perienced in this part of surgery, will instantly perceive that the pupil under such circumstances, has not that just and perfect degree of blackness which it ought to have, and that this slight dimness is caused by an im- perfectly transparent membranous veil, placed between the pupil and the bottom of the eye, which when suffered to remain, never fails, in process of time, to give rise to the secondary membranous cataract. In this case, the expert operator having depressed the opake lens, should immediately turn the curved point of the needle forward, and pass it through the pupil into the anterior chamber of the aqueous humour, in order to perforate this semi- transparent membranous veil with the greatest certainty; then turning the point of the needle backwards and making it pass as far as possible between the posterior surface of the iris and this membrane, should press the point of the instrument into it and lacerate it from be- fore backwards, making a movement as if he had to de- press the lens again. In doing this he will have the satisfaction to see the pupil assume the deep black co- lour of velvet, and a degree of clearness which it had 336 ELEMENTS OF SURGERY. not before, although the opake lens had been completely removed from the axis of vision. "Hitherto I have supposed the cataract to be of a firm consistence, and to resist the pressure of the needle. But if the operator should meet with a fluid cataract, the mil- ky for instance, which is not an unfrequent occurrence, when he has passed the needle between the corpus ci- liare and the capsule, until it appears uncovered be- tween the pupil and the anterior hemisphere of the mem- branous sac of the chrystalline lens, and the curved point has been cautiously advanced between the iris and the margin of the capsule, nearest the internal angle of the eye; at the moment that the point of the needle is deeply pressed into the capsule and cataract, a whitish milky fluid will be seen to issue from the capsule, which extending itself in the form of a cloud or smoke, will be diffused through both the chambers of the aqueous hu- mour, and obscure the pupil and the whole of the eye. The surgeon should not on this account lose his confi- dence, but, guided by his anatomical knowledge, should make the small hook describe the arc of a circle from the internal towards the external angle of the eye, and from before backwards, as if he were depressing a solid cata- ract, with a view of lacerating as much as possible, the anterior hemisphere of the capsule, upon which the fa- vourable success of the operation principally depends, not only in this, but in every other species of cataract. For as to the effusion of the milky fluid into the cham- bers of the aqueous humour, it disappears spontaneous- ly a few days after the operation, and permits the pupil and the whole of the eye to resume their former natural brightness. "The method of operating which the surgeon should employ will be little different from this, if, during its performance, he should meet with a soft or cheesy cataract. The anterior convexity of the capsule should be lacerated as much as possible opposite the pupil, so ELEMENTS OF SURGERY. 337 that the opening may equal the diameter of the pupil in its ordinary dilatation. And with respect to the pulpy substance of the cataract, which, in such cases, re- mains behind, partly diffused in the aqueous humour, and partly swimming beyond the pupil, all that is necessary, is to divide the most tenacious parts of that substance, that they may be more easily dissolved in the aqueous humour, and to push those molecular of the caseous substance of the chrystalline, which cannot be sufficiently divided, through the pupil into the anterior chamber of the aqueous humour, in order that they may not be carried opposite the pupil, but being situated at the bottom of the anterior chamber, may be gradually dissolved and absorbed without obstructing the sight.' (Scarpa) vol. r. xx ELEMENTS OF SURGERY. CHAPTER LIX. Of Congenital Cataract. The late Mr. Saunders of London instituted an infir- mary for the reception of patients afflicted with diseases of the eyes—he lived but a few years after its founda- tion, long enough however, to be very useful as sur- geon to the establishment, and a small posthumous vo- lume published in 1811 contains a number of highly in- teresting remarks on various affections of this important organ. The following observations on congenital cata- ract are extracted principally from his writings. The causes of congenital cataract are unknown: it appears sometimes in several of the same family. Mr. Saunders saw sixty cases of the disease between June 1806 and December 1809? so that it is by no means un- frequent. He relates many cases where several chil- dren of the same parents were born blind. The opacity is generally seated in the capsule; the lens being absorbed. Sometimest he lens is opake, and solid or fluid as in adults. Mr. Saunders found that the only treatment necessary, was to perforate the centre of the capsule, and if a permanent aperture was made in that membrane, the lens if it existed was subsequently absorbed. Children affected with the disease possess various de- gress of vision. Some indistinctly see external objects. others can only discern bright colours or vivid lights. If the privation of vision be nearly complete, volition for want of an external object to attract these organs, is not exercised over the muscles belonging to them, and their ELEMENTS OF SURGERY. 339 actions are not associated, but the eye rolls here and there with rapidity, and trembles as it moves. The excessive mobility of the eye, the unsteadiness of the little patient, the small field for the operation, and the flexibility of the opake capsule, are the difficulties with which the surgeon has to contend. Mr. Saunders overcame thein by fixing the eye-ball with a speculum,- controlling the patient, dilating the pupil with belladon- na, and by using a diminutive needle armed with a cut- ting edge from its shoulders to its point, and thin enough to penetrate with the most perfect facility. This needle is delineated in Fig. 5. The extract of belladonna is to be diluted with water to the consistence of cream and dropped into the eye, or the extract undiluted may be smeared over the eye- lid and brow. In half an hour, or an hour the pupil i* fully dilated, and the application should be then washed off. The patient is confined in a proper position and in a situation near a window by a sufficient number of as- sistants, who take great care to fix the head motionless, and to secure the limbs from moving. The operator is seated on a high chair, behind the patient, takes the spe- culum in one hand and the needle in the other. Should the capsule contain an opake lens, the sur geon gently introduces the bow of the speculum under the upper eye-lid, his assistant at the same time depress- ing the lower, and at the moment he is about to pierce the cornea, he fixes the eye by resting the speculum with a moderate pressure upon the eye-ball. The position of the operator enables him to do this with perfect safety, and by that consent which can only exist between the hands of the same person, he not only discontinues the pressure, by using the speculum merely as an elevator of the lid, as soon as his purpose is accomplished, but he with facility renews or regulates the pressure at any moment in which it may be required. He penetrates the 310 ELEMENTS OF SURGERY. cornea as near to its junction with the sclerotica as it will admit the flat surface of the needle to pass, in a di- rection parallel aud close to the iris, without injuring this membrane. When the point of the needle has arrived at the centre of the dilated pupil, he does not boldly plunge it through the capsule into the lens, and perform any depressing motion; it is a material object with him not to injure the vitreous humour or its capsule ; neither does he lift the capsule of the lens on the point of the needle, and by forcibly drawing it forward into the an- terior chamber, rend it through its whole extent. Such an operation would dislocate the lens, deliver it into the anterior chamber, or leave it projecting in the pupil, and stretching the iris ; and although its soft texture in the child should exempt him from any disorganizing in- flammation, the most favourable result will be a perma- nently dilated iris, deforming the eye. He proceeds with a gentle lateral motion, working writh the point and shoulders of the needle only on the surface and centre of the capsule, in a circumference which does not ex- ceed the natural size of the pupil. This object is per- manently to destroy this central position of the capsule : merely to pierce it would not answer his intention, be- cause the adhesive process will speedily close the wound. Having acted upon the centre of the anterior lamella of the capsule to the extent which he wishes, he gently sinks the needle into the body of the lens, and mode- rately opens its texture. In doing this he may, if he pleases, incline the edge of the needle, by which motion the aqueous humour will escape, and the lens will ap- proach his instrument; but at the same time his field for operating will be diminished by the contraction of the pupil. The needle and speculum are now to be with- drawn, the eye is to be lightly covered, and the patient put to bed. ELEMENTS OF SURGERY. 341 Inflammation is seldom excited by this operation on the child; but its first approach, marked by pain and unusual redness of the conjunctiva, or serous effusion under it, must immediately be arrested by the applica- tion of leeches on the palpebrae, and, in stouter children, by bleeding from the arm, followed by purgatives and a very low diet. Soon after the operation the extract of belladonna should be applied over the eye-brow, to pre- vent, by a dilatation of the iris, the adhesion of the pupil- lary margin to the wounded capsuie. Nature now per- forms her part of the cure, and the lens, loosened in its texture, and through the aperture in the capsule, sub. jected to the action of the aqueous humour, is gradually dissolved and absorbed. A single operation sometimes suffices, and the cure is completed in the space of a few weeks ; but if the process should not advance with sufficient rapidity, the operation may be repeated once or oftener, interposing at least a fortnight between each operation. If the ad- hesive process has counteracted his former operation on the capsule, he will take care now to eftect the perma- nent aperture in its centre, and he may use greater li- berty than at first in opening the texture of the lens. Some have supposed that the fluid cataract is not only the most frequent, but the most manageable of the congenital cases. Both suppositions are erroneous. It is not only the least common, but the fluid, when extra- vasated sometimes excites a hazardous inflammation. In these cases, after puncturing the anterior lamella of the capsule, and discharging its contents into the anterior chamber, it will be prudent to desist for the time, and to guard against inflammation: by this operation the case will be converted into a capsular cataract. Where the lens is nearly or quite absorbed, and the capsule only is opake, the surgeon may isse the needle with more freedom than in the lenticular cataract, but in O I .1 o-±4i ELEMENTS OF SURGERY. other respects he proceeds in the manner above describ- ed. If any portion of the lens remain as a small nucleus or scale, in the centre of the capsule, his efforts will be exclusively directed to detach this portion, by which he will fulfil the intention of the operation, that of effecting a permanent aperture in the centre of the capsule. Mr. Saunders in some cases punctured the sclerotica and .perforated the capsule from behind : he observes, that in this posterior operation the surgeon has more power, but that the anterior operation -excites less pain and inflammation, and inflicts a slighter injury (if any) on the vitreous humour; from the facility with which the cornea heals I should prefer the anterior operation. The number of operations which may be necessary to accomplish the cure of a congenital cataract, will de- pend much upon the texture of the capsule, and the size of the lens. It is frequently cured by a single opera- tion ; more frequently it requires two; often three; sometimes four; but very rarely five. In sixty patients Mr. Saunders, (the author of the operation) succeeded in giving sight to fifty-two. In thirteen he operated on sin- gle eyes. In forty seven he operated on both eyes. The ages were as follows : five, from 2 to 9 months; nine, from 13 months to two years; four, from two and a half to three years ; five, from three and a half to four years ; eight, from four to six years. Seven, at seven years ; eight, from seven to 9; ten, from nine to fifteen; and four from twenty to twenty-eight. The greatest suc- cess attended the operation when performed between the ages of 18 months and four years. The age of two years is perhaps preferable to any other. It is extreme- ly important to operate as early as possible, because, the muscles acquire an inveterate habit of rolling the eye, so that for a long time, no voluntary effort, can con- trol this irregular motion; nor direct the eye to objects ELEMENTS OF SURGERY. 343 with suffi|ient precision for the purpose of distinct and useful vision. I cannot refrain in this place from expressing my high sense of the ingenuity of Mr. Saunders, in the contriv- ance of the simple and important operation which has been described. When the advantages of education are considered, and the necessity of sight for this pur- pose, the magnitude of the object will appear very great, and when the success of his practice is recollected, (52 cures of 60 patients) his skill and judgment cannot be too highly rated. Before concluding this subject, I beg leave to sug- gest the propriety in cases of cataract where the pupil is greatly contracted, of using either the belladonna as directed by Mr. Saunders, or the extract of stramo- nium, which operates in the same manner ; great difficul- ty sometimes attends the extraction of the lens, owing to the contracted state of the pupil, the applications just proposed will probably be found to obviate this difficulty, and perhaps another, the entangling of the iris on the point of the knife, because the dilatation of the pupil, occasioned by stramonium and belladonna, is so great, that the iris actually resembles a narrow ring at the mar- gin of the cornea. The effect of certain narcotic plants in dilating the pupil of the eye, both when externally and internally ad- ministered, has been long known, but it is only a few years since surgeons have availed themselves of it, in ex- amining cataracts, and facilitating their extraction. Mr. Wishart, in a paper published in the Edinburgh Med. and Surg. Journal, for January 1812, recommends very strongly the hyosciamus, and quotes professor Himly of Gottingen, who has made comparative experiments with belladonna and hyosciamus, and prefers on his authori- ty, as well as from his own observation, the latter ar- ticle. The mode of using it is, to dissolve a dram of 344 ELEMENTS OF SURGERY. the extract in an ounce of water, of which solution a few drops are to be let fall into the eye. It occasions no pain nor redness. The effect on the pupil commences in an hour, and continues five or six hours. There are several advantages which may be gained by artificially dilating the pupil. I have known a lady blind except at noon; her pupil was no larger than a pin's head, the use of stramonium enabled her to see tolerably in various degrees of light. In examining ca- taracts, the larger the pupil, the more readily we may ascertain the circumstances of the case. It is always in the surgeons power to learn whether the iris be adhe- rent, in which case no dilatation of the pupil will be occasioned by the narcotic applications. In cases of partial opacity in the cornea, the dilatation of the pupil enables the patient to see by withdrawing the iris from behind a lucid part of the cornea, and thus forming a temporary substitute for an artificial pupil: the advan- tages of a dilated pupil during the operation of extract- ing a cataract, have been already mentioned ; but an in- convenience has been dreaded from the escape of the vitreous humour, in consequence of a want of that sup- port which the iris afforded. The experiments of Him- ly quoted by W ishart, appear to prove that this fear need not be entertained, and the surgeon may doubtless avail himself safely of the benefits which are to be derived from the application of these narcotics to the eye. Among the consequences of the extraction of cataract, hypopion and staphyloma are the most formidable, happily they are of rare occurrence, I have never seen either. Hypopion is a collection of matter in the an- terior chamber of the eye. The term empyesis signifies a collection of pus in the posterior chamber, both are consequences of violent inflammation, and occasionally occur after ophthalmia. elements of surgery. 315 In case^of hypopion the continued use of the reme- dies for inflammation seldom fails of producing an ab- sorption of the pus;—as this absorption progresses, the pus being heavier than the aqueous humour falls to the bottom of the anterior chamber of the eye, forming a semicircle of a yellow colour, the circumference of which is formed by the cornea. It is very seldom necessary to puncture the cornea for the evacuation of the pus, ac- tive purges are to be repeatedly administered, but, if aid- ed by the usual depleting remedies they are unsuccess- ful, a puncture must be made. These remarks apply equally to hypopion from inflammation of the eye aris- ing from other causes. The staphyloma is a tumour projecting through the wound of the cornea, formed generally of the iris, but in some cases of a transparent membrane, which Wen- zel calls the capsule of the aqueous humour. When upon looking at the eye for the first time, which is gene- rally done in six or eight days after the operation, the iris is observed protruding through the w ound, no atr tempt should be made to replace it; as the opening in the natural cornea closes, the iris generally regaius its situa- tion. The tumor formed by a transparent membrane, is of a very different nature. The membrane is probably an adhesion formed of coagulating lymph, distended af- terwards by an abundant secretion of aqueous humour ; if cut off or destroyed, it generally returns again, which would not be the case if it were formed of an organized capsule. Wenzel recommends the case to be left to na- ture, the eyelids gradually produce by friction and pres- sure, an absorption of the tumour. Staphyloma some- times results from ulcers of the cornea; in these cases, if it continue obstinate and do not subside spontaneously, the lunar caustic must be applied. Scarpa denominates the staphyloma formed by the , vol. i. v y 346 elements of surgery. iris " procidentia iridis," which is surely a more proper appellation, for it is perfectly distinct from the tumour just described, which is often pellucid, but when opake is of a pearly white colour, and easily distinguishable from the protruded iris. Staphyloma is sometimes occasioned by small-pox— in this case the tumour is of a white colour like the opake cornea. In general it ulcerates and occasions inflam- mation of the eye ; in these cases the tumour may be cut off, and should it reappear lunar caustic is to be ap- plied. The term staphyloma has been vaguely applied to many and various tumours of the cornea. It has been called total when the whole cornea is morbidly promi- nent, and partial when the tumour is confined to a portion only. For some very interesting remarks on this sub- ject the reader is referred to Wardrop, and Scarpa. IE J.II. ftye S47 V- x*!wsm fc. " "vi Xii3$X"-'-."; 'X.£|'', vj.i.^^^Z'id? - ^X;.^X: >X$&$&? ^ Carcinoma of the Eve ./S/Ji'/mx dd /»' Sctf^t ELEMENTS OF SURGERY.' 34/ CHAPTER LX Extirpation of the Eye. This operation, terrible in its nature, is extremely sim- ple. The diseases which render it necessary are not very accurately defined. In general it is performed for the removal of a disorganization which commences, and terminates in a fungous tumour : in some cases t his af- fection begins without pain, but commonly it is preced- ed by head-ache, and itching and watering of the eye. It is in some cases truly cancerous, but in others, pro- bably, has no cancerous tendency. It occurs at all ages, but oftenest in young persons. More than one-third of Desault's patients were under twelve years of age. As the disease progresses great pain is perceived—sight is lost—the cornea inflames, ulcerates, and bursts—a fungous red tumour projects through it, discharging a purulent sanies, fetid and acrid—the size of the tumour becomes very great. I extirpated a fungous tumour of this nature from the socket of a boy's eye, resembling, except in co- lour, a cauliflower, its size and form is represented in the annexed plate—no return of the disease took place. The plate affords a tolerable idea of the general form of this dreadful malady. The operation is to be performed, when practicable, by separating the lid, from the ball of the eye with a scalpel: but in many cases this is impracticable, and all that can be done is to save as much of the upper lid as possible, provided it be sound. A straight bistoury of sufficient strength is to be passed as quickly as possi- ble round the basis of the tumour, the surgeon making it revolve upon its point in •uich a manner as to keep the 318 ELEMENTS OF SURGERY. edge close to the bony orbit. Having seen Mr. Dubois at Paris perform the operation in this simple manner, I have imitated his example, and in a very short time the operation is completed. Any portions of the tumour which remain may be afterwards removed, but as the hemorrhagy is always very profuse, whatever cutting is done, should be done quickly. The orbit is to be tilled with lint, and the bleeding soon ceases. The antiphlo- gistic regimen should be adhered to for a few days. Sometimes the fungus returns, and although often destroyed, as frequently springs up. In these cases the event is fatal. But as death is inevitable if the disease be not extirpated, the attempt ought always to be made. TAPPING THE EYE. Dropsy of theeye, or hydrophthalmy, sometimes ren- ders it necessary to evacuate the aqueous humour, accu- mulated in too great quantity. Scarpa states that in the cases of dropsy of the eye which he has dissected, the vitreous humour has been in a morbid state of fluidity, and he was unable to distinguish it from the aqueous humour. The proper internal remedies having been in vain administered, if the eye-ball continue to aug- ment in volume, and protrude from the socket, it be- comes necessary to open the eye by a surgical operation. Nuck used to puncture the centre of the cornea with a small trochar; other writers recommend the puncture to be made through the sclerotica. Scarpa advises a small circular incision to be made in the upper part or centre of the cornea, as the best mode of evacuating the eye. In several cases I have punctured the cornea by inserting the point of a sharp cataract knife through it, the evacuation of the aqueous humour although not sud- den, was amply sufficient, but if necessary it is very easy to turn the knife a little, so as to make the incision some- elements of surgery. 349 what circular whereby the fluid will more readily es- cape. Dr. Physick from an idea that gutta serena is in some cases occasioned by pressure upon the retina and optic nerve from an over secretion of aqueous humour, has punctured the eye with a view to relieve this affec- tion. In some instances the operation has been evident- ly advantageous—in others no benefit whatever has re- sulted. I have suggested this because I shall not enter into the history of this paralytic affection of the eye, as many excellent histories of it are iu the hands of every medical man. Richter, Scarpa, and Ware are among the best writers on the subject, and to them I refer, only suggesting that in very obstinate cases where other re- medies have failed, tapping may be tried, as it has been sometimes useful, and the repeated application of blis- ters directly over the eye-lids, are also occasionally be- neficial. 350 ELEMENTS OF SURGERY. EXPLANATION OF THE PLATES. Fig. 1. Represents the most usual form of Pterygium or Unguis. 3. The appearance of an eye, after the excision of that portion of the palpebra, from which the cilia project; an operation performed for the cure of Entropium or Trichiasis. 0 3. Curved scissars used in various operations on the eye. 4. Forceps. 5. Saunders' couching needle. 6. Scarpa's couching needle. 7. Hey's couching needle. 8. Represents the section made in the cornea in the operation of extracting a cataract. 9. An artificial pupil, near the external margin of the iris. 10. The place of introducing the cornea knife and the mode of passing it through the anterior chamber of the eye. 11. This figure represents an accident which some- times happens in the operation of Extraction, the floating of the iris before the blade of the knife. 15. The forceps contrived by Dr. Physick with a circular punch on the extremities of the blades. 13. A small hook useful in the operation of Ex traction. 14. Wenzcl's knife for incising the cornea. 1.?. Curette and needle. 16. Wenzel's forceps. 17- The nail headed style used in fistula lachrv- malis. Plate xm. Tagt M(: PcycSS ELEMENTS OF SURGERY. 331 CHAPTER LXI. Of Polypus. A polypus is a fleshy excrescence, of various densi- ty and colour, originating from the lining membrane of a canal or cavity, as the nose, vagina, rectum &c. The nostrils are the most frequent situation of this complaint. It commences as a small pendulous tumour, void of pain, accompanied with watering of the eyes, sneezing, and the usual symptoms of catarrh. The co- lour of these tumours is generally a pale red. They commonly commence from the ossa spongiosa; but oc- casionally from all the parts concerned in forming the cavity of the nostril. They produce at first no other effects than have been noticed, but as they enlarge, the defluxion from the eyes increases, sneezing is fre- quent, and the tone of voice is much altered. The weather has a great influence on the patient. In dry weather the tumour appears to diminish, and it increases in damp and cold weather—augmenting gradually in size, it at length obstructs the passsage of air through the nostril and in this stage produces a very unpleasant nasal tone of voice. The polypus assumes gradually the shape of the cavity of the nose, being-formed in it as in a mould. It becomes visible at the anterior nostril and at the fauces behind, where it may be seen situated over the soft palate, and sometimes hanging down be- hind the uvula. In this state great inconvenience is experienced—the eyes are constantly suffused with tears, from the obstruction to the ductus ad nasum. In some instances, ulceration takes place, and a fetid matter 352 ELEMENTS OF SURGERY. is discharged, attended with great inflammation and se- vere pain. In some cases, however, it is remarkable that the tumour acquires a great size and the pa- tient suffers no pain. From the nose being stopped pa- tients generally sleep with the mouth open, and incon- venience is sustained from the dryness of the mouth and throat. Hearing is often injured, probably from pres- sure against the Eustachian tube. In swallowing, some difficulty is experienced from the weight of the tumour which presses against the velum pendulum palati. The appearance of the face becomes changed from one nos- tril being wider than the other, the root of the nose ap- pears swelled, and violent head-aches come on—the bones eventually become carious and ulcerated—a foul fetid sanies mixed with blood is discharged—hemor- rhage sometimes ensues—the teeth fall out and a fun- gus shoots through the sockets. These symptoms in some cases increase and exhaust the patient's strength;— frequent bleedings and an incessant discharge of matter take place and during the last stage of the disease, stupor and coma come on, and eventually death.—Such are some- times the dreadful effects of a disease at first trifling, and to all appearance of very little consequence. The causes of this complaint are not well understood. Borne have supposed picking the nose, or violently blowing the nose to have produced it, but for this there is no foundation. Several species of nasal polypi are described by au- thors, one of which is said to be of a malignant nature, disposed to end in cancer. This, however, I believe is extremely rare; the most common are a fleshy, red vas- cular polypus, and a pale tough, firm polypus, neither of which is of a cancerous nature. TREATMENT. The cure of polypi consists in extracting or destrov- ing them with caustic. ELEMENTS OF SURGERY. 353 The extraction may be performed by forceps, or by passing a ligature round the base of the tumour in such a manner as to destroy the circulation, after which the polypus soon falls off. The application of a ligature is to be preferred in cases where the pedicle by which it hangs is very small, or in cases where the patient is too feeble to bear the loss of blood which is apt to follow the use of the forceps. The mode of applying the ligature must vary in different cases. Sometimes all that is ne- cessary is to pull the polypus forward with a hook and pass a silver wire over it—or a waxed ligature may be formed into a noose and passed round the base of the tu- mour in the same way. When the wire is to be used a double canula is generally the best instrument for fix- ing it—it must be drawn very tight, and in a few days the polypus will fall off. It is of great importance to watch when the polypus becomes loose, as it has occa- sionally separated in the night time and endangered suf- focation by falling over the glottis. A case of this com- plaint occurred several years ago in which Dr. Physick practised a new mode of extraction that will probably be found useful in many other instances. A gentleman having suffered many unsuccessful attempts for the re- moval of his polypus, came to Philadelphia and consult- ed Dr. Physick—he found a large tumour projecting be- hind the soft palate as low as the extremity of the uvula and filling completely the posterior nares and cavity of the nose, after vain attempts to extract it in the usual manner with ligature and forceps, a piece of tape was made stiff by passing silver wire through it, and this was fixed on the projecting part of the tumour by a firm knot-^the tape was now pulled forcibly and with it came away the polypus, which was of prodigious size, VOL, I. Z 7 354 ELEMENTS OF SURGERY. In using the forceps they must be applied as near the root of the polypus as possible. Hemorrhage generally attends the operation but it is not often alarming—cold water or brandy injected into the nose generally checks it. If not, a plug of lint may be introduced into the nos- trils so as to press on the part whence the blood issues. If necessary the posterior nostrils may be stopped up by passing a double catgut through the nose into the mouth and by means of this a roll of lint is readily in- troduced into the posterior nares which invariably suc- ceeds in putting a stop to the hemorrhage. The application of caustic is often requisite to prevent the growth of the tumour after the greater part of it has been removed. This is in general easily effected by means of a bougie, or a roll of waxed linen in which is included a piece of caustic alkali. The application may be repeated daily until the tu- mour no longer grows up. ELEMENTS OF SURGERY. 355 CHAPTER LXII. Of Hare-Lip. Fissures in the upper lip of infants extending in many cases through the roof of the mouth, affecting the bone as well as the soft parts, have received from the resem- blance to the mouth of the hare, the appellation of hare- lip. In some cases the fissure is in the middle of the lip; more generally it is on one side, and occasionally there is a double hare lip, a fissure existing on each side. Its extent varies considerably; sometimes it is confined to the edge of the lip, at other times it extends up to the nose and even into the nostril; sometimes the lip alone is affected, in other cases the gum, and superior maxil- lary bone are divided, and the fissure extends even through the roof of the mouth completely to the soft pa- late, the nostril and mouth forming one cavity. The velum pendulum palati is sometimes divided. The deformity, if no other inconvenience existed, would be a sufficient motive for the performance of any operation necessary to effect its removal, but in addition to this, the child sucks and swallows with great difficul- ty, and if a cure be not effected will remain unable to articulate distinctly. It is the custom to postpone the operation for hare-lip (ill the infant advances to the age of two years and up- wards, under an idea that convulsions will result from it—this caution is I believe superfluous, and the earlier the operation is performed, the more complete will be its beneficial consequences; especially in those cases 356 ELEMENTS OF SURGERY. where the bones are affected, because in very early life the vacuity will be more perfectly filled up. The operation for the cure of hare-lip consists in par- ing off the epithelium and skin of the lip, on each side of the fissure, and keeping the cut surfaces in contact by means of the twisted suture. We are directed in the more modern surgical authors, to perform the operation with a sharp scalpel, from a fear that the contused wound occasioned by scissars will not unite by the first inten- tion, this caution, proceeding from an unnecessary re- finement upon the doctrines of adhesion is totally use- less, the operation may with great facility be performed by scissars, and the wound heals in every instance by the first intention, provided the suture is properly ap- plied. It is of great consequence whether the knife or scis- sars be employed, to cut out the upper angle of the fis- sure, that the piece removed shall form the letter V, if this be not attended to, the whole of the surfaces will not unite. When the skin of the lip is removed, the wound re- sembles any other incision through the same part, and the mode of treatment must be similar to that employed in wounds through the lip. Two silver pins with move- able steel points are to be passed into the lip half an inch from the wound, these pins are to be pushed through the substance of the lip in such a manner as to pass through the wound; they should not extend deeper than two birds through the substance of the lip, the points are to be brought out half an inch from the wound on the op- posite side, and then removed; a firm ligature of waxed thread is now to be passed round and round these pins in the form of the figure 8, in such a manner as to con- fine the sides of the wound in contact. In this manner the twisted suture is formed, and it certainly is more con- venient and effectual than the interrupted suture in this ELEMENTS OF SURGERY. 357 particular instance, although the latter is preferred by some surgeons, and no doubt answers tolerably well. When the operation for hare-lip is deferred until the teeth have grown, we often find the large incisors pro- jecting on the edges of the fissure in the upper maxillary bone, they should be removed in such cases before the operation is performed. In double hare-lip the same method of removing the skin is to be performed on both sides, but the number of pins need not be increased in this case, they must pass through the insulated central portion of the lip, and great care is necessary in the accurate co-aptation of the wounded surfaces. When the lower lip is totally or partially affected with cancer its removal becomes necessary, in these ca- ses an incision is to be made on each side of the diseas- ed part with a bistoury or scalpel, and the lip dissected loose from the lower jaw; if practicable the incisions should meet in a point at the chin, or on one side of it, and then the sides of the wound can be closed by the twisted suture, the pins being introduced and the liga- ture applied, just as in cases of hare-lip, if even the whole lip is extirpated the deformity is by no means very great. The bleeding, in operations both on the upper and under lip, is generally profuse at first, but soon ceases. Cancer of the upper lip is to be extirpated and treated when practicable in the same manner. 358 ELEMENTS OF SURGERY. CHAPTER LXII1. Of Ranula. This consists in a tumour under the tongue containing a glairy fluid, resembling the white of an egg. It is supposed to proceed from an obstruction in the salivary duct. The tumour is generally on one side of the frse- num linguae, and varies greatly in size, sometimes ex- tending to the very point of the tongue, and elevating it considerably.* The tumour sometimes contains instead of the viscid fluid which has been mentioned, a purulent matter, and, sometimes, a calculous concretion. When uninflamed the disease gives no pain, but from its bulk is more or less inconvenient; when it inflames considerable pain is experienced. TREATMENT. The remedy for ranula, that is for a tumour, actually formed by a dilatation of the salivary duct, consists if possible in dilating the duct by means of a probe, as re- commended by Desault; but it is not often in our power to effect this, and other measures become necessary. The extirpation of the tumour is difficult and danger- ous on account of the large blood-vessels in the vicinity. The British surgeons are in the habit of laying open the cavity of the tumour, by a free incision, after which they apply caustic to its surface. This plan does not always effect a cure, and is unnecessarily severe ; a simpler and * I have never seen these tumours very large, but when suppuration takes place in them, large abscesses have been formed, and as much as a pint of mat ter has been discharged from under the tongue. ELEMENTS OF SURGERY. 359 easier method should therefore have the preference. In a majority of cases the disease may be cured by passing a seton through the cavity of the sac, a common curved needle armed with a ligature can readily be passed through the tumour, the needle being cut off, the string is suffered to remain in the cavity of the tumour where it excites inflammation and suppuration, after which a fistulous orifice is established through which the saliva afterwards flows, and this is soon followed by a complete obliteration of the cavity. I have known this simple re- medy successful in a great number of cases, and I be- lieve it will be found to fail in very few. If calculous concretions are found in the sac they must be removed, and the caustic if necessary can be applied for the purpose of destroying the sac. It has occasionally happened that a small calculus in the duct produces the obstruction, in which case all that is necessary is to remove it, after which the tumour will subside. Mr. B. Bell relates such a case which terminated in ulceration of the cavity. The ulcer could not be healed until the calculus was removed. 360 ELEMENTS OF SURGERY CHAPTER LXIV. Of Abscess of the Antrum Maxillare. This eavity is sometimes the seat of inflammation and suppuration. The complaint commences like a fit of tooth-ache, a severe darting pain extending through the jaw, without any external tumefaction : afterwards sup- puration takes place; the pus flows into the nostril of the affected side, especially when the head is inclined in such a position as to favour its escape. The disease even after suppuration is established is not always easily known, for the mucus of the nostril often resembles pus, and the pus is mistaken for the common secretion of the nostril. In some cases the affection subsides after sup- puration takes place, but more generally it continues, and occasions caries of the bone. The absorbents re- move portions of bone, and make outlets for the pus in different places. In some cases the sockets of the molar teeth are absorbed, the teeth loosened, and the pus dis charged through the openings thus formed into the mouth. The cause of the disease is often a caries of the upper molar teeth and consequent inflammation of the sockets, extending gradually to the antrum. The treatment of the abscess is to be commenced by extracting any carious teeth which may exist in its vici- nity ; this removes in many instances the remote cause of the disease, and also affords not unfrequently a ready outlet for the "pus at the most depending part of the ab- scess which is an object of great importance. If the fang of the tooth should not extend into the an- trum, a perforation is to be made cautiously with the ELEVIEXTS OF SURGERY. 36l stilette of a small trochar, or a common pointed probe. If, however, the teeth be sound, and pus evidently exists in the antrum, the third or fourth molar tooth should be removed, and an aperture made through its socket into the abscess. The removal of carious bone should never be attempt- ed before it is quite loose; this process may be very safe- ly trusted to the absorbent vessels. Besides inflammation and abscess, the antrum is occa- sionally the seat of fungous tumours. These occasion an enlargement of the bone, and subsequently an ab- sorption of it. The alveolar sockets are protruded down- ward, and the teeth pushed out from their sockets. The nostril becomes filled up; the excrescence extends in every direction; the eye is pushed upward, and in some cases the skin ulcerates, and the fungus protrudes through it. The only remedy is an early extirpation of the tumour, by removing a portion of the bone, and dissecting out the tumour with a knife and destroying what may remain with caustic; if the disease have made much progress be- fore the operation is performed, its efficacy is very doubt- ful. In one case I extirpated a very extensive fungous tumour, extending almost to the orbitar plate of the up- per maxillary bone, in a girl, and after a cure was appa- rently nearly effected, the tumour recommenced its growth and neither the knife nor caustic had any effect in ar- resting its progress. The disease although not very fre- quent is extremely formidable, and often terminates fa- tally. In the collection of Mr. Heaviside at London there is a skull exhibiting a very extensive bony excrescence from the antrum and upper jaw an engraving of which may be seen in Mr. Fox's treatise on teeth. The early extirpation of all such tumours is the only remedy in which confidence can be placed. vol. i. 3 A 362 ELEMENTS OF SURGERY. CHAPTER LXV. Diseases of the Tongue. The frsenum linguae is occasionally too short to allow the free motion of the tongue, and it sometimes extends to the extremity of the tongue and thus confines it. Chil- dren suck with great difficulty in these cases, and it be- comes necessary to divide the fraMium. The operation is extremely easy, and may be performed either with scissars, or, what is better, a sharp pointed bistoury. Care should be taken to avoid the ranina artery. It is proper to remark that surgeons are often consult ed about children, said to be tongue-tied in whom there is no confinement of the tongue, a certain difficulty in speaking is generally the reason for the supposition ; an inspection of the mouth will readily enable the practi- tioner to ascertain whether the tongue is preternaturally confined or not. Ulcers of the tongue arise from various causes and are often very difficult of cure. Sometimes a carious tooth occasions ulceration of the tongue; this ought cer- tainly to be removed or filed smooth. Slits or fissures occasionally form in the tongue which swells and be- comes indurated in their vicinity. The use of caustic is generally proper in these cases. Dr. Physick has em- ployed with advantage the actual cautery in a very ob- stinate case of this kind, with a view to change the na- ture of the sore into the state of a burn. Cancer occasionally forms on the tongue ;•*—extirpa- tion is the only remedy; and in performing it, all the dis- eased parts should be carefully removed. Mr. Home elements of SURGERY. 363 advises in these cases to pass a needle armed with a strong double ligature through the middle of the tongue beyond the diseased part, and to tie one ligature on each side; in this manner the diseased part being deprived of its circulation, will mortify and drop off. The pain is not very great, and no danger of hemorrhagy exists. A salivation in some cases follows, but soon subsides. It will be obvious to every one that a little attention and dexterity will enable the surgeon to remove such parts only as are diseased, leaving the sound parts of the tongue uninjured; he should always, however, ap- ply the ligature in sound parts. If any circumstance should induce the surgeon to prefer the knife, he should be careful to take up all the bleeding arteries and to have at hand a heated iron in case he should be unable to secure them with ligatures. I particularly urge this precaution upon the young surgeon, because no one un- accustomed to surgical operations upon the mouth can be aware of the difficulty of securing a bleeding artery in these parts. Ulcers of the tongue are not unfrequently occasioned by diseases of the digestive organs—here the remedies must be internally administered and different cases call for very opposite medicines. In some, alkalies are use- ful, in others, acids. Opium has relieved a number of these cases. Tartar emetic, in small doses long conti- nued has occasionally succeeded. In addition to these remedies leeches should be applied in the vicinity of the ulcer, and various astringent lotions are to be tried. Ulcers from the use of mercury, generally get well when the medicine is discontinued. 364 ELEMENTS OF SURGERY. CHAPTER LXVI. Diseases of the Uvula and Tonsils. Inflammation of the throat and fauces produces some- times a considerable elongation of the uvula. In gene- ral it resumes its usual length after the inflammation subsides, but in some cases it is permanently elonga- ted, and in these instances should be removed;—a hook may be inserted into the uvula to prevent its slipping backwards, and then with a pair of scissars a portion of it can be easily cut off. There is no danger of hemor- rhagy. The tonsils in this climate are particularly liable to inflammation. In some cases the swelling is very con- siderable and breathing and deglutition are greatly impe- ded. In these cases, in addition to the remedies em- ployed by the physician, scarifications become necessary. A sharp scalpel answers the purpose very well. A num- ber of small incisions are to be made, and the vessels suffered to unload themselves; the mouth and throat should be rinsed with warm water to promote bleeding. In case of suppuration the abscess may be opened by a common lancet, and great relief will be immediately perceived. A particular instrument has been construct- ed for the purpose of opening abscesses of the throat, called pharyngotomus, an engraving of which may be seen in Brambilla's Instrumentarium. It has no advantage over a common lancet or scalpel. The tonsils are sometimes enlarged and indurated from successive inflammations, and sometimes an en- largement occurs without any evident cause. The com- ELEMENTS OF SURGERY. 365 plaint is usually, but improperly, denominated schirrhus. It has no disposition to terminate in cancer, but great inconvenience is experienced from the bulk of the tu- mour. A part or the whole of the tonsil may be remo- ved by means of a knife, but in this operation the bleed- ing is sometimes troublesome. Caustic may also be em- ployed, but it is the most tedious and painful mode of removing the glands. The application of a ligature around its base, is I believe the safest and best mode of extirpating schirrhus tonsils ; at least I have never seen any inconvenience from this method, and I have seen it very frequently performed. When the base of the tumour is small, a silver wire in a double canula, is to be applied round it, in the same manner as around the root of a polypus; this wire is to be drawn very tight and secured to the shoulders of the instrument. In a great majority of cases this operation is very readily performed, and in a few days the tumour drops off. Great care is necessary to make the ligature sufficiently tight iu order to prevent all cir- culation in the tumour, otherwise a portion of it only will be destroyed, the central part remaining after the rest had dropped off. When the base of the tumour is large, it is best to cut off at least a considerable portion of the gland with a bistoury; the bleeding may in general be restrained by washing the mouth with cold water. If the whole of the tonsil be removed with the knife, it is said that a great discharge of blood takes place. I believe that no dan- gerous hemorrhagy would be likely to occur, for if the bleeding vessels did not speedily contract, it would be easy to apply a hot iron and put a check to the dis- charge. The great improvements of modern surgery have almost entirely banished the actual cautery from practice, but in certain hemorrhages from the fauces, it is indispensable. 366 ELEMENTS OF SURGERY. CHAPTER LXVII. Of Foreign bodies in the (Esophagus. Substances occasionally become arrested in the oeso- phagus, and by pressing forwards the membranous part of the trachea obstruct respiration. I believe with Mr. Charles Bell, that the obstruction in these cases is not purely of a mechanical nature, but that spasm is excited by the irritation produced, and the muscles of the glottis, diminish very much the aperture through which the air passes. If the substance be not likely to occasion unpleasant consequences in the stomach, it is generally easier to push it down than to extract it through the mouth—pins, needles, sharp bones, or any pointed substance which wouldjprobably wound the oesophagus, or any portion of the alimentary canal, and also substances which from their chemical qualities would be likely to occasion mis- chief, as copper coins &c. should if possible be extract- ed through the mouth. This can only be done when they are situated high up near the fauces. If near the stomach they must be pushed down, and the risk of the consequences must be incurred. To extract substances from the oesophagus the fingers and forceps are generally the only instruments which can be employed, and we are very often able to see the fo- reign body by pressing down the tongue with a spoon, even when the sensations of the patient lead him to suppose that it has descended very low; a hook of curved wire is also useful in some cases for extracting foreign matters especially when they are of considerable size. In two instances I have known the spasm which ELEMENTS OF SURGERY. 367 had arrested a foreign substance, speedily relaxed by a solution of emetic tartar. In each of these cases, a large peach stone had slipped into the oesophagus, and the pa- tients were of course unable to swallow, and could not breathe without great difficulty. They were directed to hold in their mouths a solution of emetic tartar, and at- tempt to swallow it. Nausea came on, and the spasm relaxing, the peach stones were readily discharged. An ingenious mode of extracting small substances, as needles, fish-bones, &c. is described by Mr. S. Cooper. " The art of employing compressed sponge in the most advantageous manner, consists in taking a piece about the size of a chesnut, and introducing each end of a strong ligature through it. The ends of the ligature are then to be passed through a tube, and fastened to that end of the instrument which the surgeon holds. The sponge is then to be introduced down the oesophagus be- yond the foreign body, and water is to be injected through the tube, in order to moisten the sponge and make it expand. After this the ends of the ligature are to be firmly drawn, for the purpose of pressing the sponge against the extremity of the canula to make it expand still more. Then the tube is to be withdrawn, together with the sponge, observing to twist the instrument to the right and left in this part of the operation. "When the foreign substance cannot be extracted with this instrument a probang may be tried, to the end of which a bunch of thread, doubled so as to make an immense number of nooses, is fastened. Little bodies may frequently become entangled, and be extracted in this way, when the other one fails." When the foreign matter cannot be extracted, it be- comes necessary to push it forcibly into the stomach, this is generally done by means of a probang, a piece of sponge tied on the end of a whalebone, or large firm bougie of waxed linen. In many cases where much in- 368 ELEMENTS OF SURGERY. convenience has been anticipated from the nature of the foreign substance, it has passed through the alimentary canal, without occasioning any great inconvenience. I have known, however, a very extensive fistula in ano, produced by a large fragment of bone accidentally swal- lowed. When the foreign body cannot be either extracted or pushed down into the stomach, it sometimes occasions very speedy suffocation. Benjamin Bell relates two cases of death from this cause, and Desault mentions one instance in which a woman swallowed a bone with so much voracity that it lodged in the middle of the pharynx and occasioned suffocation; she died in three minutes : numerous accidents of a like nature have hap- pened. In other instances the foreign matter remains for many years occasioning no inconvenience. A boy four years old, playing with an English farthing, slipped it into the oesophagus and was unable to swallow or eject it. The accident happened in Dublin; Dr. Dease and several other surgeons of eminence attempted to extract it, but without success; the immediate symptoms of suffocation soon subsided, and the coin, although very inconvenient to the patient in his attempts to swallow, remained with- out occasioning any very alarming symptoms. He came to America, and was attacked in this city with a vomit- ing of blood of which he died after a few hours illness, at the age of seventeen years. Upon examination after death, I found the coin lodged vertically in the oesopha- gus opposite the bifurcation of the trachea, it was so loose as easily to move upwards, its motion downwards was more difficult. The copper was encrusted with a thick coat of dark greenish matter, which was detached at one part shewing the metallic surface. How it was detained thirteen years in this situation I am at a loss to imagine; certainly it would have been an easy matter to have ELEMENTS OF SURGERY. 369 pushed it into the stomach, and by no means impractica- ble to have withdrawn it through the mouth. Sometimes pins and needles are swallowed, they oc- casion abscesses by sticking in the oesophagus, when they get into the stomach they are generally evacuated with the faeces. In other instances they travel to differ- ent parts of the body, and ultimately approach the sur- face. A case is related in the Memoirs of the Academy of Surgery, in which a needle remained eighteen years before it made its appearance externally, during which time very little sensation was occasioned by it. The operation of cutting into the oesophagus in order to extract foreign bodies, I have never known necessary, and I believe it ought very seldom to be done. The memoirs of the French Academy contain, however, two cases in which it was successfully performed. Whenever suffocation is dreaded, and the patient is unable to breathe in consequence of a foreign body in the oesophagus, it becomes necessary to maintain the communication of air to the lungs, by artificial means hereafter to be described. By these means we have it in our power to prevent suffocation, and thus to afford time for the removal of the foreign body. vol. i. 3 B 370 ELEMENTS OF SURGERY- CHAPTER LX VIII. i Of Strictures of the (Esophagus. The oesophagus being a muscular canal is capable of contracting at times and of being again dilated. Occa- sionally spasm takes place at a particular part of the oesophagus and produces a spasmodic stricture, similar to the same disease in the urethra. Permanent stric- tures in the oesophagus also occur, producing a narrow- ness at the part, with thickening of its substance, and at length if not prevented, an almost total obliteration of the canal. The case in this way proves fatal by cutting off supplies of food, from the stomach, unless medical aid is successful in relieving it. The disease can in no manner be better explained, than by a history of cases in which it has occurred. Mr. Home has published several in his second volume on strictures to which the reader is referred. The com- plaint generally commences with a difficulty of degluti- tion, gradually increasing until fluids only can be swal- lowed, and at last every attempt at deglutition becomes extremely painful and attended with a sense of suffoca- tion, from the substance passing into the glottis. Ema- ciation takes place—hunger is extreme, and the patient unless relieved, is literally starved to death. I have seen one case in which this actually happened—upon dissection the oesophagus was found so nearly oblite- rated that a probe could not without difficuly be forced through the stricture. The treatment recommended by Mr. Home is to dilate the stricture by introducing bougies of waxed linen, com ELEMENTS OF SURGERY. 371 mencing with such as readily enter it and gradually enlarging their diameter so as to dilate it. In some cases this method is ineffectual, and the progress made in dilating the passage is too slow. Mr. Home has employed the caustic in such instances with ad- vantage, and Dr. Andrews of Madeira has lately pub- lished some cases in which the same remedy proved suc- cessful. The lunar caustic is to be preferred. It must be fastened securely in the extremity of a bougie, of such a size as to pass readily down to the stricture; another bougie of a larger diameter is first to be introduced, and when the resistance of the stricture is felt the patient by shutting his mouth makes a mark with his teeth, upon the instrument, by which the precise distance of the stricture is ascertained. This bougie being withdrawn, a mark corresponding to it, is to be made on the bougie armed with caustic, which is next to be introduced, and suffered to remain half a minute in contact with the stric- ture ; this may be repeated as often as necessary. In passing the bougie, it will be an advantage to preserve as accurately as possible the curve which the first in- strument had assumed, as this facilitates greatly the operation of introducing it. 372 ELEMENTS OF SURGERY. CHAPTER LXIX. Of Obstructions in the Glottis and Trachea. Whenever respiration becomes interrupted in conse- quence of obstruction in the trachea either from disease, or from foreign substances accidentally introduced into it, it becomes necessary to make an artificial opening into this canal, below the obstructed part, in order to preserve the free communication of air to the lungs. This has generally been done by cutting into the trachea, an ope- ration which may be performed with great safety and without risk of any permanent inconvenience—this truth is established, not only by the frequency with which the operation has been performed, but also by the facility with which even the most extensive wounds of the wind- pipe heal up, after unsuccessful attempts to commit sui- cide. Although the operation of cutting into the trachea may become necessary in a variety of instances, yet the ne- cessity for performing it has been greatly diminished by the introduction of a plan of treatment in which the knife is dispensed with : the passage of a flexible tube through the glottis into the trachea. The causes which may render one of these operations necessary are numerous. Inflammatory swellings in the vicinity of the glottis, as in the tonsils, sometimes occa- sion great difficulty in breathing, and though I have never known tracheotomy performed in this place in consequence of an enlargement of the tonsils, yet it may possibly become necessary.—Tumours sometimes form in such situations as to impede respiration by pressing ELEMENTS OF SURGERY. 373 on the trachea.—Substances lodging in the oesophagus, by pressing forward the membranous part of the trachea and exciting spasm of the glottis, lessen the size of its cavity so as to cut off the free access of air to the lungs. -In some cases the tongue becomes so much swelled from the use of mercury as to fill up the mouth, and obstruct respiration. In most of the cases which have been enu- merated, we may frequently avail ourselves of the intro- duction of a large elastic catheter into the trachea, and thereby avoid the necessity of tracheotomy. The introduction of foreign substances into the glottis occasions always great uneasiness, v iolent coughing, and much irritation; hence it would appear from theory, a most imprudent act to force an instrument into this pas- sage. Experience, however, proves that no danger re- sults from it, and many eases have now occurred which establish the fact, that an elastic catheter may be left for many days in the trachea without exciting any other in convenience than a convulsive cough at its first introduc- tion. Even in cases where the irritability of the parts is augmented by inflammation, the introduction of a ca- nula into the glottis is easily tolerated. The cough is at first violent, but it soon subsides and the patient breathes very well through the instrument. When the tumour exists in the mouth and the glottis is not diseased, the canula may be passed through the nostril, and readily finds its way into the windpipe. In cases where foreign substances exist in the oeso- phagus pressing forward the membranous part of the trachea, nothing is easier than to pass a catheter into the glottis which will prevent the canal from being clo- sed and allow the patient to respire freely. In these cases tracheotomy has often been performed—a surgeon once performed the operation to relieve from suffocation a young man, who for fear of being robbed, had swal- lowed his money, tied in a rag—it stopped in the pha- 3/4 ELEMENTS OF SURGERY. rynx, and would have killed him, had not tracheotomy been performed—now in this and similar cases, the ope- ration recommended by Desault would certainly have prevented suffocation and afforded time to extract or force through the oesophagus into the stomach the sub- stance arrested there. The advantages of the plan are very considerable. The operation is not difficult;—there is no danger from bleeding vessels;—no wound to heal;—no risk of a fistu- lous opening;—consequences which sometimes follow the operation of tracheotomy. A tube may with great safety be left a considerable time in the trachea; this fact is established by the case of a soldier in the hospital at Lyons, who cut his tra- chea through, and wounded the oesophagus. His sur- geon introduced a large flexible catheter into the trachea, another into the oesophagus, by means of one he was nourished, and through the other he breathed during the cure. Although the operation of opening the trachea may sometimes be dispensed with and the introduction of a flexible tube substituted, yet this cannot always be done. Tracheotomy becomes necessary in certain cases when foreign bodies are lodged in the trachea and can- not be coughed up. Writers also mention polypi and other excrescences in the trachea, as causes demanding the operation ; these are, however, very rare. Foreign substances having entered the glottis some- times get fixed in the ventricles of the larynx, this ac- cident has often happened, they produce less distur- bance here than in the trachea or glottis, sometimes remaiuing many years without occasioning any unplea- sant effects ; they must of necessity be very small. If the foreign body should rest in the glottis so as to im- pede respiration, no time is to be lost, an opening must be made below it, and the substance pushed up with a probe. ELEMENTS OF SURGERY. 375 When any substance falls into the windpipe, it occa- sions violent coughing and difficulty of breathing, attend- ed with the usual symptoms of suffocation ; but if the fo- reign body be not discharged by the efforts of coughing, and death be not occasioned by the obstruction to respi- ration, then we are to infer that the substance has passed through the glottis into the trachea, the irritation in this case is greatly diminished and after a short time entirely subsides. Heister relates several instances in which foreign bodies have passed down to the bifurcation of the trachea, and there remained for many years. In consequence of the facility with which the mem- branous partition between the oesophagus and trachea may be pushed forward, so as to diminish the cavity of the latter canal, and of the spasmodic action of the mus- cle of the glottis exeited by any irritation of these parts, it is occasionally difficult to ascertain, whether the fo- reign substance be actually in the oesophagus, or trachea. Indeed mistakes have been made, and the trachea has been laid open in cases where nothing has been found in it, the obstruction having proceeded from pressure in the oesophagus. It is of the utmost importance before pro- ceeding to such an operation to ascertain precisely whe- ther the body be in the oesophagus or not, and this can readily be done by passing a probang or catheter cjown the oesophagus, which will remove all doubt. When the catheter is to be introduced, it should be one of the largest size in use for the urethra. It is to be held as a pen, and passed through the mouth, or if this be inconvenient from the nature of the disease, through the nostril, at the fauces it readily passes either into the larynx or pharynx ; at the former it produces. First, A cough and tickling pain, with desire to vomit, and a spasmodic elevation of the larynx. Secondly, The flame of a candle placed before the end of it is blown to one side. Thirdly, In passing it still further, resistance 376 ELEMENTS OF SURGERY. is felt at the bronchiae. In the pharynx and oesophagus there is less irritation—no cough—no blast of air—but if some fluid is injected through the tube, the doubt ceases : if it pass into the larynx, violent coughing is oc- casioned, and it returns; if on the contrary into the oeso- phagus, no inconvenience results. When any difficulty is found in passing the tube into the glottis, a stilet may be introduced into it properly curved ; by this means it acquires sufficient firmness to be passed through the glottis. When introduced it is to be secured to the patients night cap, and a piece of gauze must be fastened over the orifice of the tube in order to prevent the dust and floating matter of the air, from being drawn into the lungs. The tube is to be often removed and cleansed, as the apertures at its ex- tremity are soon filled with mucus so as to obstruct the free passage of air. When the operation of bronchotomy becomes neces- sary there are two places of performing it, one at the lower part of the larynx, the other in the trachea. Tra- cheotomy consists in making a puncture between the rings of the windpipe, or if necessary for the extraction of foreign matters it may be divided longitudinally, for a considerable length. But of late the French surgeons have preferred very much the division of the larynx, and they state the following advantages which this operation possesses. In dividing the membrane between the cricoid and thy- roid cartilages, the skin and a very small portion of cel- lular membrane are the only substances met with. While in tracheotomy, the skin, much cellular substance, and generally a part of the thyroid gland, are divided. There is never any hemorrhage from the puncture between the cricoid and thyroid cartilages, whereas the other operation is almost always followed by more or les« hemorrhage, and this is an important circumstance, ELEMENTS OF SURGERY. 377 because it occasions delay, or, by falling into the tra- chea, produces unpleasant effects. Desault relates an instance of a child who died from loss of blood before the operation could be completed. The larynx is firm- ly supported, and the operation is easily performed; in the trachea, so much motion is allowed that it is often pushed before the knife, and in one case the carotid ar- tery was opened owing to this circumstance; laryngo- tomy is therefore upon the whole to be preferred. operation. The patient is to be seated, and the head inclined somewhat backwards, a bistoury and a curved canula adapted to the larynx are to be provided. The sur- geon placed before the patient searches for the space between the thyroid and cricoid cartilages, and makes an incision with the bistoury an inch long, through the skin and cellular membrane, from the bottom of the thy- roid to the cricoid cartilage—the edges of this wound being separated, the bistoury is to be passed through the membrane of the trachea, low down, so as to avoid a small artery sometimes found on the lower edge of the thyroid cartilage. If this be divided however, it is to be taken up immediately. The canula is next introduc- ed and secured by tapes, the angles of the wound cover- ed with lint, and the end of the canula with gauze. When a foreign substance is to be extracted, the aperture may be enlarged, by means of a pair of forceps and a bistoury; the forceps when introduced into the wound may be opened so as to stretch the trachea and liberate the substance, which may then be extracted, or pushed upwards through the glottis. The cricoid car- tilage, if necessary, may he cut through in this operation, and a considerable portion of the thyroid may be di- vided. vol. i. 3 c 378 ELEMENTS OF SURGERY. Where the object has been to remove a foreign sub- stance, the wound may be immediately closed, and in general it soon unites, but it is sometimes necessary to leave the canula in the wound, and then great attention must be paid to frequently cleansing it, because the col- lection of mucus is so great as to impede the passage of air when this caution is neglected. I have sometimes found it necessary to introduce a ca- nula into the trachea, in cases where it has been opened by persons attempting to destroy themselves. In these cases it is difficult to prevent the collection of blood and mucus in the cavity of the canula, and great care is ne- cessary to change the tube frequently, in order to re- move the obstructions which may be formed within it. Plate xv fir/u//a /or /, arxiu/otomy Page 378 ELEMENTS OF SURGERY. 379 CHAPTER LXX. Of Salivary Fistulce. In consequence of wounds of the cheek or of ulcers, the duct of the parotid gland is sometimes opened and discharges its contents externally. When the patient is eating, the saliva instead of being poured into the mouth flows out upon the cheek. Whether the loss of this fluid occasions any effect upon the digestive organs or not, the complaint is found extremely inconvenient, two ounces of saliva are said to have flowed out of such a fistula during a single meal. In case of a recent wound which opens the parotid duct, great care should be taken to unite very accurate- ly the sides of the wound externally ; in this way the probability is, that the duct will either reunite or form a fistulous orifice internally, either of which occurrences will prevent the formation of an external fistula. When the fistula has existed for a considerable time, and attempts have been made by pressure, caustic ap- plications, and other means, to heal up the ulcer without effect, more difficulty is to be anticipated. In these ca- ses it is necessary in the first place to establish an open- ing into the mouth, and afterwards.to heal up the external orifice. Mr. Charles Bell directs the following measures, which I believe were contrived by the celebrated Dr. Monro : " Our first attempt will be to pass a small silver probe from the mouth into the natural opening of the duct, and enlarge it, if it shall be found contracted ; then to sub- stitute a small tube, which being introduced from the 380 ELEMENTS OF SURGERY. mouth shall also pass some way into that part of the duct which discharges the saliva. Lastly, while the tube is retained in its place, the outward lips of the wound are to be made raw, brought together and healed. ec But the circumstances of the case may be such, that it will be better to make a new duct, from the fistulous opening into the mouth. To do this we must push a straight needle, obliquely from the bottom of the fistula into the mouth, and draw through a small seton, which is to be worn until the passage is callous. Then either with or without introducing the tube, we have to endea- vour to unite the edges of the outward opening." Desault made use of the seton in the treatment of sali- vary fistulse, but instead of introducing it in the usual man- ner, he complicated his operation by using a trochar in- stead of a needle. His mode of cure which differs in se- veral particulars from the one just described, appears to have no advantages over it. The patient during the cure, should as much as possi- ble avoid speaking, and should be nourished principally upon spoon victuals. ELEMENTS OF SURGERY. 381 CHAPTER LXX1. Accidents and Diseases of the Ear. The meatus auditorius externus is frequently plugged up in children with foreign substances, as corn, beads, &c, and in adults with hardened wax. In these cases a common eyed probe bent so as to form a hook at the perforated extremity, is a very convenient instrument for extracting them. The wax if necessary may be softened by injections of warm water. In general the hearing is immediately restored when the passage is Cleared. Insects sometimes crawl into the ear and excite ex- treme pain;—a little olive oil poured into the external meatus kills them very speedily, and they can be rea- dily extracted. Worms have occasionally been found in this canal, their ova having been previously deposited, probably during sleep ; an infusion of tobacco in these cases may be poured into the meatus; it does not irritate the parts, and is fatal to the insects. Abscesses sometimes form in the vicinity of this canal and discharge themselves into it—when this is the case, the hearing is generally unimpaired. Should the tym- panum, however, be affected, the bones of the ear are sometimes discharged through the membrana tympani and hearing is greatly injured or entirely destroyed. When the symptoms of inflammation exist in this impor- tant organ, the usual remedies for it are to be employed, with a view to prevent the formation of pus;—a number of leeches behind the ear, and blisters afterwards are to be applied. Mr. Saunders observes that when these 382 ELEMENTS OF SURGERY. remedies are unsuccessful and matter has formed, it is generally evacuated, as far as he has observed, between the auricle and mastoid process, or into the meatus. If it has been evacuated into the meatus, the opening is most commonly small, and the spongy granulations, squeezed through a small aperture, assume the appear- ance of a polypus. Sometimes the small aperture, by which the matter is evacuated, is in this manner even closed, and the patient suffers the inconvenience of fre- quent returns of pain from the retention of the discharge. When the parts have fallen into this state, it will be expedient to hasten the cure by making an incision into the sinus, between the auricle, and mastoid process. It occasionally happens that the bone itself dies, in consequence of the sinus being neglected, or the original extent of the suppuration. The exfoliating parts are the meatus externus of the os temporis or the external lami- na of the mastoid process. When polypi are found in the external meatus they are to be removed by the knife or forceps. The cavity of the tympanum is sometimes, as has been remarked, the seat of abscess; in these cases the membrane is destroyed, and air passes through the ear when the patient closes his mouth and blows forcibly; these abscesses are sometimes the result of common in- flammation, and sometimes follow small pox and other diseases. The usual remedies for inflammation are the only means of preventing suppuration, and where pus is evidently formed, notwithstanding their exhibition, Mr. Saunders advises a puncture to be made through the membrana tympani, in preference to allowing the abscess to burst. When the discharge of pus continues a great length of time, astringent injections of white vit- riol and sugar of lead dissolved in water, may be used. Blisters and setons applied behind the ear are also ad- vantageous. ELEMENTS OF SURGERY. 383 The eustachian tube is sometimes obstructed and occasions a considerable degree of deafness. A severe catarrh frequently produces a temporary deafness of this kind. When this tube is obstructed the patient is un- able to inflate the tympanum as in health; the sensation attending this inflation is more easily felt than described; to produce it, is only necessary to make a forcible at- tempt at expiration while the nostrils and mouth are closed. Mr. Astly Cooper has proposed when perma- nent obstructions exist in the Eustachian tube, to perfo- rate the membrane of the tympanum, an operation which has been repeatedly performed, and sometimes with suc- cess. I have tried it but without any benefit, though I should have no hesitation in repeating it, because it can do no harm to a deaf person and has in many eases proved beneficial—a couching needle or sharp pointed probe answers the purpose very well—when inserted through the membrana tympani a sharp pain is felt, but it quickly subsides. The instrument should not be pushed so far as to wound the parts within the mem- brane. Air in this manner will be admitted to the cavi- ty of the tympanum, and if deafness should have arisen from a want of it, it will be relieved. Mr. Saunders in one case by this operation instantaneously relieved a deafness of thirty years standing—he recommends a large aperture to be made, a small one being apt to close up. Diseases of the labyrinth are very generally be- yond the reach of surgery. In some cases the parts upon dissection evince no morbid alteration, and the want of sensation has probably been owing to the state of the nerve. In other cases the labyrinth is found filled with a cheesy concretion, instead of the natural fluid which should be found. Mr. Saunders considers most of the diseases of the internal ear as depending on the nerve of hearing, the 384 ELEMENTS OF SURGERY portio mollis of the auditory nerve being probably para- lytic. Various noises are generally perceived by pa- tients labouring under deafness from the palsy of the nerve, such as the murmuring of water, the hissing of a boiling kettle, &c. The remedies which, have oftenest been useful (and they have been but very rarely so) are long continued purging, low diet, and the use of mercury, with blisters, issues, and setons applied in the vicinity of the ear. Mr. Saunders has known a nervous deafness, origina- ting from a syphilitic source, to be relieved completely by a mercurial course. Deafness, however, is a very rare consequence of the venereal disease, unless when ^t arises from ulcers, or scabs, in the external meatus, in which case it is temporary, and amounts merely to an ex- ternal obstruction readily removable. ELEMENTS OF SURGERY. 385 CHAPTER LXXII. Of Scirrhus and Cancer. A painful, incurable ulcer, results from the suppura- tion of certain indurated tumours. The tumours are de- nominated scirrhous ; the ulcer is called cancer. These definitions (if they deserve the name) are by no means satisfactory, but it is not easy to describe in a few words, those tumours which will certainly produce cancer, nor those ulcers which are decidedly can- cerous, except in particular cases. The truth of this remark will not be doubted by any person who will take the trouble to consult the different surgical writings which contain histories of cancerous complaints. There is perhaps no subject on which accurate discrimination is of more importance, and none in which it is made with more difficulty. Scirrhus and cancer occur in every part of the body, glandular parts are however much more liable to the disease than others. A true scirrhus, before it degenerates into a cancer- ous sore, is hard and unequal on its surface, slightly sensible to the touch, not tending to suppuration, and en- larging very slowly in its commencement; "' but at length assuming a more active form, it is surrounded with superficial varicose veins, it becomes more painful, and changes the texture of the adjacent cellular mem- brane or cuticular covering, to which it frequently ad- heres : the skin will, in this advanced perjod, sometimes be discoloured, and puckered or retracted, especially in the female breast; perhaps attended with a degree of vol. i. 3 r> 386 ELEMENTS OF SURGERY. softness or fluctuation in some part of the tumour, with shooting pains in its neighbourhood ; and at last break- ing into a malignant sore, with fungous flesh, and re- troverted edges; it is named an open cancer." The progress of the disease is not always equally ra- pid; in some cases a scirrhous tumour remains for many years indolent, and in other instances it ulcerates in a a few weeks after it is first noticed. It is always satisfactory to ascertain, if possible, the nature of a tumour after it is removed. The appearance of a scirrhous tumour has been very well described by Mr. Home. "When a section is made of such a tu- mour in an early stage, provided the structure can be seen to advantage, it puts on the following-appearance : the centre is more compact, harder to the feel, and has a more uniform texture than the rest of the tumour; and is nearly of the consistence of cartilage. This middle part does not exceed the size of a silver penny: and from this, in every direction, like rays, are seen ligamentous bands of a white colour, and very narrow; looking, in the section, like so many extremely irregular lines, pass- ing to the circumference of the tumour, which is blend- ed with the substance of the surrounding gland. In the interstices, between these bands, the substance is differ- ent, and becomes less compact towards the outer edge. On a more minute examination, transverse ligamentous bands, of a fainter appearance, form a kind of net-work, in the mashes of which the new-formed substance is in- closed. This structure accords with what Dr. Bailley describes to be the case, in cancerous diseases of the stomach and uterus. " In a further advanced stage of the tumour, the whole of the diseased part has a more uniform structure; no central point can be distinguished; the external edge is more defined, and distinct from the surrounding gland; and the ligamentous bands, in different directions, are ELEMENTS OF SURGERY. 387 very apparent, but do not follow any course that can be traced. " When the tumour has advanced to what may be called cancerous suppuration, which, however, does not always happen in the centre, before it has approached the skin, and formed an external sore ; it then exhibits an appear- ance totally different from what has been described. In the centre is a small irregular cavity, filled with a bloody fluid, the edges of which are ulcerated, jagged, and spongy. Beyond these, there is a radiated appearance of ligamentous bands, diverging tow ards the circumfer- ence ; but, the tumour near the circumference is more compact, and is made up of distinct portions, each of which has a centre, surrounded by ligamentous bands, in concentric circles. " In some instances, the scirrhus has no appearance of suppuration, or ulceration in the centre, but consists of a cyst, filled with a transparent fluid, and a fungous excrescence, projecting into this cavity, the lining of which is smooth and polished. When a large hydatid of this kind occurs, a number of very small ones have been found, in different parts of the same tumour; and, in other cases, there are many very small ones of the size of a pins' head, without a large one. These hyda- tids are certainly, by no means, sufficiently frequent in their occurrence to admit of their forming any part of the character of a cancerous tumour." In some cases cysts exist of various forms and sizes, and in different parts of the tumour; a late writer (Dr. Adams) pronounces these to be living hydatids. When tumours are extirpated exhibiting these appearances, we may rest assured that they would never have been dis- cussed and in all probability would have advanced to the state of true and malignant cancer. We are not how ever always able to predict what tu- mours will become so, and what particular tumours may 388 ELEMENTS OF SURGERY. remain unsuspected. Mr. Home with great and com- mendable candour remarks, that so much does the same disease differ in its appearance in different pa- tients, from the almost endless peculiarities of their con- stitutions, by which every part of their bodies must be more or less influenced, that it is not possible in prac- tice to distinguish, in all cases, between cancerous and scrofulous tumours, after they have advanced to a cer- tain stage, and he confesses that he has in many in- stances mistaken the one for the other, and has removed by operation tumours, which at the time had the appear- ance of being cancerous, but which upon examination after their removal were found of a scrofulous nature ; and, on the other hand, he has neglected to remove tu- mours, from circumstances making it probable that they were scrofulous, which afterwards became cancerous and destroyed the patient. Although surgeons generally have not confessed their mistakes, yet the immense disparity which appears in the record of their successes establishes the fact that Mr. Home has not been singular in confounding can- cerous with other diseases. Mr. Nooth, for example, declares, that in one hundred and two cases in which he extirpated scirrhous tumours, every patient remained free from a return of the complaint. Dr. Monro, on the contrary states, that of sixty cancers which he had seen extirpated, only four remained free of the disease for two years, and these afterwards became cancerous. Mr. Hill, in his Cases of Surgery says, he had ope- rated on eighty-eight genuine cancers, all ulcerated ex- cept four, and all his patients except two recov ered of the operation; ten however had the disease afterwards in other places. Among the diseases resembling cancer, Mr. Home describes one by which parts of a glandular nature are ELEMENTS OF SURGERY. 389 often attacked, as the alse of the nose, the os tincai and the glans penis,—this differs from cancer in not contami- nating the surrounding parts, and in not affecting the absorbent glands, nor the skin at a distance; it is pro- perly speaking an eating sore which is uniformly pro- gressive ; whereas in cancer, after the sore has made some progress, a ridge is formed upon the margin, and the ulceration no longer takes that direction. It also differs from cancer in admitting of a cure in many in- stances, and under different modes of treatment. Cancer has by many writers been considered as a contagious disease, of this opinion there is however no well grounded proof. Some facts have been recorded which prove disease to have resulted from the applica- tion of cancerous matter to sound parts, but no instance has been produced in which a cancerous sore has been the consequence. Mr. Pearson who has treated this sub- ject with great ingenuity, remarks, that " virulence and contagion are very different things; the bite of a viper, or the sting of a scorpion, may poison a part by the ma- lignant quality of the venom that is injected, without communicating a contagious disease, and the fluid taken from a pustule or an ulcer, may erode a part by its che- mical qualities, and yet the matter formed by this new sore shall not possess similar properties with that which produced the ulceration. It is not sufficient therefore to assert, that the fluid of a cancerous sore occasioned an ulcer in a sound person ; it ought to be proved that the ulcer thus produced was truly cancerous." Cancer has also been considered an hereditary dis- ease. Mr. Home is inclined to believe that a predispo- sition to cancer, depending on local peculiarities of struc- ture, may be transmitted from parents to their descen- dants, and in this sense of the word, the disease is no doubt hereditary. This idea originated with Mr. Hun- ter who illustrated it by observing that of fifty persons who may receive similar accidents in glandular parts. 390 ELEMENTS OF SURGERY. not more than one or two will be afflicted with subse- quent cancers. The disease occurs at almost every age; it is most frequent, however, in advanced life. The period of the cessation of the menses in women, is supposed very obnoxious to cancer. Dionis says that he saw very many women in the nunneries of France, afflicted with cancer, and that by much the greater part were between the ages of forty five and fifty, and that in those who had cancers at an earlier period the catamenia were either very irregular or had been entirely obstructed. The female mamma is perhaps the most frequent seat of cancerous affections, and as this part is liable to se- veral other diseases, it may not be improper to describe some, with which cancer has often been confounded. In some cases the whole substance of the mamma will enlarge gradually till it acquires an enormous size, with- out very acute pain; the patient complains of great ten- derness and soreness, but the greatest inconvenience is derived from the bulk and weight of the tumour; some- times the swelling is attended with considerable heat and redness of the part and symptomatic fever. The skin of the breast in many instances, is not at all disco- loured, in some it is reddened. This complaint is not peculiar to married women but occurs also in the sin- gle. In these cases copious depletion, and antiphlogistic measures, local and general, must be used, cupping, bleeding, purging, low diet, &c. They generally suc- ceed, but even if they do not leave the breast of its usual size, the swelling has no cancerous tendency and re- mains without any inconvenience being sustained, but from its bulk and weight. These, however, are in them- selves serious evils, and the breast is sometimes removed to relieve the patient from them. Under such circum- stances no doubt of a recovery need exist. ELEMENTS OF SURGERY. 391 A chronic inflammation sometimes occurs in the breast, producing considerable deep seated pain;—a tumour is felt very hard and deep in the substance of the mam- ma;—heat and throbbing are perceived, and sometimes shooting pains through the diseased part;—the skin ge- nerally retains its natural appearance, but if the disease advances to suppuration it becomes red and sore;—it at- tacks young women chiefly, and without any exciting cause being evident. Very copious depletion will ge- nerally prevent suppuration and relieve the patient. Local and general bleeding with the usual antiphlogis- tic means are to be tried, and if any hardness remain after their use, cicuta and mercury may be administer- ed—and these generally produce a speedy absorption of the tumour. The breasts of females like every other part of the body are liable to scrofula. Scrofulous tumours have been described by the ancient writers, under the name of spurious scirrhi; sometimes they commence so gra- dually as to assume many of the appearances of scirrhus, but in general they may be distinguished. Where the skin only is affected no danger of scirrhus exists. In scrofula the disease is more diffused, the skin soon becomes red, and the symptoms of inflamma- tion are more rapid, and sometimes terminate very spee- dily in suppuration. Where a number of tumours exist in the breast we may pronounce them in most cases to be certainly scro- fulous. Hydatids are sometimes found to constitute the tu- mours, which are removed as scirrhi, these are not rea- dily distinguished, and when extirpated there is no dan ger of a return of disease. Notwithstanding this, it must be confessed that it is in many cases very difficult, nay in the present state of sur- gical knowledge, absolutely impossible to pronounce with 392 ELEMENTS OF SURGERY. certainty, what cases are scirrhous and what scrofulous. This should induce the surgeon in doubtful cases to choose the safest side, and to extirpate those tumours which have a suspicious aspect. It is not necessary to say much of any remedy for cancer except the extirpation of the diseased parts. It will be sufficient to state that certain discutient, corro- sive, and narcotic medicines, from the vegetable, ani- mal, and mineral kingdoms have been employed, most of which have had a temporary reputation but do not at this time retain the confidence of medical men. The use of narcotics is proper with a view to alleviate pain, and corrosive medicines are sometimes employed to destroy fungous flesh from the surface of the sore; discutient applications, as has been already stated, have no effect upon genuine cancer. The internal use of arsenic has lost its character as a remedy for cancer, and preparations of iron, a fashion- able substitute, lately introduced by Mr. Carmichael, will no doubt speedily share the same fate. The best mode of abating the pain of cancer is by a very abstemious diet; Mr. Pearson recommends a diet so low, as barely to support life, such as barley water, tea, &c. A milk and vegetable diet has relieved the agonies of many cancerous patients. As local applications I subjoin the following list from the article Cancer in Rees' Cyclopedia.—Fresh bruised hemlock leaves.—Scraped young carrots.—-The ferment- ing poultice.—Finely levigated chalk.—Powdered char- coal.—Carbonic acid gas.—A watery solution of opium. —Liquid tar, or tar-water. The internal remedies which have been most beneficial are—-Very small and long continued doses of arsenic.—Liberal doses of cicuta. —The free use of opium.—Belladonna.—Solanum.— Martial flowers.—Corosive sublimate.—The juice of clivers or goose-grass. But neither the external nor in- ELEMENTS OF SURGERY. 393 ternal remedies, however apparently useful for a time, can be in the least depended on for the cure of a ge- nuine confirmed cancer. Where the operation is concluded on, it should be performed early, for authors agree that where the poison is absolutely formed, and the neighbouring parts conta- minated, the prospect of success is greatly diminished, and in cancer of the breast where the glands of the axilla are affected, Mr. Cline and Mr. Home declare it too late to perform the operation with any " assurance of success."*—But experience warrants us in differing from the gentlemen whose names have been mentioned. In this country Dr. Physick has extirpated the breast in se- veral instances in which the glands of the axilla have been affected, and he has applied ligatures so as to eradi- cate these also. In some cases the disease has returned, but in several he has had the satisfaction to believe that life has been prolonged by the operation, and at the ex- piration of several years his patients remain free from all disease. Two methods of extirpating tumours are in use. The knife and caustic. The advantages of the former are very great; the surgeon has it in his power to remove the whole of the diseased parts from the healthy, and th* diseased may be discriminated in the course of his inci- sions, but with caustic it is impossible to judge precisely what parts will be removed. If, however, from the great terror of surgical operations which exists in some patients, or from any other cause, the caustic be preferred, Mr. Home recommends a preparation of equal parts of white arsenic and sulphur. When the knife is to be used, the following are en- • ll is here necessary to state that the glands of the axilla may be enlarged rom sympathy, in which case they vary in size at different times; where they are contaminated by the poison Uiey gradually and uniformly increase, and the knife is often useless. To the latter case the present observations refer. VOL. I. 3 E 394 ELEMENTS OF SURGERY. couraging circumstances :—First, Where the diseased parts are so situated as that they may be removed*with- out wounding any large blood-vessels and nerves, and where the whole of them may be completely eradicated. Second, Where the disease has resulted from accident, and has not occurred spontaneously. Third, Where the patient is in good general health. Fourth, Where the disease is slow in its progress, and has not contami- nated the surrounding parts. OF THE EXTIRPATION OF CANCEROUS BREASTS Previously to the operation, the parts should be ex- amined with great attention, in order to ascertain the ex- tent of the disease, and the surgeon in this, as in every operation for the removal of cancerous parts, should not merely cut away the parts already indurated and diseas- ed, but likewise some portion of the surrounding sub- stance in which a diseased disposition may probably have been excited. In performing the operation the patient is to be seated in a chair in a good light. If the skin be sound, and a tumour only exists in the breast, a straight incision may be made through it, and the diseased part dissected out. But if it is determined that a part of the skin should be removed with the tumour, two incisions are to be made, forming an oval figure between them, in which all the skin to be taken away, is included ; and as dividing the skin is the most painful part of the operation, both these incisions should be completed before any thing else is done ; and the lower part of the skin should be divided first, since, if a wound is made in the upper part, the ef- fused blood covers the skin below, and prevents the sur- geon from seeing accurately where the second incision ought to be made. These incisions should be nearly in the direction of the fibres of the pectoral muscle. If the ELEMENTS OF SURGERY. 395 glands in the axilla are diseased, tfie incision should be high enough in that direction to allow of their removal with the tumour. The best way to do this is to dissect the diseased breast out first, and then to dissect upwards, without cutting it off, and detach the hardened lympha- tics and glands in the arm pit which will be pulled down by the weight of the tumour, and thus the operator will be enabled to extirpate them more conveniently. As soon as the fingers can be passed above the indurated axillary glands, they are to be cut off, but before this, the cellular membrane connecting them above is to be tied by a firm ligature, to prevent hemorrhage from any vessel that may be contained in it. This direction is of the utmost importance ; for if it be neglected, the vessels will retract so high into the axilla, that the surgeon will be unable to secure their orifices. When the tumour is taken out, the bleeding vessels should very carefully be tied, and the edges of the wound brought into contact, and kept so by adhesive plasters and compresses, so that as much as possible of the wound may unite by the first intention. The ligatures are to be left out at the angles of the wound. Scirrhous tumours sometimes form in the neck, and when they are deeply seated great hazard attends their removal; in general, however, the tumours found in the neck are of a scrofulous, and not a cancerous nature. Mr. Pearson denies that the absorbent glands, which are found indurated under the lower jaw, are in any case scirrhous, unless they have been com -mated by can- cerous ulcers of the lip, tongue, or fauces. In some ca- ses it is necessary to remove them, even when they are evidently not scirrhus, on account of their impeding the functions of respiration and deglutition, or because they compress the blood-vessels of the neck : no unpleasant consequences result from their ext' rpation, and the chief eaution necessary is to avoixl wounding the vessels. 396 ELEMENTS OF SURGERY. The parotid and submaxillary glands are often the seat of true cancer. The nose and other parts of the face are also occasionally attacked by cancerous ul- cers. The term noli me tangere has been applied to some of these complaints. The ulcers described by dif- ferent writers under this name, are so very various, that it is certain they have attached no precise idea to their definition. One author describes it as a disease of the nose exclusively.* Others have seen it on the legs and arms. The term lupus has been attached to it when in these latter situations. I am persuaded that the disease recently described by Mr. Hey and Mr. Burns under the titles of fungus hematodes, and spongoid inflam- mation, are of the same nature, as many of the cases de- nominated by the older writers noli me tangere. In many of these ulcers on the face, as well as in other situations, fungous granulations arise to a very great height, and their growth is in some cases so rapid that Wiseman asserts it to be obvious to the eye. The ap- plication of caustic has proved successful in some cases ; where the whole of the diseased parts can be completely extirpated by the knife, they should be removed. In general, however, when the parotid gland is affected, this cannot be done, and the attempt will only aggravate the disease, and hasten its progress. Cancer of the tongue is unusual, but is occasional- ly met with; Mr. Home has seen two cases of it, one of which occurred in a gentleman between fifty and sixty years of age. Upon dissection after death, a large gland was found under the coronoid process of the lower jaw, weighing two ounces and a half, all the lymphatics in the vicinity were diseased, and the cancer extended to the pharynx. As cancerous ulcers are probably in the present state of our knowledge incurable, and always unless the diseased parts are removed, terminate fatally, * Cooper. elements of surgery. 397 we should not hesitate to extirpate the tongue when af- fected with cancer; the mode of effecting this has al- ready been described, it is however proper to add, that from the testimony of Desault and others, we learn, that patients in whom great portions of this important organ have been removed, have not entirely lost the power of speaking intelligibly. The rectum is sometimes affected with scirrhous and cancer, no cases of recovery from this complaint are re corded. Opiate clysters, and opium, introduced in form of pills into the rectum give great relief. The ulcera- tion, in a case described by Mr. Home, extended through the bladder, and faeces were voided with the urine. The tunica vaginalis testis has been found can- cerous. Mr. Hunter once extirpated nearly the whole of it in a scirrhous state. The bladder is liable to cancer. Gooch relates a case in which the bladder of a boy, only eight years of age, was affected with scirrhus,—he died,— and upon examination, the bladder was found thickened and con- tracted, so as to resemble "the gizzard of a fowl," and was incapable of containing more than a spoonful of urine; it contained two calculi. Cancer of the penis is not unfrequent, it commences usually with a wart or tubercle on the prepuce, frenum, or glands. This often remains quiescent for many years, but if irritated becomes painful, increases in bulk, aud attains in a short time a very large size. Ulceration takes place attended with a discharge of fetid sanies. When the ulcer continues long, the urethra is exposed and fistulous openings form, through which the urine flows, and the disease is aggravated. The glands in the groin and upon the ossa pubis are affected, and the di« 398 ELEMENTS OF SURGERY. ease extends in their course. To distinguish venereal warts from those tending to cancer is in general not diffi- cult ; and when the cancer exists, the penis should be re- moved before contamination is gone too far. Mr. Hey has published seven cases of cancer penis, jn six of which the patients had a natural phymosis. He remarks that the occurrence is extraordinary if it have no connection with the disease. In six of these cases Mr. Hey effected a cure by amputation. In the seventh the disease recurred. The amputation of the penis is to be performed when- ever the disease is evidently of a cancerous nature. The operation is very simple, a circular incision is to be made through the skin, with a bistoury at some distance (half an inch if practicable) from the diseased part, the skin is to be drawn back a little, and the body of the penis cut through with one even stroke of the knife, at the part to which the skin has been retracted. The bleeding ves- sels are then to be secured with ligatures. Three prin- cipal vessels are to be looked for, one on the dorsum pe- nis, and one in each corpus cavernosum. An elastic catheter is now to be introduced into the urethra, and the skin drawn forward so as to cover the stump, and secured in this situation with strips of adhesive plaster. The catheter is objected to by Mr. Pearson, but in some cases where it has been omitted the external aperture of the urethra has been greatly contracted by the healing of the wound. After the first dressing is removed, a pled- git of simple cerate is to be applied and renewed as often as may be necessary. Mr. Hey says that in amputating the penis he has found great advantage from having wrapped some tape round the sound part; in this way he was enabled to divide the integuments more easily and correctly, and he was also furnished with a useful kind of tourniquet, which secured the divided vessels from bleeding, till he was prepared to take them up with the tenaculum and ELEMENTS OF SURGERY. 399 ligature. He remarks, that "it requires great care to se- cure the larger arteries, as they are apt to shrink and conceal themselves under the loose integuments to which they have no strong attachment." Cancer of the uterus though a rare, is a deplorable and hopeless case. The use of all irritating injections is improper. The greatest benefit will be derived from a strict adherence to a very low diet. Pain is to be re- lieved by the administration of opium. I have relieved the pain in one case very considerably by injections of warm barley water thrown up the vagina. An aqueous infusion of opium may be substituted if the barley water should not answer the purpose. Anodyne enemata are also very often necessary. The scirrhous testicle is a frequent disease, and sooner or later ends in cancer unless extirpated. Mr. Pott's description of this complaint is extremely accu- rate. "When the testicle becomes enlarged in size,— hardened in texture,—craggy and unequal on its sur- face,—painful ou being handled,—attended with irregu- lar pains shooting up the groin into the back, and this without any previous inflammation, disease, or external violence, the testicle is said to be affected with a scir- rhus"—he further adds that in such cases early castra- tion may be recommended and practised by every honest and judicious surgeon. If this is neglected—hectic supervenes—ulceration takes place—a fungus shoots out from the surface of the testicle, and the patient falls a victim to the neglect of his case. There are several diseases of the testis comprized under the general name of sarcocele which it is impor- tant to distinguish from cancer. Hernia humoralis in its recent stage cannot be mistaken for scirrhus, but after the acute symptoms subside a great degree of indu- £00 ELEMENTS OF SURGERY. ration remains, with an enlargement and unequal sur- face. The epididimis often continues hardened for some months, but generally we are able to produce reso- lution, or if the testicle even suppurates the abscess very readily heals without occasioning much general disease. None of the symptoms of scirrhus exist in this case, as the pain ceases and the hardness subsides. A scrofulous tumour of the testis is described by writers which exists either in the spermatic cord, the epididymis, or the body of the testicle. This may also be distinguished. Here the inflammation runs higher, and comes on more rapidly than in cancer, the system sym- pathizes, and fever is produced, the pain is very obtuse, and rather deserves the name of soreness than of pain. This complaint gets well very readily in some cases, and is reproduced by exposure to cold or intemperance, and suppuration, with collections of matter take place in va- rious parts of the scrotum. A disease described by Mr. Abernethy under the name of medullary sarcoma, may not improperly be no- ticed here. . It has been called soft cancer, and appears to be as malignant and incurable as that which has al- ready been described. The following case from Aber- nethy's writings will convey a clear history of the dis- ease. " A tall, thin, healthy-looking man, of about forty years of age, had, about fifteen years before, a swelled testicle from a gonorrhoea; the epididymis remained in- durated. Six years afterwards it became enlarged, and a hydrocele at the same time formed. Half a pint of water was discharged by a puncture, but inflammation succeeded the operation, and the testis became very large. An abscess formed, and burst in the front of the scrotum, and the testis subsided in some degree. Mer- cury was employed to reduce it, but without effect. The part, however, was indolent, and gave the patient no trouble but from its bulk. ELEMENTS OF SURGERY. 401 u About a year afterwards, a gland enlarged in the left groin (the same side as the testis): another then be- came swollen in the right groin, and, in the course of two years, several glands in each groin had obtained a very considerable magnitude. At this period, he was admitted into St. Bartholomew's Hospital, under the care of Mr. Long. The testis was at this time, between four and five inches in length, and about three in breadth; it resembled its natural form and was indolent in its dis- position. The spermatic cord was thickened, but not much indurated. Four or five glands were enlarged in the groin on both sides; each of which was of the size of a very large orange; and when observed together, they formed a tumour of very uncommon shape and mag- nitude. "They gradually increased in size for several months, till at last the skin appeared as if unable to contain them any longer. It became thin, inflamed, and ulcerated, first in the left groin, and thus exposed one of the most prominent tumours. The exposed tumour inflamed and sloughed progressively, till it entirely came away. As the sloughing exposed its vessels, which were large, they bled profusely, in so much that the students endea- voured, but in vain, to secure them by ligatures: for the substance of the tumour was cut through, and torn away in the attempt. Pressure by the finger, continued for some time, was the only effectual mode of restraining this hemorrhage. "The loss of one gland relieved the distended skin, which had only ulcerated in the most prominent part of the tumour, and had not become diseased. It now lost its inflamed aspect; granulations formed, and a cicatrix took place. In the opposite groin a similar occurrence happened. One gland, exposed by the ulceration of the skin sloughed out, being attended by the circumstances just recited. However, before the skin cicatrized, ulce- VOL. i. 3 F 403 ELEMENTS OF SURGERY. ration had again taken place in the right groin, in con- sequence of the great distension of the skin from the growth of the tumour, and sloughing had begun in the tumour, when the patient, whose vital powers had long been greatly exhausted, died." Mr. Ramsden of London has recently published some very valuable observations on certain diseases of the tes- ticle. In the preface to this work he attempts to prove, that genuine cancer of the testicle is extremely rare ; that most of the cases of sarcocele which have been mistaken for it, arise from latent irritation in the urethra; he does not deny that the testicle is liable to scirrhus and to sarcocele, both of which may lead to an untractable state of ulceration, but he believes that " the malignancy of the ulcerative stage of true scirrhus in the testicle, does not, as has been supposed, depend on the presence of any morbid poison, but differs from the malignancy of the ulcerative stage of the common indurated testicle merely with regard to the part of the gland in which irritation causing its derangement has been primarily established. In illustrating this opinion, it is to be remarked that when a testicle is effected by true scirrhus, as it is termed, its morbid alteration will be found to originate within its organic structure ; but when the gland becomes indurat- ed and enlarged, in consequence of exterior causes of ex- citements, the morbid symptoms are, in the first in- stance, entirely confined to the surrounding or interven- ing cellular substance. And hence, alone, it is that scirrhous is attended at an early period with a peculiar sallowness of countenance, and other symptoms of de- rangement in the system ; while the common indurated testicle will exist, and frequently advance to a great ex- tent, without at all interfering with the general health of the patient." There can be no question as to the propriety of em- ploying bougies in order to dilate a stricture of the ure- thra if it exist, but the extirpation of the testicle is not the ELEMENTS OF SURGERY. 4-03 less necessary because the incurable disease has been excited by " a latent principle of irritation in the urethra." The testis is doubtless liable to very numerous dis- eases, some of which have never been sufficiently inves- tigated ; one of these is an obstinate sinuous ulcer, which resists every caustic application, and refuses to heal even when all the diseased parts are, to all appearance, dis- sected or burnt out. Another is the fungous tumour which has lately excited some attention, and on which Mr. Lawrence has recently published a paper which I have not been able to procure. This fungous tumour I have known cured in a variety of cases, by the applica- tion of white oxyd of arsenic (or arsenious acid) a reme- dy, therefore, which I take the liberty to recommend, previously to removing the parts by the knife, w hich has been the general practice. OPERATION. The extirpation of the testis, when necessary, is an ope- ration by no means difficult. The skin of the scrotum becomes contaminated sooner than any other part in the vicinity, and therefore the first thing, as Mr. Home re- marks, is to mark out that portion of skin which ought to be removed. " This being done, the next thing is to dissect out the diseased testicle from its situation in the scrotum, taking care that the incision should always be in the sound and natural parts, and that every thing con- nected with the disease is left attached to the testicle it- self. Having gone thus far, the cord is to be examined, and dissected as high up as is necessary to come at a sound part, which, in the exposed state it is now in, de- tached from the skin and surrounding parts, can readily be ascertained. All that is necessary to complete the operation is tying the cord, which is best done by pass- 404 ELEMENTS OF SURGERY. ing a needle, armed with a double ligature, through it, in the interstice between the portion composed of the vas deferens and spermatic artery, and the loose veins and other parts, which, in a diseased state of the tes- ticle, are found much increased in size, and very vascu- lar. These ligatures are to be tied sufficiently tight to deaden the substance which is included in them, and then the cord is to be divided. " The cut edges of the scrotum are to be brought to- gether, and retained there by needle and ligature, adhe- sive plaster, or, simply by compresses of lint, according to the peculiar circumstances of the case. " It is a common practice, which is adopted by sur- geons of eminence, to cut down upon the cord, in the first instauce ; and, after exposing it for an inch in length, to pass a ligature behind it; and, having thus included the cord, and secured the spermatic artery, divide it below the ligature, and afterwards dissect out the testicle, like any other detached tumour. The motives for this prac- tice are founded in humanity, since the moment the nerves of the testicle are cut through the patient will be sensible of no material pain during the rest of the opera- tion. This advantage appears to me to be more than counterbalanced by the risk there is of the operation not being completed in the most satisfactory manner. " The first consideration in every operation in surgery is, that it should be so performed as to leave nothing to chance, and that the patient should have every security that the operation can afford him; its being done with a less or greater degree of pain, however desirable it may be that it should be as small as possible, is therefore only a secondary consideration. " From not seeing operations in this extensive view, young surgeons, upon slight grounds, are induced by theoretical opinions, to vary their mode of performing them, and too often make themselves liable to meet with ELEMENTS OF SURGERY. 405 more serious difficulties than those which they feared to encounter. " In this operation it is even recommended to cut down upon the cord, expose the spermatic artery, include it by itself in a ligature; and, by this neat and delicate opera- tion, save the patient much pain. Those cases, however. which require an operation, have the cord much thick- ened, and consequently much more vascular than in its natural state. I have known a surgeon take up the sper- matic artery alone, then five or six vessels one by one; and, after having kept the patient the time necessary for this purpose, find himself obliged to include the whole cord in a strong ligature, so many other vessels conti- nued to bleed." (Home) I wish merely to add to Mr. Home's account of this operation, that the best mode of tying the cord, is in my opinion to pass one strong ligature round the whole of it, including every nerve and vessel in it. The pain is not augmented, nor its duration increased by this, and the operation is greatly expedited by it. In making the first incision I would also recommend to carry the edge of the knife into the substance of the testis, which will immediately demonstrate the nature of the tumour, and will certainly divide all the investing membranes, which it is useless to do by a slow, cautious, and painful dis- section. OF FUNGUS HEMATODES. As this affection is in the opinion of most surgeons of a cancerous nature I shall describe it in the present chap- ter. Mr. Burns states that "it generally begins with a small colourless tumour which is soft and elastic, if there be no thick covering over it, such as a fascia; but other- wise is tense. At first, it is free from uneasiness; but, 406 ELEMENTS OF SURGERY. by degrees, a sharp acute pain darts occasionally through it, more and more frequently, and at length becomes in- cessant. For a considerable time, the tumour is smooth and even; but, afterwards, it projects irregularly in one, or more points; and the skin at this place becomes of a livid red colour, and feels thinner. In this place it ea- sily yields to pressure, but instantly bounds up again. Small openings now form in these projections, through which is discharged a thin bloody matter. Almost im- mediately after these tumours burst, a small fungus pro- trudes, like a papilla, and this rapidly increases, both in breadth and height, and has exactly the appearance of a carcinomatous fungus and frequently bleeds profusely. The matter is thin, and exceedingly fetid, and the pain becomes of the smarting kind. The integuments, for a little around the ulcers, are red, and tender : after ulce- ration takes place, the neighbouring glands swell, and assume exactly the spongy qualities of the primary tu- mour. If the patient still survive the disease in its pre- sent advanced progress, similar tumours form in other parts of the body, and the patient dies hectic. "After death, or amputation, the tumour is found to consist of a soft substance, somewhat like the brain, of a grayish colour, and greasy appearance, with thin mem- brane-like divisions running through it, and cells or ab- scesses in different places, containing a thin bloody mat- ter, occasionally in very considerable quantity. There does not seem uniformly to be any entire cyst, surround- ing the tumour; for it very frequently dives down be- twixt the muscles, or down to the bone, to which it often appears to adhere. The neighbouring muscles are of a pale colour and loose their fibrous appearance, becoming more like liver, than muscle. The bones are always ca- rious in the vicinity of these tumours. "The distemper is sometimes caused by external violence, though in general there is no evident cause whatever." ELEMENTS OF SURGERY. 407 The fungus nematodes occurs in different parts of the body. I have seen one case in which it sprouted from under the tendon of the biceps flexor cruris, and in another its situation was so high in the arm, that ampu- tation was performed very near the shoulder joint. Mr. Hey has seen it in the female breast; in the leg, neck and arm; on the back of the shoulder, and he thinks, also in the eye. Mr. Burns has seen it in the hip joint; upon dissection he found the joint surrounded with a soft matter resembling the brain inclosed in thin cells, and here and there, cells full of thin bloody water; 1fc- the head of the thigh bone and the acetabulum were ca- rious. With respect to the treatment of fungus hematodes, it must be confessed that there is no remedy but an entire extirpation of all the affected parts, and unfortunately, the patient often opposes this decisive practice in the commencement of the disease, which is the most proper time for it. Mr. Hey has applied numerous escharotics without the effect of checking the growth of the tumour. When the disease is seated on a limb, it ought, if possi- ble, to be removed without amputation. Not a vestige of morbid structure should be left after the operation, but the incisions should be made in sound parts, and if notwithstanding this, the disease should be reproduced, amputation ought to be performed without delay. Wher- ever the disease is seated, the parts ought to be freely and carefully removed. END OF VOLUME FIRST. wz. 5-70 J)7H?t 1313 v.l