*;;■ '* s « * • INSTITUTES AJ\ 1» PRACTICE SURGERY: BEING THE 0"TrELXlTBS A 0©WS£SS Off. SdOOVVSaft WILLIAM JgJBSON, M. D. PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SENIOR SURGEON AND CLINICAL LECTURER TO THE PHILADELPHIA HOSPITAL__BLOCKLEY. Segnius irritant arjimos demissa per aurem, Quam quee sunt oculis subjecta fidelibus.—Hor. FIFTH EDITION, ENLARGED. VOL. II. PHILADELPHIA: CAREY, LEA &'BLANCHARD. 1838. ViO G45U 1S3S v. a, Eastern District of Pennsylvania, to wit: BE IT REMEMBERED, that, on the twentieth day of January, in the forty- eighth year of the Independence of the United States of America, A. D. 1824, William Gibson, M. D., of the said district, hath deposited in this office the title of a book, the right whereof he claims as Author, in the words follow- ing, to wit:— "The Institutes and Practice of Surgery: being the Outlines of a course of Lec- tures, by William Gibson, M. D., Professor of Surgery in the University of Pennsylvania, Surgeon and Clinical Lecturer to the Aims-House Infirmary, &c. Segnius irritant animos demissa per aurem, Quam qux sunt oculis subjecta fidelibus.—Hor." In conformity to the Act of the Congress of the United States, entitled, "An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the limes therein mentioned"—And also to the Act, entitled, "An Act supplemen- tary to an Act, entitled, * An Act for the Encouragement of Learning, by se- curing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned,' and extending the bene- fits thereof to the arts of designing, engraving, and etching Historical and other Prints.'* D. CALDWELL, Clerk of the Eastern District of Pennsylvania. GniGUS Stxo., printers. CONTENTS OF VOLUME II. CHAPTER I. DISEASES OF THE NOSE AND ANTRUM - - - Page 9 Sect. 1. Polypus of the Nose......- - 10 Treatment of Polypus of the Nose - 11 2. Ozeena.......... 13 Treatment of Ozaena ...... 13 3. Polypus of the Antrum - - - - - - - 15 Treatment of Polypus of the Antrum ... 15 CHAPTER II. DISEASES OF THE MOUTH...... 18 Sect. 1. Labium Leporinum, or Hare Lip..... 18 Treatment of Hare Lip......19 2. Ranula......... 21 Treatment of Ranula -------21 3. Malformation of the Fraenum Linguae - - - - 22 Treatment of Malformation of the Frasnum Linguae - 22 4. Enlarged Tonsils -...... 24 Treatment of Enlarged Tonsils......24 5. Elongation of the Uvula...... 29 Treatment of Elongation of the Uvula - - - - 29 6. Fissure of the Palate....... 31 Treatment of Fissure of the Palate - - - - 31 7. Epulis, or Tubercle of the Gums - - - 38 Treatment of Epulis.....- - 39 CHAPTER IU. DISEASES OF THE NECK ....... 40 Sect. 1. Extraneous Bodies in the.OZsophagus 40 Removal of Extraneous Bodies from the Oesophagus - 41 2. Stricture of the Oesophagus......44 Treatment of Stricture of the QSsophagus - 45 3. Extraneous. Bodies in the Larynx and Trachea 47 Removal of Extraneous Bodies from the Larynx and Tra- chea .....-...47 4. Ulceration of the Glottis...... 5q Treatment of Ulceration of the Glottis *n V CONTENTS. Sect. 5. Bronchocele, or Goitre.......Page 52 Treatment of Bronchocele.....- 72 6. Torticollis, or Wry Neck...... 79 Treatment of Wry Neck - - - - - - 79 CHAPTER IV. DISEASES OF THE THORAX...... 82 Sect. 1. Hydrothorax, or Dropsy of the Chest ... - 82 Paracentesis Thoracis ... v. - 83, CHAPTER V. DISEASES OF THE ABDOMEN - - - - - - 85 Sect. I.j Ascites or Dropsy of the Abdomen .... 86 Paracentesis Abdominis.....- 86 2. Poisons in the Stomach...... 90 Treatment of Poisons in the Stomach .... 91 3. Hernia - - -, ... . . . y4 Genera] Treatment of Hernia.....97 4. Inguinal Hernia........100 Treatment of Inguinal Hernia ... . - 103 5. Femoral Hernia - - i . . . . . 108 Treatment of Femoral Hernia.....Ill 6. Umbilical Hernia -......114 Treatment of Umbilical Hernia.....115 7. Congenital Hernia - - - . . . . 119 Treatment of Congenital Hernia - - - - 120 8. Artificial Anus........122 Treatment of Artificial Anus.....123 CHAPTER VI. DISEASES OF THE RECTUM --...-. 128 Sect. 1. Prolapsus Ani -,- -......J28 Treatment of Prolapsus Ani.....130 2. Tumours within the Rectum......133 Treatment of Tumours within the Rectum - - 133 3. Hemorrhoids -*--. ..... 135 Treatment of Hemorrhoids.....136 4. Fistula in Ano - - -.....144 Treatment of Fistula in Ano - - . .' . 145 5. Encysted Rectum........jgj Treatment of Encysted Rectum .... 154 6. Stricture of the Rectum - - - . . . . j^g Treatment of Stricture of the Rectum - - . 157 7. Imperforate Anus - -.......ign Treatment of Imperforate Anus - 161 8. Foreign Bodies in the Rectum.....I64 Removal of Foreign Bodies in the Rectum - - 165 CONTENTS. CHAPTER VII. DISEASES OF THE TUNICA VAGINALIS AND TESTIS Sect. 1. Hydrocele ..... Treatment of Hydrocele .... 2. Hematocele ..... Treatment of Haematocele .... 3. Irritable Testis . . Treatment of Irritable Testis 4. Chronic Enlargement of the Testis Treatment of Chronic Enlargement of the Testis . 5. Encysted Testicle . . . • Treatment of Encysted Testicle 6. Tumours of the Scrotum .... Treatment of Tumours of the Scrotum Page 168 . '168 170 176 176 178 179 180 181 183 184 185 186 CHAPTER VIII. DISEASES OF THE PENIS . Sect. 1. Wounds of the Penis , Treatment of Wounds of the Penis 2. Ulcers of the Penis Treatment of Ulcers of the Penis . 3. Phymosis ..... Treatment of Phymosis 4. Paraphymosis .... Treatment of Paraphimosis CHAPTER IX. DISEASES OF THE URETHRA AND BLADDER . Sect. 1. Stricture of the Urethra Treatment of Stricture of the Urethra . 2. Fistula in Perinaeo . Treatment of Fistula in Perinaeo 3. Enlarged Prostate .... Treatment of Enlarged Prostate 1. Retention and Incontinence of Urine . Treatment of Retention and Incontinence of Urine 5. Urinary Calculus . . ... Treatment of Urinary Calculus 6. Lithotrity 7. Lithotripsy . . CHAPTER X. DISEASES OF THE EYE .... Sect. 1. Conjunctival Ophthalmia .... Treatment of Conjunctival Ophthalmia . . 188 189 190 192 193 195 196 198 198 200 200 202 207 208 210 211 212 214 219 223 235 245 277 279 281 VI CONTENTS. Sect. 2. Sclerotic Ophthalmia Page 283 Treatment of Sclerotic Ophthalmia 284 3. Iritic Ophthalmia . ... 285 Treatment of Iritic Ophthalmia 286 4. Psorophthalmia . 287 Treatment of Psorophthalmia 288 5. Pterygium ...... 289 Treatment of Pterygium 289 6. Encanthis ...... 291 Treatment of Encanthis 291 7. Opacity of the Cornea . - 292 Treatment of Opacity of the Cornea 293 8. Ulcer of the Cornea . 294 Treatment of Ulcer of the Cornea 294 9. Staphyloma ...... 296 Treatment of Staphyloma 296 10. Hypopion ...... 298 Treatment of Hypopion . / . . 298 11. Hydrophthalmia . 300 Treatment of Hydrophthalmia . 300 12. Obliterated Pupil .... 302 Treatment of Obliterated Pupil 302 13. Procidentia Iridis . 304 Treatment of Procidentia Iridis . 304 14. Cataract ..... 305 Treatment of Cataract .... 306 15. Congenital Cataract .... 312 Treatment of Congenital Cataract 312 16. Amaurosis ..... 314 Treatment of Amaurosis 315 17. Hordeolum ..... 316 Treatment of Hordeolum 316 18. Encysted tumours of the Eyelids 317 Treatment of Encysted Tumours of the Eyelids 317 19. Entropeon . . . . . 318 Treatment of Entropeon 318 !c0. Ectropeon ....'. 320 Treatment of Ectropeon 320 21. Fistula Lacrymalis .... 322 Treatment of Fistula Lacrymalis 323 CHAPTER XI. DISEASES OF THE EAR . . . . 326 Sect. 1. Diseases of the External Ear, and Meatus Auditorius 327 Treatment of Diseases of the External Ear . 329 2. Diseases of the Tympanum and Eustachian Tube 331 Treatment of Diseases of the Tympanum, &c. 332 3. Diseases of the Internal Ear 334 Treatment of Diseases of the Internal Ear . 335 contents. Vll CHAPTER XII. DISEASES OF THE ARTERIES Sect. 1. Aneurism .... Treatment of Aneurism 2. Aneurism of the Aorta Treatment of Aneurism of the Aorta 3. Aneurism of the Carotid Treatment of Carotid Aneurism 4. Axillary Aneurism Treatment of Axillary Aneurism 5. Brachial Aneurism Treatment of Brachial Aneurism 6. Inguinal Aneurism Treatment of Inguinal Aneurism 7. Popliteal Aneurism Treatment of Popliteal Aneurism 8. Aneurism by Anastomosis Treatment of Aneurism by Anastomosis 9. Varicose Aneurism Treatment of Varicose Aneurism CHAPTER XIII. DISEASES OF THE VEINS Sect. 1. Varicose Veins . . . Treatment of Varicose Veins . 2. Cirsocele .... Treatment of Cirsocele . . CHAPTER XIV. INJURIES OF THE HEAD . Sect. 1. Fracture of the Skull Treatment of Fracture of the Skull . 2. Concussion of the Brain . Treatment of Concussion of the Brain 3. Compression of the Brain Treatment of Compression of the Brain 4. Inflammation of the Brain Treatment of Inflammation of the Brain 5, Fungus Cerebri, or Encephalocele Treatment of Fungus Cerebri CHAPTER XV. * LOCAL DISEASES OF THE NERVES Sect. 1. Neuritis .... Treatment of Neuritis . Page 336 340 343 350 352 353 354 ... 356 356 361 361 363 363 368 369 370 370 375 377 .378 379 380 , . 382 382 384 385 386 388 389 390 392 396 397 398 399 401 402 403 vm CONTENTS. Sect. 2. Neuralgia Treatment of Neuralgia 3. Neuroma Treatment of Neuroma 4. Tetanus . . . Treatment of Tetanus CHAPTER XVI. AMPUTATION . Sect. 1. Amputation of the Thigh 2. Amputation of the Leg . 3. Amputation of the Arm and Fore-arm 4. Amputation at the Shoulder Joint, 5. Amputation at the Hip Joint 6. Amputation of the Fingers and Toes CHAPTER XVII. HYSTEROTOMY OR CAESARIAN SECTION Page 404 . 406 408 . 410 412 . 414 416 423 427 429 430 432 434 436 DIRECTIONS TO BINDER. FOR VOLUME SECOND. ate I. opposite . Page 26 II. 35 III. 148 IV. 229 V. . 307 VII. 308 VIII. 358 IX. . 359 X. 373 XI. 376 XII. 393 THE INSTITUTES AND PRACTICE OF SURGERY. CHAPTER I. DISEASES OF THE NOSE AND ANTRUM. The subjects embraced in the first volume of this work cor- respond with the arrangements of the anatomical lectures in the University, so closely, that by the time the latter are disposed of, the former may be entered upon. The same correspondence, however, has not existed, hitherto, in the arrangement of the matter of the second volume. To effect this, the distribution of the text, in the present and last edition, has been altered. If upon any occasion, then, the diseases should appear in this volume dis- jointed, let it be remembered that accurate collocation has been sacrificed to convenience and expediency. With these views, I commence with the diseases of the nose and antrum. The mucous membrane which lines the cavity of each nostril, not only covers the spongy bones, but extends to the antrum maxillare, to the frontal, ethmoidal, and sphenoidal sinuses, and even to the mouth and throat. Hence a similarity of disease is found to pervade each of these parts, the foundation of which may be said to be laid, generally, by inflammation produced by cold, specific diseases, and other causes. The most common dis- eases of these cavities, are polypous tumours, collections of pu- rulent matter, and ulcerations. Vol. II. 2 10 Polypus of the JVose. Section 1. Polypus of the JVose. • A polypus may spring from any portion of the Schneiderian membrane: it originates, however, most frequently either from the superior or inferior spongy bone. In shape it is usually pyri- forjn—being narrow at its root and expanded below; though this will depend very much upon the natural form of the cavity it occupies. Sometimes the base of the tumour is exceedingly broad. Not unfrequently a polypus originates high in the nose, and instead of falling forwards or towards the anterior nares, takes a backward direction, hangs behind the palate, and sometimes reaches the pharynx. One or both nostrils may be the seat of this disease. When both are filled, the patient breathes with difficulty, and with a peculiar rattling noisek In damp weather, the tumours often project beyond the nose, and contract and dis- appear as soon as the weather becomes dry. The consistence of polypus is not less variable than its form. Firm, fleshy, and very solid, in some instances, it is, upon other occasions, extremely soft, and so tender as to tear upon the slightest touch. The most common variety, so far as my experience goes, is that which bears, in consistence, shape, colour and size, a striking similitude to the common oyster. Most polypi are extremely vascular, and if rudely handled, bleed profusely. No age, or sex, is exempt from the disease, which sometimes assumes a malignant form, at bther times destroys the patient, by exciting, from pressure, caries of the spongy and ethmoid bones, inflammation of the brain, &c. Polypus of the JVose. 11 Treatment of Polypus of the JVose. Several operations, very opposite in character, have been practised for the removal of nasal polypus. I prefer in most cases the use of the forceps. These, when properly made, should be stouter than the common dressing forceps, with their extremities slightly curved, serrated, and a considerable slit or hole in each blade, about half an inch from its point. The pa- tient being seated before a strong light on a low chair, with his head moderately thrown back and firmly supported by an assist ant, the surgeon carefully introduces the instrument with its blades expanded, as far as the root of the tumour, takes firm hold of it, and by two or three turns of the instrument, instead of pulling in a straight line, twists it away. A copious gush of blood generally follows, especially if the tumour be partially re- moved. Clearing this away, the forceps are again and again in- troduced until the whole nostril be free, the strongest proof of which will be the freedom with which the patient can breathe or force air through the nostril. In performing this operation, great care must be taken not to use unnecessary violence, be- cause it has sometimes happened that the ethmoid bone has been broken up, and other mischief produced sufficient to lead to fatal consequences. This operation is chiefly adapted to polypi with narrow necks, and confined to the cavity of the nostril. The operation of excision has been recommended by J. Bell, Whately and others, for the removal of polypi of large size and broad base. There are very few cases, it appears to me, re- quiring such a measure. Independently of the difficulty of the ope- ration, the hemorrhage is always very profuse, and, besides the uncertainty of removing the whole of the disease, the surgeon will run considerable risk of injuring the sound parts in the neighbourhood of the tumour. Mr. Whately employs a sheathed knife, somewhat similar to Dr. Physick's bistoury for fistula in ano. The ligature, although recommended by some writers for every variety of polypus, can seldom be employed advantageous- ly, except where the tumour arises by a narrow neck and hangs beyond the posterior nares. In such cases, a silver or iron wire, 12 Polypus of the JVose. or a piece of catgut, eighteen inches long, should be doubled so as to form a loop, and introduced into the nostril until it appears below the palate, when it should be caught by a pair of narrow forceps, and drawn towards the mouth, and the loop at the same time expanded by the fingers of the surgeon. As soon as this is accomplished, the operator, still holding the loop with one or two fingers, draws the projecting ends of the wire with the other hand from the nostril, and thus by one simultaneous movement, carries the loop over the base of the polypus, and thence to its neck. The ends of the wire are next passed through the double cannula of Levret, and after being drawn so firmly as to constrict the neck of the polypus, are twisted upon the wings of the in- strument and secured. In proportion as the wire becomes loose from the shrinking of the tumour, its ends must be tightened every few hours until the polypus drops off, which it does some- times so suddenly as nearly to suffocate the patient. If the sur- geon should experience any difficulty, as he often does, in intro- ducing the wire and noosing the polypus in the manner directed, he may resort with advantage to the cannula of Bellocque. Whatever method may be practised for the removal of poly- pus, there are two points which must always be particularly at- tended to—the suppression of hemorrhage, and the removal of any fragments of the tumour so situated as to elude the instru- ments directed against them. The first may be accomplished, generally, by cold astringent solutions thrown up the nostrils by a syringe, or if these do not succeed, bypassing a catgut to which two or three dossils of lint are secured, through the nostril and mouth. The pressure thus created, hardly ever fails to stop the flow of blood. To guard against the return of the disease, from portions of the tumour being left behind, the argentum nitratum, repeatedly applied, will be found the most effectual remedy. See Foil's Chirurgical Works, by Earle, vol. 3, p. 165—/. Bell's Principles of Surgery, vol. 3,p. 89- Whately's Cases of two extraordinary Polypi removed from the Nose, the one by Excision with a new Instrument, the other by Improved For- ceps, 8vo. 1805—Callisen's Sysiema Chirurgise Hodiernae, vol. 2, p. 207—Lossus' Pathologie Chirurgicale, torn. 1, p. 528-Desehamps' Traits des Maladies des Fosses Nasales, &C.—C. BelVs Operative Surgery, vol, l,p. 208. Ozama. 13 Section II. Ozcena. A troublesome ulceration of the lining membrane of the nos- trils, attended with fetid discharge, and sometimes followed by destruction of the cartilage and by caries of the bones of the nose, is denominated by most modern writers ozaena. The ori- gin of the disease is very obscure, though there is reason to be- lieve that, in most instances, it is connected with the primary or secondary forms of syphilis. In other instances, marks of the purely scrofulous character are apparent. One of the most troublesome attendants of the disease is the accumulation of in- spissated mucus, or of incrustations in the cavities of the nose. These are sometimes so considerable in quantity, as to block up entirely the passages. After the ulceration is fairly established, it not only takes possession of the cartilaginous septum, the eth- moid and spongy bones, and the other bones of the nose, but ex- tends to the cheek. If the patient should recover after such ra- vages, he must for ever remain horribly deformed. Treatment of Ozcena. The remedies best adapted to the cure of ozsena are bark, iron, the mineral acids, muriate of lime, sarsapaiilla, and antimony. When there is any suspicion of the disease having originated from syphilis, mercury alone, or conjoined with other prepara- tions, should be employed. During the height of the inflamma- tion, solutions of opium and of the acetate of lead, may be in- jected into the nostrils, or applied to the ulcerated surface on lint Vol. II. 3 14 Ozcena. Some of the mild animal oils introduced into the cavities of the nose, will also prove serviceable, by softening the incrustations and lessening pain. After the inflammation has abated, more stimulating materials may be employed, such as solutions of lu- nar caustic, sulphate of copper, the ointment of the red oxide of mercury, citrine ointment, &c. Within the last five years, chloride of lime has been particu- larly recommended, in ozaena, by Dr. Horner. The first case in which it was tried was a very inveterate one of several years' standing, large quantities of very fetid matter being con- stantly discharged .from both nostrils, and after passing into the stomach occasioning great sickness and loss of appetite. A tea- spoonful of chloride of lime was put into a wine-glass full of wa- ter ; the clear solution was then injected into each nostril twice a-day, and the practice having been continued for a few weeks, a perfect cure was accomplished. Other similar instances have been reported, but time will show whether the medicine can be depended upon in the generality of cases. On the subject of Ozaena, consult Pearson's Principles of Surgery, p. 279—Hor- ner's Case of Ozaena, in American Journal, No. XL, May, 1830.—Craighie's Case of Pereostitas with Ozaena, in Ed. Medical and Surgical Journal, for January, 1834. Polypus of the Antrum. 15 Skction III. Polypus of the Antrum. Fuxuus or polypus of the antrum maxillare, is less frequent- ly met with than abscess of that cavity—a disease already treated of in another place.* It is, however, one of the most formida- ble affections in surgery, and unless speedily arrested, generally proves fatal. The tumour sprouts from the lining membrane of the antrum, from what cause it is always exceedingly difficult to determine, and grows with more or less rapidity, until it fills the whole of the cavity. By this time, considerable pain is ex- perienced in the cheek and eye of the affected side, and soon af- ter a perceptible enlargement of the face may be observed. These symptoms are, in the course of time, followed by distortion of the nose, projection of the eye, enlargement of the gums cor- responding to the antrum, profuse discharges of ^sanious, fetid, matter, and finally by protrusion of the bones of the face and alveolar processes, and, as a necessary result, by hideous deformi- ty. In consistence, the tumour is generally firm and fleshy, some- times soft, and in a few rare instances, ostco-sarcornatous or even bony. Treatment of Polypus of the Antrum. If, instead of temporizing, as is too common, until the disease is so advanced as to leave no reasonable hope of effecting a • See Vol. I. p. 128. 16 Polypus of the Antrum. cure, the surgeon were always to follow the practice of the en- lightened and fearless Desault, and operate at an early period, most patients, perhaps, would recover. As soon, therefore, as the nature of the tumour is ascertained, the surgeon should not only determine to remove it, but resolve to set no limits to the sacrifices it may be necessary to make. With this view he must provide himself with several curved and angular scalpels, of un- usual strength and thickness, two or three cauterizing irons, a key for pulling teeth, chisels, gouges, a mallet, &c. Every ar- rangement being made, the surgeon first separates, with a com- mon scalpel, the cheek from the maxillary bone, by opening the patient's mouth as widely as possible, and cutting through the internal membrane. His next object should be to remove the molares teeth and their alveolar processes corresponding with the floor of the antrum. This may be done by the tooth key, or by two or three strokes of a gouge and mallet. Having in this way exposed the cavity of the antrum and the surface of the tumour, the curved and angular knives must then be employed until every remnant of the disease is rooted out. The hemorrhage that follows the operation is sometimes extremely profuse, but may be instantly arrested, and with little pain to the patient, by one or two applications of the cautery. I have, however, performed several operations of the kind without ever being un- der the necessity of doing more towards stopping the flow of blood than plugging the antrum witli lint or tow. If the opera- tion prove successful, the antrum is filled in a few weeks with healthy granulations; but if the disease return, this is soon ren- dered evident by the reappearance and rapid growth of the fun- gus. To repress this, repeated applications of caustic, or the cautery, will be found necessary, or perhaps a second operation may be demanded. Sometimes the teeth and alveolar processes appear sound. In such cases, an incision should be made through the cheek from its outer surface, the anterior walls of the antrum perforated by a trephine, and the tumour removed through the opening. I say nothing of the modern proposal of curing polypus of the antrum by tying the carotid, because I have reason to be- lieve that all attempts of the kind hitherto made, (in which the ligature of this vessel was entirely depended upon,) have proved abortive. I should conceive it equally unnecessary, and Polypus of the Antrum. 17 not less reprehensible, first to tie the carotid, and afterwards to extirpate the tumour, inasmuch as the patient's danger must be increased tenfold, and without any adequate compensation. Cases occur, now and then, in which spontaneous cures of this formidable disease are effected. Twelve or fourteen years ago, a mulatto man with a large fungus of the antrum, came to me from Petersburg, Virginia, but refused to submit to an ope- ration, and returned home. From that period the tumour ceased to grow, and never afterwards, I have reason to believe, occasioned inconvenience. Ten years ago, a negro man from Fredericktown, Maryland, visited Philadelphia, and consulted me respecting a similar tumour of the antrum. I advised the operation, but he, also, refused to submit to it. A few months afterwards, the inflammation subsided, and eventually, the tu- mour was converted into bone. It has so remained ever since, is now entirely free from pain, and the health of the patient has long been excellent. Consult JDesault's Works, by Smith, vol. l,p. 141—Desault's Parisian Chirur- gical Journal, vol. 1, and 2—Traite" des Maladies Chirurgicales, et des Operations qui leur Conviennent par MM. Chopart, et Desault, torn. 1, p. 195—/. L. Des- champs' Traits des Maladies des Fosses Nasales et deleur Sinus—Suite d'Observa- tions sur les Maladies des Sinus Jfaxillaire, par M. Bordenave, in Memoires de FAcademie Royale de Chirurgie, torn. 13, edit, duodecimo, p. 367—Aber- nethy's Account of a Singular Disease in the Upper Maxillary Sinus, in Trans- actions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. 2, p. 309—Gibson on Bony Tumours, in the Philadelphia Journal of the Me- dical and Physical Sciences, vol. 3, p. 100—C. Bell's Surgical Observations, vol. 1, p. 413. 18 Disease of the Mouth. CHAPTER II. DISEASES OF THE MOUTH. Under this head may be included several diseases, some of which have already been treated of in the preceding volume. The principal affections of the mouth, and of the parts in its im- mediate vicinity, are hare lip, cancer of the lip,* cancer of the tongue,t ranula, malformation of the fraenum linguae, enlargement of the tonsils, elongation of the uvula, epulis or scirrhus of the gums, and caries of the teeth. To give even a general account of the diseases of the teeth, and of the various operations prac- tised upon them, would alone occupy a volume. The present state of surgical science, however, and the subdivision of profes- sional labour, would seem to obviate altogether the necessity of treating of these affections in a work of this descr ion. Section I. Labium Leporinum, or Hare Lip. This is a congenital [deformity, and takes its name from a supposed resemblance to the lip of a hare or rabbit. There are two varieties of the disease—the single and double. The for- mer is the most common, and is a simple fissure or slit, extending ♦See Vol. I. p. 171. | Vol. I. p. 174. Labium Leporinum, or Hare Lip. 19 from the edge throughout the substance of the lip to a greater or less extent: the latter is comparatively rare, and differs from the single variety chiefly in having a wider opening, and an intermediate hanging portion. Both varieties are often com- plicatedjwith a cleft or opening in the bones of the palate. The upper lip is, in nine cases out of ten, the seat of the disease, and the borders of the fissure are invariably rounded, and covered with the red and delicate membrane peculiar to the edges of the na- tural lips. Hare lip, independently of its deformity to the in- fant, proves a serious inconvenience by interfering with its powers of suction, and to the adult by interrupting speech, and preventing the articulation of labial sounds. Sometimes one or more of the incisor teeth project from the upper part of the hare lip nearly in a horizontal direction, and add very much to the deformity. Treatment of Hare Lip. * The only effectual remedy for hare lip is an operation, and the sooner this is performed the better. If the fissure in the lip is single, it will be sufficient to remove each of its rounded edges in the following way. The infant being firmly held in the arms of a nurse, or laid on a pillow with its head elevated and securely fixed by an assistant, the surgeon having previous- ly separated the internal membrane of the mouth and its frae- num, introduces between the lip and gums a narrow flat piece of wood five or six inches long. This being held by another assistant, the operator himself stretches the lip upon the board, and commencing near the nostril, makes an incision downwards, and at a single cut removes in a straight line the edge of the lip. The opposite edge is next detached in a similar manner, when the chasm left will resemble the letter V inverted. It only remains' to draw the edges of the wound together, and retain them'by the"twisted suture, taking care to commence by passing 20 Hare Lip. a pin first through the hanging edge or lower portion of the lip, instead of the upper. Two or three pins will generally be sufficient. They should be.passed horizontally, at regular in- tervals, and rather nearer the internal than the external surface of the lip. The close contact of the edges of the wound, and the pressure necessarily occasioned by the tightening of the ligatures, are sufficient to arrest the hemorrhage. Each pin should be surrounded by a separate ligature passed about it in the form of the figure 8. In four or five days, the adhesion is usually complete, and the pins may be withdrawn, to prevent them from exciting ulceration. When the operation for double hare lip is performed, it should be conducted upon the principles just laid down. But four in- stead of two incisions should be made—one on each side of the intermediate projection, which may then be dove-tailed, as it were, with the outer edges of the lip by one or two pins passed entirely across. The cleft in the bony palate, should it exist, generally closes up, sua sponte, provided trie operation be not too long delayed. When it is said, " the sooner the operation is performed the better," it should not be understood that it must be done immediately after birth. Infants of two or three weeks old, are very apt to die in convulsions, from operations. Four or five months after birth, will be a favourable period for the operation. See Sabatier de la Medicine Operatoire, torn. 3, p. 273, 8vo. 1810—Lassus' pathologie Chirurgicale, torn. 3, p. 45l—Richerand's Nosographie Chirurgicale, torn. 2, p. 255—Dictionnaire des Sciences Medicales, torn. 3, p. 55, article Bee de Lievre—Desault's Works, by Smith, vol. \,p. 148—5. Bell's Surgery, vol. 4, p. 447—C. Bell's Operative Surgery, vol. 2, p. 38—Kirby's Cases in Surgery, p. 61. Ranula. 21 Section II. Ranula. An obstruction of one or more of the ducts of the sublingual gland gives rise to the formation of a semipellucid soft tumour, denominated by the older surgeons ranula—from an imaginary resemblance to the belly of a frog. This tumour is generally filled with saliva, or with a viscid fluid resembling the white of an egg. Sometimes it attains so large a size as to interfere with speech and deglutition, and even to displace the teeth. It arises either from adhesion, or natural imperfection of the duct, or from the lodgement of a calculous concretion within its passage. Children and infants are more subject to the complaint than adults. Treatment of Ranula. A simple evacuation of the fluid with a lancet answers no purpose, inasmuch as the opening closes again in a few hours. To effect a permanent cure the cyst must be laid open freely, or a portion of it removed with scissors. The application of caustic may afterwards become necessary. See Lassus' Palhologie Chirurgicale, torn. 1, p. 402—C. Bell's Operative Sur- gery, vol. 2, p. 2\—Callisen's Systema Chirurgise Hodiernaf, vol. 2, p, 108. Vol. II. 4 22 Malformation of the Fmnum Lingua. Section 1U. Malformation of the Fmnum Linguce. It sometimes happens, though not so frequently as imagined, that children are born with the fraenum of the tongue so short, as to prevent them from sucking. To ascertain whether this be really the case, the surgeon should endeavour to raise the point of the tongue with a spatula. If he should fail in this attempt, and the tongue appears upon examining it on the side to be un- naturally confined, little doubt can remain of the fraenum being defective. Treatment of Malformation of the Fmnum Lingua. Although the division of the fraenum linguae is usually looked upon as a trifling operation, it is one that should not be lightly performed, and upon every common occasion. Petit relates two instances, in which death followed from the fraenum being so much loosened, as to permit the tongue to fall backwards into the pharynx, and suffocate the patient. Other cases are recorded of fatal hemorrhage from wounds of the ranine ar- teries and veins. To guard against accidents of this description, the operator should use a pair of probe-pointed scissors, and lake JHalformation of the Fmnum Lingua. 23 care to direct their points downwards, and divide no more of the fraenum than is absolutely necessary. Dr. Dewees, whose experience in the treatment of the diseases of infants, is equal, perhaps, to that of any practitioner living, objects to the use of scissors in the division of the fraenum linguae, and employs, instead of them, a common gum lancet. He has never met with a case in which the tongue was swallowed, or of hemor- rhage, from the division of the ranine arteries, or other vessels. Hence it may be fairly inferred that such accidents must be ex- ceedingly uncommon. According to the same practitioner, there are two causes that may give rise to an operation, the one an adventitious membrane, which pursues the natural fraenum throughout its whole course, and even continues beyond the fraenum, and ties the tongue so completely down, that the child cannot raise the tongue, or carry it beyond the lips—the other, an actual shortening and thickening of the proper fraenum itself. See Petit's TraiU des Maladies Chirjirgicales, torn. 3, p. 260—Burns' Surgi- Anatomyof the Head and Neck, p. 264—C. Bell's Operative Surgery, vol. 2, 24 Enlarged Tonsils. Section IV. Enlarged To?isils. Enlargement of the tonsils is very common among scro- fulous children, and arises from exposure or repeated attacks of catarrh and sore throat. Sometimes, however, the disease is slowly induced without being preceded by pain, swelling, or any of the characteristics of acute inflammation. H suffered to remain for any length of time, the tumours occasionally attain so large a size as to interfere materially with respiration and deg- lutition. Persons troubled, with this disease, have a peculiar hoarse, husky, or croaking voice, and when labouring under cold, wheeze excessively. Treatment of Enlarged Tonsils. The knife and ligature have been frequently employed in the removal of enlarged tonsils. To the latter the preference is usually given, inasmuch as there is no risk of hemorrhage, a consequence sometimes apt to follow the use of the knife even when employed with the utmost caution. Formerly the liga- ture was suffered to remain upon the enlarged gland for several days, or indeed until the tumour sloughed away, and from this practice great irritation about the fauces, tongue, and mouth, en- sued. To obviate these inconveniences, Dr. Physick first sug- Enlarged Tonsils. 25 gested the following mode of practice. The operator takes a double cannula, about four inches long, and passes through it, doubled, a piece of soft, flexible iron wire, one twenty-fourth part of an inch in diameter, secures one end of the wire to an arm of the cannula, and permits the other end to project about five or six inches beyond the opposite barrel of the instrument. The cannula being thus armed, the loop of wire is spread out to a sufficient extent to pass over the tumour, and is bent a little to one side, that it may with the greater facility approach its base. An assistant holds down the patient's tongue with the han- dle of a large spoon, while the operator conveys the wire over the base of the tumour, and taking hold of its projecting end draws it loosely in order to ascertain whether it is properly fixed. Finding this to be the case, and that the uvula is not included, the end of the wire is then seized with a pair of flat pliers, drawn as firmly as possible, and secured by wrapping it around the re- maining arm of the cannula. The wire, thus applied, should be permitted to remain on the tonsil twenty-four hours, and then dis- engaged in the following way. The cannula being firmly held with one hand, the other is employed in loosening the end of the wire from the arm of the instrument; having accomplished which, the surgeon straightens the wire with the pliers, and pushes it backwards until it is removed from the tonsil. In a few days the tumour drops off entire, or in fragments, and the ulcer left heals without difficulty. For several years the late Dr. Physick pursued the above prac- tice ; but experience taught him that although the operation, thus modified, was free, in a measure, from the inconveniences of the old method of using the wire, there were yet objections to the practice which he had not anticipated. In particular, he found that, in some instances, profuse ptyalism, swelling of the throat, difficulty of breathing and swallowing, (sometimes followed by ulceration of the soft palate and fauces,) were induced. Of late years, therefore, he has abandoned the ligature, in toto, and em- ployed the knife. The instrument he uses was originally in- vented by him for truncating the uvula. " In the operation for cutting off the uvula, Dr. Physick has, until very lately, used scis- sors ; but being unable to complete the operation by one applica- tion of that instrument, several have been necessary to effect the 26 Enlarged Tonsils. division of the part. To obviate this difficulty, he determined to try the old instrument, as modified and represented by Benjamin Bell, in his System of Surgery. He found, however, that al- though he could divide with that instrument the greater part of the uvula, a portion of the membrane that covers the back part of it was not always divided, making the use of the scissors necessary to cut it through. To remedy this inconvenience, he caused an instrument to be made having two plates instead of one, between which the knife was passed; but still the same dif- ficulty was experienced in cutting through the membrane on its posterior part. He then thought of wrapping a strip of waxed linen over the semicircumference of the opening, to sup- port the membrane until it should be divided by the knife. Thus constructed, the instrument answered the purpose com- pletely, and cut through the whole substance of the part in an instant. Dr. Physick has since used an instrument of similar construction, for the removal of scirrhous tonsils. He finds it easy to cut off the whole, or any portion that may be necessary, of the enlarged tonsil in this manner. The operation can be finished in a moment of time. The pain is very little, and the hemorrhage so moderate that it has not required any attention in four cases, in which he has lately performed it. The size of the perforated end of the two plates, and of course that of the knife, must be larger in the instrument for extirpation of the tonsils, than in that for truncation of the uvula."* The con- struction of this instrument will be better understood by ex- amination of Plate I. fig. 1 and 2. In a subsequent account of Dr. Physick's instrument, it is remarked, that "occasionally there is some difficulty in passing the circular aperture in the extremity of the two plates completely and speedily over the tonsil to its base. In such cases the operation may be much facilitated, by using a forceps with a lunated extremity, to which teeth are adapted, invented by Dr. Physick, by means of which the tonsil may be seized and drawn through the aperture to any distance that maybe deemed proper, when its extirpation can be immediately effected. It may not, however, be improper to observe that, under ordinary circumstances, the aid of the forceps * American Journal of Med. Sciences, Feb. 1828. ^ Enlarged Tonsils. 27 is altogether unnecessary. The forceps is about seven inches long, curved near its extremity, which is lunated and armed with teeth."-* Having experienced more or less difficulty in the removal of enlarged tonsils—owing, chiefly, to the number of instruments, such as spoons, hooks, forceps, &.c, required—it occurred to me that an instrument might be contrived that would answer the purpose of all these—by keeping down the tongue, holding the gland firmly, and separating it nearly at the same moment. Such I accordingly projected, and ordered made, and upon trial found to answer my most sanguine expectations. For several years past I have used it, in a number of instances, and have seen it used by others, and can, therefore, speak of it decisively. It consists of a pair of forceps nine inches long, the eighth of an inch thick, half an inch broad, when shut, with extremities an inch and a half long, slightly serrated and somewhat curved, in- cluding, when closed, an oval space a quarter of an inch wide, and terminating, at the other extremity, in handles which stand off obliquely from the shafts of the instrument. A knife, or blade, the length and breadth of the forceps, rounded on its cut- ting edge, and having a button placed perpendicularly to its axis on the opposite extremity, works backwards and forwards by means of a groove, to the extent of an inch and upwards, be- tween the blades of the forceps, to one of which it is secured by screws. A sheath upon each end of the forceps, to keep the knife from starting off the moment it touches the tumour, com- pletes the instrument.! See Plate I. fig. 3. To apply the instrument properly, it will only be necessary to introduce it into the patient's mouth with the blades closed and resting flat upon the tongue, which is thus kept depressed. The instrument is then turned on its edge, still resting on the tongue, its blades expanded, placed fairly around, and completely behind the tumour, which is then seized, and firmly held, while the thumb, resting on the button-like extremity of the knife, pushes it forwards and instantly separates the enlarged tonsil, which is immediately brought away in the grasp of the forceps. * Am. Journal of Med. Sci. May, 1828. ■j- This instrument, as well as Dr. Physick's for the same purpose, was manu- factured by Mr. H. Schively, 28 Enlarged Tonsils. To prevent any portion from being left, or the tumour from hanging by a narrow neck, the surgeon should see that the knife reaches to the very extremity of the forceps, and should be sure that the whole of the tumour is fairly within the grasp of the in- strument. The instrument may be applied indifferently to either tonsil—care being taken always to place the surface of the for- ceps on which the knife rests to the base of the tumour. Profuse hemorrhage sometimes follows the excision of the ton- sils. The surgeon, aware of the possibility of this, should take care not to apply the knife too near the base of the tumour. More than twenty years ago, I cut off an enlarged tonsil with scissors from a medical student, now a respectable practitioner at Bedford, Pennsylvania, and had great difficulty in preventing the hemorrhage from terminating fatally. Wiseman and Moscati point out danger from another source—the falling of the tonsil backwards, when partially cut, upon the rima glottidis—and re- late cases of suffocation from that cause. See Desault's Works, by Smith, vol. 1, p. 193—Sharp's Treatise on the Opera- tions of Surgery, p. 199, edit. 9—Chevalier's New Mode of Tying Diseased Ton- sils, in vol. 3, p. 79, Medico-Chirurgical Transactions—Dorsey's Surgery, vol. 1, p. 422—The Double Cannula and a Wire, recommended in the Operation of Ex- tirpating Scirrlious Tonsils, and Hemorrhoidal Tumours, by Philip'Syng Physick, M. D. in vol. 1, p. 17, of the Philadelphia Journal of the Medical and Physical Sciences—Case of Obstinate Cough, occasioned by Elongation of the Uvula in which a portion of that organ was cut off, with a Description of the Instrument employed for that purpose, and also for Excision of Schirrhous Tonsils, by Philip Syng Physick, M. D., Professor of Anatomy in the University of Pennsylvania, in Journal of Medical Sciences, for 1828—Description of a Forceps employed to faci- litate the Extirpation of the Tonsil, and invented by P. S. Physick, M. D. Id. 1828. Elongation of the Uvula. 29 Section V. Elongatio?i of the Uvula. The uvula, from colds or other causes, is frequently enlarged or elongated. If it continues so, for any length of time, trouble- some irritation about the epiglottis, nausea, vomiting, and even haemoptysis, and phthisis pulmonalis may be induced. Treatment of Elongation of the Uvida. To obviate some of these consequences, an operation has been practised from time immemorial—the excision or amputation of the uvula. This may sometimes be performed by a hook and common scissors, or by the particular scissors described and en- graved by Mr. Samuel Cooper, in his " First Lines of the Prac- tice of Surgery."* These are so contrived, as, by means of a transverse projection from one of the blades, to support the uvula, and keep it from falling backwards at the moment the operator attempts to divide it. Even with this instrument, however, the operator is extremely apt to fail, or else divide a part only of the uvula, which is immediately drawn upwards, and lodged be- hind the velum in such a way as to render it difficult afterwards to remove it. It will be better, therefore, to resort to the late Dr. Physick's instrument for the removal of the tonsils, or to the one I have recommended for the same purpose. The instrument, however, should be made smaller for the uvula than the tonsil. Mr. Benjamin Bell states that he has known very profuse he- morrhage to follow amputation of the uvula. I have very often * Vol. I. p. 526, edit. 4. Vol. II. 5 30 Elongation of the Uvula. performed the operation, but never met with an accident of the kind. The real importance of amputation of the uvula has only been estimated of late years, and it remained for Dr. Physick to point out the cases to which it was peculiarly adapted. He had met with several instances of troublesome cough, followed by emaciation of the whole body, sometimes by hemorrhage from the lungs, and eventually phthisis pulmonalis, which were pro- duced apparently by elongation of the uvula. This determined him to try the effect of an operation in the early stages of the disease, and the result was favourable in the extreme—the cough and other urgent symptoms disappearing almost immediately, and the patients recovering perfectly in a very short time. From experience I can speak confidently of the value of the remedy, and have reason to believe that it seldom fails unless too long delayed. Fissure of the Palate. 31 Section VI. Fissure of the Palate. A deficiency of the soft palate, or rather a division of it, either conioined with, or independent of, a cleft in the palate bones, is a congenital malformation, almost as common as that of hare lip, with which, indeed, it is not unfrequently associated. Like hare lip, too, it not only, during infancy, interferes with the suction of the child, but in after life impedes deglutition, and in many instances renders articulation nearly unintelligible. Many patients, indeed, fall a sacrifice to the disease, from extraneous matters getting into the windpipe, and bronchiae, and laying the foundation of pulmonary affections. At other times, the patient suffers extremely from fluids, and even solids, being thrown from the stomach, or mouth, into the nares, where they excite sneezing, great irritation, and even ulceration. Treatment of Fissure of the Palate. Although surgeons have long been acquainted with the exist- ence and nature of malformation of the palate, few, if any, at- tempts had been made to obviate the deformity, until Roux, an eminent Parisian surgeon, drew the attention of the profession to an operation which he denominated Staphyloraphy, and by which he had succeeded in reuniting the edges of the soft palate in twelve cases. These cases were published in 1825. 3S Fissure of the Palate. Since that period, Roux has performed, with more or less suc- cess, the operation fifty-one times. Out of this number, but one case has been followed by death.* It occurred in a young female, who, on the evening of the operation, was seized with inflammation of the throat, and, subsequently, with that of the chest, and died on the eighth day. Roux's operations were soon followed by those of Graefe, D'i'effenbach, and others, on the con- tinent of Europe; by Alcock, in Britain; and, subsequently, by Warren, Stevens, and Hosack, of our own country. The first case upon which Roux performed his operation, was that of a Canadian student, attending lectures in Paris. Be- fore cutting away the edges of the soft palate, as in hare lip, Roux determined to introduce three stout ligatures into the border of the palate, and at regular distances from each other. To accomplish this, he employed a small, curved needle, fixed in the porte-aiguille; passed it through the palate about a quar- ter of an inch from its edge, then seized its point with the com- mon dressing forceps, and drew it, together with the ligature, forward. In like manner the other ligatures were introduced, always carrying .the needle from behind forwards. The edge of the palate was then cut away by the knife and curved scis- sors, to the extent of a line in thickness. The same operation having been performed on the opposite side of the palate, the edges of the wound were approximated by drawing each inter- rupted suture, tying it, and then cutting off the ends of all the ligatures. To prevent the first knot from slipping, it was held by a pair of forceps, called pince a anneaux, until the second knot could be secured. The patient was kept on low diet, and not permitted to speak. At the end of the third day, the two upper ligatures were removed, and, on the fourth day,.the re- maining ligature. Lest the reunion, which had taken place throughout each edge, might be endangered, the patient was not permitted to speak until the eighth day. By that time, how- ever, the adhesion was complete, the cicatrix firm, and the de- formity, with all its inconveniences, namely, imperfect articu- lation, difficult deglutition, &c, completely removed. Roux's object, in first inserting the ligatures, and subsequently paring • Lancette Fransaise, 1830. Fissure of the Palate. 33 ihe edges of the palate, was to prevent the hemorrhage from in- terfering with the operation by obstructing the view of the parts, in which view most surgeons will probably concur with him. Professor Warren, of Boston, was the first to perform, there is reason to believe, staphyloraphy, in the United States. The ligatures were introduced by an instrument, apparently very simple, resembling a common dissecting hook in form, with an eye near its extremity, through which passed a triple thread of strong silk. " The palate was pierced by the hook at one- third of the length of the fissure from the upper angle of the wound, so as to include about three lines of the edge of the soft palate. The eye, with the ligature, being seen, the latter was seized with a common hook, and drawn out. The eyed-hook was then drawn back, turned behind the palate, and the other edge transfixed in a similar manner." Two other stitches were made in a similar way, the edges of the palate drawn toge- ther, and the knots tied without difficulty with the fingers. Un- like Roux's operation, the edges of the palate were cut away by a bistoury previous to the introduction of the ligatures. The patient recovered perfectly, and in a short time. In a second operation of the kind, performed by Dr. Warren on a boy during the prevalence of influeuza, the inflammation, owing to that disease, was so high as to require the ligatures to be removed. The operation consequently failed, although adhesion had taken place, but was afterwards destroyed by the finge/s of the boy, in attempting to relieve his cough. Dr. Warren has improved, subsequently, his instrument, by making the point removable, so that the ligature and point can be drawn out together. The operation of staphyloraphy was performed by Dr. Ste- vens of New York, in 1826. The ligatures were introduced by a curved needle attached to a handle by means of a screw, and the edges of the velum supported by forceps, afterwards dissect- ed away by a cataract knife. Reunion speedily took place, and by the tenth day the patient returned home with the voice much improved, but not so perfectly restored as in some of the cases reported by Roux. But my friend Dr. Alexander E. Hosack of New York, an ex- cellent surgeon, has paid more attention, perhaps, to staphy- 34 Fissure of the Palate. loraphy than any one else in the United States. In a memoir by him on the subject, published in 1833, at the request of the Medical Society of the City and County of New York, in- teresting observations are made, cases reported, and ingenious instruments invented by himself, described, which ought to be familiar to every one before undertaking one of the most diffi- cult operations in surgery. Under these impressions I shall in- sert a short account of Dr. Hosack's instruments, which, toge- ther with the plate and explanation of them, cannot fail, I hope, to render them perfectly intelligible. " It occurred to me," says Dr. H. " that as the greatest diffi- culty and delay were experienced in the passing of the ligatures, —arising both from the irritability and constant motion in the palate, as well as the unavoidable disposition to swallow,—an instrument might be constructed, calculated to lessen the incon- venience, as well as shorten the time. I consequently caused one to be made, as represented in the plate, and which I have since improved, and find perfectly to surmount the objections. In the application of this instrument, the surgeon is enabled to fix his eye on the part through which the ligature is to pass; the palate is at the same time, and with the same instrument firmly held, so as to avoid displacement, by any involuntary motion that may occur. The time required for passing each needle is but an instant, and it can always be accomplished with the greatest accuracy, as regards the relative distances, as well from the borders as from each other. This point being determined, I di- rected my attention to the second step of the operation, which is properly that of excision.—The straight bistoury, and the ordi- nary angular scissors, are as yet the only instruments used for that purpose.—In offering objections to them, I trust I may es- cape being censured for a great desire of finding fault, as well as from any unreasonable prejudice, in favour of invention. Having performed the operation, I feel myself at liberty to suggest an al- teration in the scissors, which, while it embraces all the advantages possessed by the above instrument, oflers facilities to the surgeon. He is at once enabled to follow with his eye every movement of the blades, until the borders are entirely separated, and thereby con- trol the extent and amount of substances to be removed. Two scissors will be required—one for either side, six inches in length. Piatt 'J.f'o/.'J. Draun byJDraym ■ Fissure of the Palate. 35 When viewed in profile, their form inclines to that of the let- ter/. The blades form the junction to the point, and curved la- terally and forwards, so as very much to resemble the beak of an eagle, or any other bird of that class, and which, when applied to the palate, adapt themselves to the arched sides of the cleft. No. 1, represents a front view of the instrument for passing the needle. A, the hollow shaft with the curved extremity. B, an aperture; through which the eye is to direct the head of the needle into the thimble. C, the rod drawn out, with the chain, and thimble-like extremity attached to it. D, the bayonet fix- ture, adjusted upon the shaft, with the forceps for receiving the needle. E, a profile view of the forceps holding the needle. F, the rings for receiving the first and second fingers of the right hand. G, the guard upon which the thumb, of the same hand, is to rest. H, the wheel, or the part of the bayonet fixture, by which its motions are controlled. The index finger of the left hand is to be placed upon it; by which means it is turned, until brought opposite to the crook, in which the needle is concealed; it is then to be pushed quite up, holding the palate between. The thumb, of the right hand, is at that moment to glide through the guard upon the button of the rod, which is to be thrust for- ward, driving the needle, armed with the ligature, into the for- ceps; the bayonet fixture is then drawn back and turned off, carrying the needle, with it.—No. 2, a profile view of the same, in the act of receiving the needle." See Plate II. I have reason to believe that the operation of staphyloraphy has been performed, likewise, by Dr. P. Metteaur, an eminent surgeon of Virginia, as I recollect to have seen some years ago, an ingenious instrument devised by Dr. M. for that purpose, in the hands of the maker—the celebrated Schively. It may have been performed by other surgeons in America; but if so I am not aware of the fact. ' An interesting case of extensive wound of the soft palate, cured by drawing together with sutures the divided edges, is reported in the tenth volume of the American Journal, 1832, by Dr. Wells, of Columbia, South Carolina. " A lad, aged five years," says Dr. Wells, " was running with one end of a piece of reed cane a foot long, and about an inch in diameter, and square across at the extremities, in his mouth. He fell forward; the end of the cane coming in contact with the ground, it was thrust 36 Fissure of the Palate. violently into his throat. I saw him very soon after the ac- cident happened. There were two lacerated incisions, extend- ing from the centre of the back part of the bony arch of the mouth backwards and outwards on each side, something more than an inch, and terminating within less than half an inch of the inferior margin of the velum palati. The soft parts were cut, or torn through, making a triangular flap, the apex of which had fallen forwards or downwards, and hung dangling. upon the root of the tongue, leaving the posterior nares and pharynx fully exposed. There was considerable hemorrhage, and the child and friends were extremely alarmed. A short common surgeon's needle was heated in the flame of a lamp, bent to a proper curve, armed with a ligature, and confined in Dr. Physick's forceps for taking up deep-seated arteries. The patient was placed upon a table and held by assistants. The mouth was kept open by a large cork placed between the back teeth, and his tongue depressed with a spatula. The needle was passed through the apex of the flap, and then through a corresponding portion of the mucous membrane, and cellular substance on the roof of the mouth, and the ligatures tied by the common stems for such operations when the fingers have not ac- cess. It was not attempted to insert more than one suture, al- though this did not bring the parts into exact contact; but the swelling which supervened in the course of a few hours, as was anticipated, fully obviated that difficulty. He was kept as quiet as possible—not allowed to swallow any thing for the first four days, except a little milk and toast water, and then as seldom as practicable. At the end of this period adhesion was found to have taken place at every point. There is not the slightest deformity of the parts remaining. There was considerable dif- ficulty in this little operation, from the struggles of the patient and the contracted space left for us to act in—the mouth being already pretty well occupied by the apparatus for keeping it open and depressing the tongue; indeed, without the above in- struments, or others equivalent, it would have been found im- practicable either to pass the ligature or to tie it." On Stayphyloraphy, consult Memoire sur la Staphyloraphie, ou Suture du voile, du Palais, par Phil. Jos. Roux, Paris, 1825— On an Operation for the Cure of Fissure of the Palate. 37 natural Fissure of the soft Palate, by John C. Warren, M. D., Professor of Ana- tomy and Surgery in the Medical Institution of Harvard University—in Ameri- can Journal of Medical Sciences, vol. 3d, 1828.—Staphyloraphy, or Palate Suture, successfully performed, by A. H. Stevens, M. D., Professor of Surgery, in the College of Physicians and Surgeons, New York, in North American Medical and Surgical Journal, Vol. 3d, p. 233, 1827—A Memoir upon Staphyloraphy, with Cases and a Description of the Instruments requisite for the Operation, by Alexander E. Hosack, M. D., one of the Surgeons of the Marine Hospital, New York, 1833. Vol. II. 6 38 Epulis, or Tubercle of the Gums. Section VII. Epulis, or Tubercle of the Gums. This disease, like polypus of the antrum, sometimes assumes a malignant form, and, involving the teeth and adjoining parts, is soon beyond the reach of surgery. This will show the pro- priety of attending, in the commencement, to every small tu- mour about the gums, however harmless may be its appearance. Any one, indeed, who will peruse the melancholy but instruc- tive cases detailed by Messrs. John and Charles Bell, the only writers who appear to have taken a deep interest in the subject, will need no further proof of the importance of the disease. Epulis generally sprouts from the sockets of the incisor teeth of the upper or lower jaw. The teeth themselves are frequent- ly sound and perfectly white, and in many instances long before the tumour is perceptible, are loosened and carried above the range of the adjoining teeth. In other cases, a small seed-like excrescence is seated upon the gum between the teeth. This remains stationary for months together, or it grows so slowly, and is attended with so little inconvenience, as scarcely to attract the patient's attention. At last it loses its hard and solid feel and gristly appearance, becomes soft and rugged on the surface, bleeds upon the slightest touch, and throws out a prolific fun- gus. After this, no bounds are set to the increase of the tumour, the teeth are successively displaced, the lymphatic glands and other soft parts in the neighbourhood contaminated, the mouth filled with a mass of disease so large as to embarrass the breathing and swallowing the texture of the bones of the face or lower jaw broken up, and the patient eventually destroyed by hemorrhage, suffocation or irritation. Epulis, or Tubercle of the Gums. 39 Treatment of Epulis. Extirpation of this tumour, in its very incipiency, is the only remedy likely to effect a permanent cure. In performing this operation the surgeon will find it necessary to provide himself with forceps and other instruments, for pulling teeth, one or two short and very strong scalpels, two or three fine watch-spring saws, tenacula, sponges, a vial of the muriated tincture of iron, lint, &c. If there is strong evidence of the tumour having originated deep among the sockets of the teeth or in the cells of the bone, the teeth surrounded by the tumour, however perfect they may appear to be, must be sacrificed, and not only the teeth, but the alveolar processes also. The cuj in this case should be made with one of the fine saws perpendicularly through the bone on each side of the tumour. By these means it will be so loosened as to be easily detached with a pair of strong forceps. The hemorrhage that.follows is commonly very profuse, but may be speedily arrested by dipping a piece of lint in the mu- riated tincture of iron, and thrusting it to the bottom of the wound (placing above the lint a bit of cork or some elastic sub- stance to support the lint,) closing the patient's jaws, and se- curing them by a bandage. In twenty-four or thirty-six hours the lint may be removed, and if necessary the application of the muriated tincture renewed at each succeeding dressing; or the lunar or vegetable caustics may, with the same view, be applied. By adopting this plan, (the one suggested and practised by Sir Charles Bell,) I have in several operations of the kind succeeded perfectly. In other instances, where I have merely removed the tumour with the knife and caustic, it has invariably returned. See John Bell's Principles of Surgery, vol. 3, p. 178—Charles Bell's Surgical Observations, being a quarterly Report of Cases in Surgery, vol. l,p. 413—Gib- son on Bony Tumours, in the Philadelphia Journal of Medical and Physical Sciences, vol. 2, p. 145. 40- Diseases of the JYsek. CHAPTER III. DISEASES OF THE NECK. The importance of the diseases of the neck can be fairly esti- mated only by those who possess an accurate knowledge of the structure and functions of its numerous and complicated organs. The student should use, therefore, in prosecuting his anatomical investigations of these parts, more than ordinary diligence. Be- sides the great blood vessels and nerves of the neck, the pharynx, oesophagus, larynx, trachea, thyroid gland, are subject to acci- dents and diseases of the most pressing and grievous nature. Wounds of these different parts have already been considered ;* but it still remains to treat of several other affections. These are the lodgement of foreign bodies in the pharynx and oesopha- gus, foreign bodies in the larynx and trachea, ulceration of the glottis, bronchocele wry-neck, &c. Section f. Extraneous Bodies in the (Esophagus. It frequently happens that persons, from hurry or voracious- ness, in attempting to swallow a large piece of beef, tripe, gristle, cheese, bread, and other similar substances, are choked', and in • See Vol. I. p. 106. Extraneous Bodies in the (Esophagus. 41 danger of suffocation. In other instances, fish bones, chicken bones, pins, and needles, pieces of coin, stick in the pharynx or oesophagus, and excite irritation in proportion to their size, shape, &c. There is reason to believe, in most cases of the kind, that the difficulty of breathing which ensues, arises from the spasmodic action of the muscles of the glottis by which this chink is preternaturally constricted. Death may follow from this cause, or from the foreign body distending the oesophagus to such a degree, as to press upon the trachea and interrupt the passage of air, or the patient may die at some subsequent period from inflammation or gangrene induced by the continued pres- sure of the extraneous body, or injudicious and violent attempts: to remove it. Removal of Extraneous Bodies from the (Esophagus. When a large substance is swallowed, it generally sticks in the pharynx or between the cornua of the os hyoides and thy- roid cartilage, and often may be seen or reached with the finger. In like manner, fish bones and other small and irritating bodies, when similarly situated, may be removed by a pair of forceps, or by tickling the fauces with a feather, or by holding a solu- tion of tartar emetic in the mouth. These last, by exciting vomiting, have the effect of expelling the foreign body. There are, however, several regular instruments well adapted to the removal of articles lodged in the throat; but the surgeon, if sud- denly called to a patient apparently choking and in imminent danger of his life, should waste little time in searching for these instruments. On the contrary, he should seize upon any thing that happens to be in his way, calculate I to dislodge the morsel —such as a horse-whip, the handle of a spoon, a rattan, &c. As a gcnoral rule, digestible articles, provided they are free from asperities, should be forced into the stomach by the probang— a whalebone rod, having a round piece of sponge fixed upon one end and a blunt hook upon the other. This instrument (,ts sponge being previously softened a little) may be easily intro- duced by thrusting it against the back part of the pharynx. The 4~ Extraneous Bodies in the (Esophagus. sponge imbibing freely moisture, fills up entirely the oesophagus, and carries the body before it, unless very firmly fixed. Copper coins, and all sharp or ragged bodies, should, if pos- sible, be extracted by the gula forceps, probang hook, or by a hook made of a piece of bell wire, upon the spur of the occa- sion. Sometimes a rod ~of whalebone, with numerous loops of thread or horse hair attached to one end of it, answers an excel- lent purpose, by entangling fish bones and other sharp bodies. After extraneous substances have been pushed into the stomach, the patient should take, for several days successively, purgatives and mucilaginous draughts, to promote their passage through the intestines. For several years Dr. Physick has been in the habit of prescribing rice, and other similar articles, in large quantities, with-a view of defending the coats of the stomach from the ac- tion of foreign bodies—and usually with great success. Nee- dles and pins that have been swallowed, not unfrequently per- form extensive journeys throughout the body, and, at last, are discharged through the skin. Dr. Henry Bond,* of this city, has made a very ingenious improvement on the common gullet forceps. That instrument, as is well known, is defective, chiefly, on account of the blades closing upon each other with a flat surface, thereby leaving, necessarily, four sharp or angular edges, well calculated to pinch the lining membrane of the oesophagus. To obviate this inconvenience and danger, Dr. Bond's forceps have been be- veiled off from the edges to the centre of the inner surface of each blade, so as to produce two convexities, or ridges, which are slightly serrated, and meet each other at a single line. Besides holding the foreign body with sufficient firmness, the narrow rough line allows the article, contained in its grasp, «to vibrate freely and to assume a position nearly parallel to the blades " A case occurred, some years ago,in the Eastern States, where a fish hook, with part of the line attached to it, was swallowed In the attempts to remove it, by pulling upon the line, the hook became fixed in the side of the oesophagus. After much diffi- culty, it occurred to an ingenious person present, that the pro- per mode to extricate the hook would be, to take a large leaden * Observations on the Removal of foreisrn Iinrlin« l™io. t .■ ^ h„™ m.d., h Nortll ^cr^r^Essi* Extraneous Bodies in the Oesophagus. 43 bullet, drill a hole in its centre, pass the line through it, and let it be swallowed by the patient. The experiment was accord- ingly tried, and with success—Qie bullet, by its weight, first disengaging the hook, and then its point being afterwards brought in contact with the lead, was prevented from slick- ing again in the oesophagus, in the act of drawing upon the line, so that both the bullet and hook were drawn out together. These particulars were communicated to me formerly, by a very intelligent student, Dr. Bradley of Maine; but I have for- gotten the name of the surgeon concerned in the case. The operations called pharyngolomy and cssophagolomy should seldom, I conceive, be performed; but in order to sustain the patient's breathing, during the attempts to remove a large bbdy from the pharynx or oesophagus, it may possibly become expedient to resort to bronchotomy or tracheotomy, as will be explained hereafter. 44 Stricture of the (Esophagus. Section H. Stricture of the CEsophagus. The oesophagus, like the urethra, is sometimes the seat of stricture, either of the spasmodic or permanent kind. Nervous and hysterical patients are most subject to the former disease, and the latter may occur in patients of every variety of contitution. Occasionally, the two affections are combined. Permanent stric- ture is met with in two or three different situations. Its most common seat, however, is immediately behind the cricoid car- tilage, or in the commencement of the oesophagus. The con- traction is generally found to consist of a fold of the internal membrane of the tube. In advanced cases of the disease, the whole cavity of the oesophagus is often entirely closed, and to a considerable extent, arising, probably, from the effusion of lymph, or from the glands of the passage assuming a scirrhous or cancerous action. The symptoms of permanent stricture of the oesophagus arc difficulty of swallowing, in proportion to the duration of the disease, pain in the stomach,, nausea, troublesome eructations, pain in the fauces, and extending thence along the base of the skull. In addition to these symptoms, the patient often finds it impossible to pass either solids or fluids in the smallest portion, and as a necessary result, emaciation ensues. Some patients, however, can readily swallow fluids, especially when sipped in small quantities; others find it easier to swallow solids. The causes of this disease are very obscure. In most in- stances, there is reason to believe that the permanent stricture is the result of inflammation, however induced. By Dr. Bur- well, an intelligent practitioner of Buffalo, I am informed that several cases of the disease have occurred in his neighbourhood, from drinking of the liquor of pearl-ash, kept by most house- wives to lighten their bread, and generally deposited in the Stricture of the (Esophagus. 45 same closet-with spirits, for which it has been mistaken. Simi- lar cases have been reported by Sir Charles Bell'—from the ac- cidental swallowing of soap-lees. A disease very opposite in character to stricture of the oeso- phagus, is sometimes met with—paralysis of the oesophagus. This occurs, for the most part, in old people, and frequently as a concomitant of palsy in other parts of the body. The power of the muscular fibres of the oesophagus being impaired or lost, the patient can take neither solids nor fluids, and, unless speedily re- lieved, must die of inanition. Treatment of Stricture of the (Esophagus. Bougies, either alone or armed with lunar caustic, may be considered the only remedies for permanent stricture of the oeso- phagus. To ascertain the situation and extent of the stricture, a soft wax bougie is employed. This may be readily introduced, by directing the patient to draw back his tongue and imitate the action of swallowing. If the stricture is ascertained, from the resistance and the impression made on the end of the bougie, to be a permanent one, the caustic bougie may be immediately carried down, and kept in contact with the stricture three or four minutes. In two or three days the operation may be re- pealed, and kept up occasionally until the stricture is destroyed, or until a common bougie will readily pass. For the relief of spasmodic stricture of the oesophagus, I have often employed the unarmed bougie, and with the happiest ef- fect. In such cases, also, the internal use of valerian, camphor, opium, ether, will be found highly serviceable. Paralysis of the oesophagus may be sometimes removed by electricity. To nourish the patient during the cure, the gum elastic oesophagus tube is essential. The surgeon should take • Surgical Observation*. Vol. II. 7 46 Stricture of the Oesophagus. care that fluids conveyed through it are not too hot, otherwise the stomach may be scalded. From this cause, several patients have lost their lives. When the oesophagus, from stricture or any other cause, is so completely closed that a bougie or gum elastic tube will not pass, the patient must be nourished by clysters. The cardiac, as well tis other portions of the oesophagus, is not unfrequently the seat of scirrhous and cancerous affections. The progress of the disease is generally very slow and gradual. Often it is mistaken for common stricture of the oesophagus, and treated accordingly; by which the symptoms are aggravated and ulceration hurried on. In many instances, the disease ex- tends to the stomach, all the coats of which, as well as those of the oesophagus, are indurated and often ulcerated to a great ex- tent. Such affections, are, of course, incurable. The celebrated Napoleon died of cancer of the stomach. Tumours situated between the trachea and oesophagus, en- largement of the thyroid gland, indurated lymphatic glands, aneurism of the aorta and other affections, may, by pressure, in- volve the oesophagus, and generally admit of no relief. Extraneous Bodies in the Larynx and Trachea. 47 Section III. Extraneous Bodies in the Larynx and Trachea. During the act of deglutition, articles of food, instead of pass- ing into the oesophagus, are sometimes suddenly diverted from their course, and thrown into the glottis. An instantaneous, vio- lent, convulsive cough, and laborious respiration, are the imme- diate consequences. If the extraneous body should be detained in the glottis, death speedily follows from suffocation; but in many instances, the body passes entirely through the chink of the glottis into the trachea, or else it is forced by the cough into the laryngeal pouches. In either case, the patient is saved for the time, or eventually may recover. The lodgement, indeed, of a morsel in the sacculus laryngeus, is comparatively harmless, and the irritation occasioned by its presence soon subsides. I have known extraneous articles to remain in these cavities for years, without inconvenience, and indeed without the patient be- ing sensible of their presence. When, however, the substance descends into the trachea, incessant irritation is kept up, and, al- though the patient, even under these circumstances, may survive for weeks, months, or years, yet in the end, unless relieved by an operation, he is almost sure to die—from effusion into the cells of the lungs, from phthisis pulmonalis, &c. Removal of Extraneous Bodies from the Larynx and Trachea. It is very seldom that the surgeon succeeds in extracting by instruments an extraneous body lodged even in the vicinity of the larynx; of course, the removal of it from the larynx or trachea, by such means, is out of the question. But to obviate instanta- neous suffocation, or to remove the foreign body, an operation may be required. Laryngolomy and tracheotomy, (so denominated according as 48 Extraticous Bodies in the the larynx or trachea may be the scat of the operation,) are both occasionally required. The former, however, is best adapted' to the removal of extraneous bodies, and is performed in the following manner. The patient being laid on a table, with his head supported by a pillow, and thrown moderately backwards, the surgeon feels for the membranous space situated between the thyroid and cricoid cartilages, makes a perpendicular incision about an inch in length through the integuments, platysma-myoi- des, and between the sterno-thyroidei and sterno-hyoidei muscles. Any vessels that may have been divided, are next carefully se- cured, and the bleeding having entirely ceased, it only remains to push the knife through the crico-thyroid membrane, when the ex- traneous substance will be either immediately thrown out or pre- sented at the wound. Sometimes it is too large to pass through the membranous space. In that case, the incision should be pro- longed upwards by separating from each other the two lateral parts of the thyroid cartilage. As soon as the foreign body is removed, and the patient's breathing restored, the wound may be drawn together by adhesive straps, and permitted to heal. Tracheotomy is now seldom resorted to, both on account of the difficulty of the operation, and the danger of wounding im- portant blood vessels. Should it ever become necessary, how- ever, it may be done in the following way. The surgeon makes an incision, from below the cricoid cartilage, and extends it through the skin and platysma-myoides, nearly as far as the sternum. The sterno-hyoidei and sterno-thyroidei muscles are next carefully pushed aside by the fingers, until the surface of the trachea is cleared, and when all hemorrhage has ceased, two or three of the rings of the trachea may be divided by a perpen- dicular cut. These operations may be required for other purposes than the removal of extraneous bodies, and in that case the surgeon will generally find it necessary to keep the orifice of the wound open for some time afterwards. This should not be done, I conceive, by a cannula, which, independently of its liability to become clogged by the mucus of the passage, excites always a great deal of irritation. Upon two or three occasions in which I have found it necessary to open the membranous spactj, in order to sustain the patient's breathing, I have dissected away the corners of the crico-thyroid membrane, and instead of intro- Larynx and Trachea. 49 ducing a cannula into the larynx, have merely prevented the integuments and muscles surrounding the opening from closing, by passing a piece of tape around the patient's neck, having at- tached to each of its extremities a piece of silver wire doubled, and bent in the form of a hook, and calculated, by pulling these parts in opposite directions, to keep them asunder—at the same time covering with a bit of gauze the opening in the larynx, to prevent the admission of dust and other extraneous matters. Laryngotomy and tracheotomy will sometimes be necessary, on account of substances lodged in the cesophagus, for cynanche trachealis or croup, for enlargement of the tongue or of the ton- sils, for ulceration of the glottis, for suspended animation in per- sons apparently drowned, &c. In cases of croup, the operation seldom succeeds, owing to effusion having generally taken place in the lungs before the expedient has been resorted to. Some surgeons, and particularly Desault, in place of opening the la- rynx or trachea, on account of obstructions in the oesophagus, introduce a gum elastic tube into the windpipe, from the nose or mouth, with a view of sustaining respiration until the obstructions are removed. The practice, putting the difficulty of the opera- tion aside, in rny estimation, is injudicious and censurable. 50 Ulceration of the Glottis. Section IV. Ulceration of the Glottis. From syphilis, abuse of mercury, and from other causes, the glottis is sometimes ulcerated, the epiglottis destroyed, the bony portion of the thyroid cartilage rendered carious, and covered with abscesses. This disease originates in the glandular struc- ture of the larynx and trachea, and increases gradually, if not ar- rested, until it destroys the patient. The symptoms are-a troublesome, hacking cough, with purulent and bloody expec- toration, great difficulty of breathing, a peculiar, husky, wheezing, whistling, almost inaudible voice. After labouring under thed isease for a few months, the patient dies from suffo- cation, from effusion upon the lungs, or from irritation. Some- times the disease appears to be hereditary; at least, I have upon several occasions known different members of the same family attacked in succession by it. Some years ago, I attended with Dr. Shaw, of this city, a female, who laboured under the disease, and finally died from it. Her sister, a stout healthy young wo- man, was attacked a few months afterwards in a similar man- ner, and also died. Treatment of Ulceration of the Glottis. When there is reason to suspect that ulceration of the glottis or epiglottis depends upon a syphilitic taint, mercury, sarsapa- rilla, the nitro-muriatic bath, and other remedies of similar cha- Ulceration of the Glottis. 51 racter should be employed. As a local application, there is nothing so serviceable as a solution of the argentum nitratum in the proportion of forty grains to an ounce of water. The prac- tice originated, 1 believe, with Sir Charles Bell: his mode of apply- ing the caustic is to attach a pad of lint to a piece of wire, dip it in the solution, and, taking care to depress the tongue with a fin- ger, place the lint in contact with the ulcerated surface. As a measure of necessity, Mr. Bell once performed the operation of laryngotomy, for ulceration of the glottis, with instantaneous re- lief to the patient, who continued to breathe freely through the opening for six weeks, but at last died in consequence of closure of the aperture by fungous granulations, the growth of which it was found impossible to repress. 52 Bronchocele, or Goitre. Section V. Bronchocele, or Goitre. The terms Bronchocele, tumidum Guttur, Hernia bronchialis, Gongrona, Hernia gutturis, and others of similar import, are em- ployed to denote a morbid enlargement of the thyroid gland. The word Goter or Goitre, was invented by the Swiss, and is probably a corruption of the Latin phrase Guttur. In England the disease is known, in popular language, under the name of Derbyshire neck, or monstrous craw. Bronchocele has prevailed, in certain countries, from time immemorial. It is noticed by some of the ancient poets, and by many of the early writers on medicine. It is met with oftener in mountainous than level countries, and is frequently endemial and hereditary. According to Coxe, the disease is common in the neighbourhood of Berne, Friburg, Lucerne, Aigle, Bex, Dres- den, in the valleys of Piedmont and Savoy, in most parts of the Vallais, in the Valteline, &c* In the village of La Batia, Dr. Reeve saw many cretins and goiterous persons, who all lived in adjoining houses.! The village of Villeneuve d'Aoste, which is surrounded by very high mountains, contains an immense num- ber of persons who labour under goitres of enormous magnitude-! The late Dr. Howard of Baltimore, during his rambles in Switzerland, first met with goiterous persons and cretins near Sion. The number of each continued to increase as he approached Martigny and St. Maurice, at which places they were exceedingly numerous. As he descended the Rhone * Coxe's Travels in Switzerland. f Reeve's account of Cretinism, in the Edinburgh Medical and Surgical Jour- nal, vol. 5, p. 33. t Saussure's Voyages dans Les Alpes. Bronchocele, or Goitre. 53- their numbers decreased. In the year 1800, the villages of St. Jean, St. Michael, St. Maurice, and the vicinity of Aiguebelle, according Foden', contained a greater proportion of cretins and persons labouring under goitre than any other part of Swit- zerland. Dr. Howard was informed that both cretinism and goitre had diminished within the last few years, in consequence of the richer inhabitants sending their children, until their tenth or* twelfth year, to the mountains, where their wives also remained during pregnancy, and for some time after parturition. In the mountainous parts of Spain and Germany goitre prevails to a considerable extent. In France it is chiefly met with in .the districts of Cevennes, Soissonais, Vbsges, Rouergue, Doubs, and Ardeches. In England it is very common in the mouiS tainous parts of Derbyshire, in Buckinghamshire, Surry, and in the county of Norfolk. Occasionally it is seen in Nottingham- shire.* Sir George Stauntun says, that goitres are very common in those parts of Chinese Tartary which resemble the mountains and valleys of Savoy and Switzerland.! " In Bengal," says Turner, " this unsightly tumour is known by the name of gheig and aubi; and in Boutan is called ba'orke ba, the neck swelling, and forms itself immediately below the chin, extending from ear to ear, and sometimes growing to such an enormous size, as to hang from the throat down upon the breast. It is particularly observable among the inhabitants of the hills of Boutan, imme- diately bordering upon Bengal, and in the track of the low coun- try watered by the rivers that flow from thence to the south, be- yond the space of a degree of latitude. The same malady pre- vails among the people inhabiting the Morung, Nipal, and Almo- ra hills, which, joined to those of Boutan, run in continuation, and bound, to the northward, that extensive track of low land em- braced by the Ganges and the Burrampooter. The same dis- ease is also more particularly met with in the low lands adjoin- ing those hills. From the frontier of Assam, north latitude twenty-seven degrees, east longitude ninety-one degrees, it is to be traced through Bishee, Gooch, Bahar, Rungpore, Dinage- pore, Purnea, Tirrooto, and Betiah, along the northern boundary * Clark's Reports from the general Hospital near Nottingham, in the Edinburgh Journal, vol. 4. ■j- Staunton's Embassy to China. Vol. II. * 54 Bronchocele, or Goitre. of Oude, in Gooracpore, Barraitch, Pillibeat, and on the con- fines of Rohilcund to Hurdwar, situated in north latitude thirty degrees, east longitude seventy-eight degrees twenty-five mi- nutes. It has the effect, or is rather accompanied with the effect arising from the same cause, of debilitating both the bodies and the minds of those who are affected with it."* Park, in giving an account of the diseases of the Mandingo negroes, states that goitres are very common in some parts of Bambarra.t Throughout the island of Sumatra, bronchocele is met with as and endemic disease, and is particularly frequent in those valleys which are surrounded by the highest mountains. J In some of the Spanish settlements of America, goitres are so common, that the greater number of the inhabitants labour under the disease; and at the village of Jacaltenango, near Sacapula, it is said that no individual can be found without an enlargement of the thy- roid gland.§ In Santa Fe, Guatemala, Nueva Gallicia, and Nicaragua, the complaint has long been known. It is common also among the Indians who inhabit the valleys of the Cordilieres. According to Humboldt and Bonpland, goitre is an endemic disease at New Grenada, and is so common at the small villages Hunda and Monpar, on the borders of the Magdelaine river, that it is difficult to find an individual who is exempt from it. It affects indiscriminately all classes of inhabitants, except the blacks and those who lead a very laborious life. The ferrymen at Carthagena are not subject to it. Females are oftener affect- ed than males. At the Isthmus of Darien many persons arc horribly disfigured by enormous bronchoceles.|| In various districts, and throughout whole tracts of country in North America, bronchocele prevails as an endemic. It is very fre- quent in many parts of Lower Canada, especially near the marshes between St. John's and Montreal. At Detroit, Lake Ontario, Oneida, Erie, Huron, and among the Tuscorora, Sene- ca, Oneida, and Brothertown Indians, it is very common!l In many parts of the state of Vermont, especially Bennington and Chittenden, bronchocele is well known. It is also found at * Turner's Account of an Embassy to Tibet. f Park's Travels in Africa, p. 413. * Marsden's History of Sumatra. § Barton's Memoir on Goitre. | Alibert's Nosologic Naturelle, p. 470. , Barton>s Memoir Bronchocele, or Goitre. 53 Camden, Sandgate, and Chester, in the same state. Sandgate, some years ago, contained one thousand and twenty inhabitants, and out of that number one-fourth of the females were affected with the disease.* According to Dr. Trask, bronchocele is so common a disorder at Windsor in Vermont, that hardly any fe- male is exempt from it.t In the state of New York goitre pre- vails principally in the neighbourhood of Old Fort Schuyler, the Oneida village, the German Flats, Fort Herkimer, Fort Dayton, Henderson town, Onondago valley, Canasaraga, Bro- thertown, the townships of Manlius, and the whole of the mili- tary district.;}; I am informed by Philip Church, Esq., who re- sides at Angelica in Alleghany county, state of New York, that goitre is a very frequent complaint in his neighbourhood and the surrounding country. In Pennsylvania, where bronchocele is very common, it is found chiefly at Pittsburgh, on the waters of the Alleghany, Sandusky, Monongahela, French Creek, at Canonsburgh, Brownsville, and throughout the county of So- merset. In some parts of Virginia,^ especially at Morgantown and on the banks of Cheat river, it is by no means unfrequent. In certain situations on the western shore of Maryland, and in North and South Carolinas, the disease is occasionally met with. • Dorr's Facts concerning Goitre, New York Medical Repository, vol. 10. + Mease's Observations on Goitre. t Barton. Dec. 22d, -1831. § Dn. Gibson-, Sin, I take the liberty of communicating to you a fact, which has.fallen under rrty observation, relative to the disease known by the name of goitre, or broncho- ctlc, which, if it be not useful in throwing some light on the cause of this inex- plicable affection, will at least prove curious to the surgeon and physician. At King's Saltworks in the county of Washington, Virginia, and not far from my own residence, this disease has prevailed for a number of years; for any thing that I know to the contrary, its existence is coeval with the commencement of the manufacture of salt at that place. Hitherto, it has been confined exclusively to females, and to those who reside at the very spot where the process of vaporiza- tion is carried on; the subjects of it consistingchiefly of the families of the im- mediate superintendents. Persons living at the distance of a lialf, or even quar- ter of a mile are not subject to the disease. ConU'ary to what might be supposed from the aspect of the neighbouring coun- trv, this disagreeable affection is of exceedingly rare occurrence in this part of the state, with the exception above alluded to. No satisfactory reason has been assign- ed for its existence atthis place, it has, however, been ascribed to the water used 56 Bronchocele, or Goitre. It is probable, indeed, that goitre may be found as an endemic disease, in almost all the mountainous and marshy districts throughout the United States. All writers on the complaint, agree that it generally prevails in valleys at the bottom of the highest mountains, which are particularly exposed to the in- fluence of easterly and southerly winds. In those situations, moreover, where the temperature is mild and uniform—where the atmosphere is moist—in the neighbourhood of rivers, of falls or lakes, or of the sea,—where the soil is rich and the habita- tions surrounded by fruit trees, goitres are commonly found. Every age and sex is liable to goitre, but females are oftener affected than males. In children, it seldom occurs until after the eighth or tenth year, and old people are little subject to it. Three instances, however, are mentioned by Fodere, where it was found at birth, and another, in an infant fifty days after birth.* Dr. Sterndale has also furnished an example, where a child in Derbyshire, was born with a goitrous tumour of considerable size.f Those females who are not subject to bronchocele before marriage, generally perceive its commencement during pregnan cy.J Persons of relaxed constitutions, of white and delicate skins and whose complexions are red mixed with a brownish tinge are most predisposed to the disease. Children who are to be come goitrous, have large blue, sprightly eyes, beautiful skins and fair hair. Their memory is very forward. When the dis ease appears, every thing is changed. As it advances, the eyes become dull, the face acquires a white colour and unmeaning look, and the faculties are at a stand. When the goitre is very large, respiration becomes difficult, the pronunciation of consonants for drinking. J have drunk of the same water myself, and found it insipid and unpalatable; but was unable to detect in it the presence of any other mineral but lime, which is the common character of the water of the country It may per haps, be proper to state, that a removal to another situation is not attended with a removal of the complaint. Whatever may be the cause of tins disease, as it exists here, which, I think is entirely-inscrutable such is the certainty with which it attacks those who come withm the sphere of its influence, that every woman who goes to King's Salt- works to hve, previously makes up her mind to become sooner or later a subject ° f°'Fe." , _ ., ^ , . John T. Smith, M. D. Traite du Goitre et du Cretinisme. t London Medical Repository, vol. x. p. 200. t Fodere", p. 62. Bronchocele, or Goitre. imperfect, and the body ceases to increase except about the head and shoulders. In a goitrous country, the children are born goitrous after two generations of the intermarriage of goitrous parents. After the third marriage, the child becomes a cretin. A semi-cretin, weak and ricketty, married to a goitrous woman, has children born goitrous.* During the winter, a goitrous tu- mour is diminished in size, but it augments with the return of warm weather, and is larger during autumn than at any other season. The disease is not confined to the human race; horses, horned cattle, calves, sheep, dogs and other inferior animals are subject to it.f In the commencement of bronchocele, a small tumour may be perceived, either qk one or both sides of the trachea and larynx. Sometimes the swelling occupies each lobe of the thy- roid gland, together with its isthmus, so as to constitute a uni- form tumour; at other times, there is a depression at the centre, following the course of the trachea, and marking the natural di- vision of the lobes. Occasionally the enlarged lobes are stud- ded over with a number of lobules. The swelling generally continues small and circumscribed for a considerable time, and often extends backwards, so as to render it difficult to ascertain by inspection or examination, whether goitre exists or not. For the most part it is soft to the touch, and possessed of so little sensibility, that it may be rudely handled, without producing much uneasiness. It is sometimes closely compressed by the muscles which cover it, and is then elastic and firm. Although the thyroid gland, both in its natural and enlarged condition, is not very susceptible of inflammation, yet, when this state is once induced, it becomes exquisitely tender, and is accompanied with a difficulty of respiration and deglutition, which the most active antiphlogistic measures can hardly subdue. Almost all the goitres which have corne under my notice in America, have commenced in one lobe of the gland—the other lobe in a short time being affected in a similar manner. Alibert says that he has found the right lobe oftener enlarged than the left.J In the worst cases of goitre 1 have seen, the tumoDr has exceeded in size a large cocoa nut, and has become at particular times very • Fodere, also Chapman's Notes on Allan's Lectures. + Coxe's Travels, Barton's Memoir, Clark's Reports. t Nosologic Naturelle. 58 Bronchocele, or Goitre. troublesome to the patient, by its weight and pressure upon the trachea and adjacent parts. In countries where the disease is endemic, it is not uncommon for the tumour to attain an enor- mous magnitude. Fodere relates instances of such tumours weighing seven or eight pounds.* A case is recorded by Ali- bert of a man thirty-eight years of age, who had a goitre which extended below the middle of the chest and equalled in size a large pumpkin. " La poche dnorme qui s'est formde au dessous de son menton, resemble a celle de l'oisseau ddsigne" commun6- ment sous le nom de pelican, et qui figure comme object de cu- rioste* dans les cabinets des naturalistes." The same author de- tails the case of a female, upwards of sixty years old, who had resided the greater part of her life near Chamouny at the foot of Mont Blanc, and who, from her infancy, had laboured under a bronchocele, which was divided into innumerable lobes, which extended from ear to ear, blocked up the cavities of each, so as to destroy the hearing, and finally descended on the chest, lower than the mammas, interrupting the breathing and swal- lowing to such a degree, as almost to produce suffocation, every time she attempted to take the least particle of nourishment, so- lid or fluid. But cases have been related by Mittlemayer and others, in which the goitrous tumours have descended below the umbilicus, and even to the knees.t We have no reason to sus- pect these accounts exaggerated, when we remember the reports of Sir Robert Wilson, Larrey and others, respecting those pro- digious tumours, common in Egypt and many warm climates, in consequence of the descent of the abdominal viscera, which, in some instances, have reached the ground. The cases of enor- mous hydroceles, also recorded by Keate, and the voluminous cutaneous excrescences described by Mr. John Bell and by Dr. Roper of Charleston, leave no doubt on the subject. Notwithstanding the peculiarities of goitre, it is not easy always to distinguish it from other diseases. It may be con- founded with aneurism of the carotid artery, with scrofulous enlargement of the lymphatic glands, with encysted and sarco- matous tumours of the trachea and its vicinity, with dilatation of the internal jugular vein, and perhaps with other complaints. From aneurism it may be distinguished, in general, by want of * Traitfe du Goitre, &c, p. 497. j Nosologic Naturelle, p. 468. t Dissertalio de Strumis et Schrophulosis 1723. Bronchocele, or Goitre, 59 pulsation, by the comparative insensibility of the tumour, by the softness of its texture, by its mobility, and by the circum- stance of the swelling accompanying the motions of the larynx and trachea, when the patient is desired to imitate the action of swallowing. But sometimes the goitre is so large, and is so identified with the adjacent cellular texture, that little or no movement of the trachea can be observed. When goitre is ex- tensive, and occupies one side of the neck only, and when, at the same time, there is a pulsation in it from the enlarged and varicose state of the vessels, wc shall not find it always easy to discriminate between it and aneurism. Occasionally a pulsation is communicated from the carotid to a goitrous tumour, which happens to lie over it. One instance is noticed by Burns, where the carotid was deeply imbedded in the substance of an enlarged thyroid gland. " The carotid artery being placed," says he, " in the body of the tumour, is neither very rare in occurrence, nor very difficult to explain. It is, indeed, a natural consequence of the extension of the tumour laterally; yet it will not happen in every tumour: it will only occur in those cases, where the consistence of the morbid parts is soft. When the tumour is firm, it pushes the artery, nervus vagus, and internal jugular vein aside. When it is soft, these, as in the present instance, sink into its substance."* In most in- stances of aneurism, however, the carotid is deeper seated than bronchocele, and the pulsation so strong as scarcely to be mis- taken. Notwithstanding this, cases have been related where the most able surgeons have found it impossible to offer a de- cided opinion. A Creole negro had a tumour on the neck, which was submitted to the inspection of some of the most celebrated surgeons in America, Paris, and London; all of whom pro- nounced the disease an aneurism of the carotid artery; but it was afterwards ascertained, by Boyer, that no such disease ex- isted—but simply an extensive enlargement of the lymphatic and other glands of the neck.t The late Dr. Samuel P. Grif- fitts has furnished us with an interesting history of a tumour of the neck, bearing so strong a resemblance to carotid aneurism, as to be mistaken for the disease by himself, Drs. Chapman and • Surgical Anatomy of the Head and Neck, page 224. ■j- Uictidnnaire des Sciences Medicales, vol. xviii. p. 541. GO Bronchocele, or Goitre. Morgan, and the late Dr. Dorsey. Upon dissection by Dr. Par- rish it was distinctly ascertained that the carotid was free from disease, and that the tumour was composed entirely of the thy- roid gland. »It was elongated," says Dr. Parrish, " and had obtained a situation directly over the carotid artery; the patient's neck was very short, the pulsation in the carotid was imparted to the tu- mour lying over it; and, I am informed, there was a strong re- semblance to the aneurismal jar or thrill. We are aware, that in dropsy of the chest and pericardium, the heart often palpi- tates most violently; and this morbid pulsation may explain the throbbing of the carotid, which bore so strong a resemblance to aneurism."* One circumstance which deceived Dr. Griffitts, was the impossibility of drawing the tumour from the artery. " I had frequently endeavoured," says he, " to remove, with my fingers, the tumour from the artery, wishing to think the disease was glandular, but could not succeed, as the tumour was so firm- ly fixed over the vessel as not to be moved from it; and the pulsation was such as to convey the idea that there was no in- tervening substance." Under ordinary circumstances, this plan of drawing the tumour from the artery is excellent. It was by relaxing the muscles of the neck, and separating with the fingers the tumour from the artery, that Boyer was enabled, in the case referred to, to discriminate between the disease and aneurism. By similar means, I have often succeeded in distinguished en- larged glands and other tumours situated over large arteries, in different parts cf the body. Many writers have confounded goitre with scrofula: but there would appear to be no legitimate foundation for such a conclusion. In scrofula, the lymphatic glands of the neck and other parts of the body are particularly involved; and other marks in the system, too well known to require description, evince the existence of the scrofulous constitution. These symp- toms do not generally accompany the goitrous tumour. Goi-' tre is strictly a local complaint—scrofula affects the whole sys- tem, and appears at a much earlier period of life than goitre. In countries where bronchocele is endemic, the scrofulous are equally liable, no doubt, with others, to the complaint. Persons * Eclectic Repertory, vol. ix. p. 120. Bronchocele, or Goitre. 61 who remove from settlements where goitre does not exist, into countries where the disease prevails, are subject to it; but on residing again for some lime at their original home, the tumour disappears generally in a short time. This is seldom the case with scrofula, which is little influenced by change of climate. The scrofulous tumour is harder to the touch, and more pain- ful than the goitrous tumour. It is more disposed to suppurate than bronchocele; besides, goitre is nearly unknown in certain countries, where scrofula is the common disease. In Scotland, scrofula is almost universal,—goitre hardly ever met with. In Switzerland, goitres are very common, and affect all classes of society, while scrofula is very rare. It is possible for an en- larged thyroid gland to extend so far beyond its natural boun- daries, as to occupy the situation of the lymphatic glands of the neck. Mr. Burns has furnished a very instructive case of this kind, in which it would have been impossible, perhaps, without dissection, to have ascertained the true nature of the swelling. " Beneath the sterno-mastoid muscle," says he, " the enlarged gland was lobulated and clustered into small processes, precisely resembling a chain of enlarged concatenated glands. Indeed, had I alone trusted to the impressions received before dissection, I would have been led to believe that the lymphatic glands of the neck were actually swelled, and, besides that, several of the conglobate glands, placed behind the sterno-mastoid muscle, be- tween it and the trapezius, were also affected; for into that space processes from the left lobe of the thyroid gland extended."* A dilatation ©f the internal jugular vein is not an uncommon disease, and may sometimes be mistaken for goitre. It may be distinguished, generally, by its low situation—the swelling ap- pearing just above the sternum. The tumour may also be known from goitre, by its softness and compressibility, by its pulsatory and tremulous motion—by the sudden return of the tumour, when pressure is removed—by more or less turgescence, along the whole course of the vein. I once attended a patient, four or five years of age, with Dr. Jennings of Baltimore, upon ac- count of a large swelling of the neck, the precise nature of which, it was difficult to ascertain for some time. It resembled in many respects the enlarged thyroid, and in others, diseased lymphatic Vol. II. • Surgical Anatomy, p. 19G. 9 02 Bronchocele, or Goitre. glands, but turned out to be a dilatation of the internal jugular. The interesting case of a tumour of the neck, detailed by Mr. Hey, the nature of which he could not ascertain, I have no doubt, was an enlarged vein, and probably the jugular.* The morbid distention of this vessel has been confounded occasional- ly, with aneurism of the aorta.t An encysted tumour may occupy ihe anterior surface of the trachea ; in many respects it is analogous to gokre—is free from pain—is soft and doughy to the feel—follows the motions of the larynx and trachea, and may attain a considerable size. It ex- tends on the trachea as high as the thyroid gland, and descends behind the sternum. The disease has never been described, I believe, as occupying this situation. I have seen only two or three cases of it. An officer of the army consulted me, some years ago, respecting such a tumour, which had been shown, previously, to several practitioners, who could not give a decided opinion as to its nature. At first I suspected it to be a goitre, but the patient assured me that it had emerged, originally, from behind the sternum, and was occasioned, so far as he could de- termine, by the pressure of a leathern stock, which had been worn unusually tight. This circumstance inclined me to believe, that the tumour had no connexion with the thyroid gland, and determined me to puncture it with a lancet. A thick, yellow, cheesy matter, extremely offensive, and three or four ounces in quantity, was discharged from the wound by pressure. The open- ing was then enlarged, and a probe could be passed to a consi- derable distance behind the sternum, and upwards alono- the tra- chea. The cavity was tilled with lint and stimulating injections were frequently employed. Suppuration was established with difficulty, and the cavity was filled up in the course of two or three months. I met with a similar disease afterwards, in a young woman seventeen years of age, and removed it by the same treatment. The wound, however, remained fistulous for a considerable time, in spite of every remedy used. In both cases, these tumours extended so far upwards, and were so deeply im- bedded under the sternum, that any attempt at excision would have been hazardous, if not impracticable. In its natural state, the thyroid gland is found to vary in dif- • Hey's Practical Observations in Surgery, third edition, p. 448. | Burns on the Diseases of the Heart, p. 259. Bronchocele, or Goitre. 63 ferent subjects. In females, it is larger than in males. It is ge- nerally made up of distinct lobules, which arc collected into numerous lobes or tuberculated masses, joined to each other by a very fine celluler membrane. Rounded vesicles, containing a colourless, but sometimes yellowish fluid, are mixed with the lobes. In many subjects these vesicles cannot be discovered, and the existence of a fluid is ascertained, only by rubbing slices of the gland between the fingers, when a peculiar feeling of viscosity may be observed.* There is no proper investing membrane or capsule to the thyroid gland ; but the cellular tex- ture is slightly condensed on the surface, so as to furnish a very thin covering, from which processes proceed internally, and form septa or partitions in various directions. The substance of the gland generally consists of two portions, which are placed on each side of the trachea and larynx, and united to each other by a transverse band or slip of the same substance. Sometimes this band is wanting, and then there are two distinct thyroid glands.t No unquestionable excretory duct has yet been dis- covered. But small openings or canaliculi, described by Mor- gagni, Bordeu, Walter, and some other anatomists, have been found on the internal surface of the trachea. These openings uniformly occupy one situation, and are two or three in number. They may be found about the middle of the internal surface of the first cartilaginous ring of the trachea. Bordeu, in speaking of this ring, says, "Nous avons aussi remarqud, qu'il est, dans tous les sujets ou div.ise par une fente plus ou moins etendue et" situee vers lc devant du cartilage, on perce d'un ou deux, ct meme de trois trous bien. apparens et places aussi, vers le milieu du cerceau sur le devant, ou un pcu a cote. "Ces trous nous, frapperent la premiere fois que nous les vimes: cetoit a Montpellier, en 1741, en dissequant un larynx aopres du feu; la glande thyroide qui etoit extremement grosse, 6tant enlevoe, nous trouvames le premier cerceau presque osseux, mais assez transparent pour laisser apercevoir,au moyen du feu, les deux trous qui n'etoient rccouverts que par des membranes laches qu'on emporta facilcment. "Apres bien des recherches, on trouva un sujet mort de morte violente; nous examinames d'abord la face posterieure • Anatomie Descriptive, par X. Bichat. | Soemmering de corp. hum. fabric, vol. 6, p. 39. 64 Bronchocele, or Goitre. du cerceau de la trachee, sans avoir touche la thyroide; la mem- brane interne de ce cerceau etoit pleine de petits trous difficiles a" apercevoir; nous introduisimes des soies dans cinq de ces trous, et en les conduisant legerement, elles allerent se rassem- bler en deux endroits, trois dans l'un et deux dans l'autre; ces endroits 6toient precisement les deux trous du cartilage; ces soies allerent, en les pousant, se perdre dans la glande. M. Bar- buot, medecin de Semur, etoit present a cette operation."* From a perusal of these and other passages in Bordeu, some years ago, I was induced to examine the openings described, in a great many subjects, under an impression thaMhey were the raouths of excretory ducts from the thyroid gland. To ascer- tain this, I made a number of experiments with the mercurial injecting apparatus, the small pipes of which were introduced directly into the openings in the cartilage, and found that the mercury sometimes passed with facility through these small canals, but met with resistance when it reached the thyroid gland. In three or four instances I succeeded in pushing it to a considerable distance under the cellular covering of the gland, and even among the cellular texture into the substance of the gland, as I afterwards ascertained by cutting it open. But, in all pro- bility, the mercury passed, in each case, from rupture of the cel- lular tissue, and did not follow the natural course of the duct. I endeavoured to find a communication between the thyroid gland and the ventricles of Galen, and with this view introduced the mercury into the bottom of each of these cavities. Af- ter several ineffectual "attempts, I succeeded in filling the cellu- lar texture of the thyroid, and to a much greater degree than from the openings of the trachea. I mention these circum- stances to corroborate the suggestions of Morgagni and Bordeu, that there are passages from the thyroid gland, which serve to deposite its secretions in the trachea, and perhaps in other places. The observation may be useful to those who feel disposed to in- vestigate the subject further. In addition, I may state, that Fodere succeeded in blowing air from the larynx into the thyroid *dand, so as to distend it considerably. In another instance he filled the trachea with spirit of wine, and upon cutting into the thyroid gland, the smell of the liquor was distinctly perceivable. *■ CEuvres completes de Bordeu, par Richerand, torn. 1, p. 98. Bronchocele, or Goitre. 65 " Qu'on prenne," says he, " un larynx auquel, cette glande est attached, bien lave et netoye avec une leger6 dissolution de potasse, et ensuite seche, qu'on en bouche exactement l'extremite' inferieure, puis qu'on adapte au trou de la glotte, un tube con- tigue a une vessie pleine d'air, et qu'on lutte bien Pappariel; en comprimant la vessie, on verra la glande thyroide augmenter de volume. " La meme experience reussit, quoi qu' a un moindre degre, avec l'alcohol. En coupant la glande apres avoir comprime la vessie, on sent distinctment l'odeur de ce fluide."* Lalouette discovered an immediate connexion between the thy- roid gland and the lymphatic vessels which pass along the thy- roid and cricoid cartilages.! Many cases have been recorded by different writers, where an enlargement of the thyroid gland has been suddenly produced in consequence of violent exertions of the muscles of the neck in lifting heavy weights, or in conse- quence of laborious efforts of the patient during protracted and difficult parturition. It has been maintained, also, that goitre is produced among the inhabitants of certain European districts, from the habit, which is frequent among the lower order of peo- ple, of dragging burdens up the hills by cords tied round the up- per part of the chest. According to Mr. Heckewelder, who often met with goitre among the American Indians, the disease never made its appearance among the girls until they began to carry heavy burdens on their heads^J These circumstances would favour the idea of Bordeu, Fodere, Morgagni, and others, of the existence of a direct communication between the trachea and thyroid gland.§ Many theoretical uses have been assigned to the thyroid gland, besides those already mentioned. It does not come, however, within the scope of my purpose to detail them.|| When a goitrous tumour is examined by dissection, several circumstances are presented worthy of notice. One or both lobes, and sometimes the middle lobe or isthmus of the gland, are found enlarged beyond their natural boundaries. Upon cutting * Traite" du Goitre et du Cretinisme, p. 58. | Haller Elementa Physiologist. $ Barton's Memoir, p. 46. § See Morgagni's Adversaria, 5, p. 66. H Those who wish for information on the subject may consult Haller's Ele- menta Physiologix, lib. 9, p. 22. Soemmering de corp. hum. fabr. vol. 6, p. 41. Coxe's Museum, vol. 3, p. 27. 66 Bronchocele, or Goitre. into their substance, the texture is found more or less compact. intermixed with numerous cells, containing a transparent glu- tinous liquor, which may be drained off in such quantity, by pressure, as to reduce considerably the bulk of the tumour. These cells vary in size; some being large enough to contain a pea, while others are exceedingly small. The fluid they con- tain becomes a solid transparent jelly, when the gland has been immersed for some time in proof spirits.* Although the thyroid gland in its natural state is abundantly supplied with large arteries, yet its capillary vessels are comparatively few, and the quantity of blood determined to its substance not so great as commonly supposed. In bronchocele all the vessels arc great- ly enlarged, and varicose, and the quantity of blood materially increased, as is evinced by the throbbing of the tumour during life, and by injection of it after death. This preternatural ac- cumulation of blood so frequently accompanies the kind of dis- eased enlargement of the gland which I have described, as to cause some writers to rank it as a particular species of goitre,— denominated sanguineous goitre. This distinction, as well as every other division of the disease into species, is perhaps improper, in- asmuch as the appearances presented on dissection are never suf- ficiently uniform to enable us to characterize with precision each morbid change of structure. It is certain, however, that an un- usual determination of blood generally accompanies the structure I have described,—and which nosologists have called the sarco- matous bronchocele. Jn all probability, the other species men- tioned are but varieties of this common and perhaps original form of the complaint. Sometimes the texture of the goitrous tumour, instead of being compact and solid, is soft and spongy, and large cavities or membranous vesicles are dispersed throughout, which con- tain a thin, limpid, or serous fluid. This has been called the encysted, serous, or watery bronchocele. It is a modification only of the common disease; for sometimes the fluid changes into a yellow tenacious, and melicerous matter. The cells of the thyroid gland are said to have been filled, occasionally, with hydatids; but such appearances may have been confounded with the watery collections just described. The bronchocele ventosa cannot be considered as a variety of goitre, but only an emphy- * Baillie's Morbid Anatomy, p. 86. Also, Engravings, Fasciculus, 2, p. 25. Bronchocele, or Goitre. 67 sematous tumour of the gland, or of the adjacent cellular tex- ture. It is not uncommon to find in the substance of goitres, of long standing, bony particles, and even considerable masses of ossi- fied matter. Several examples of the kind are mentioned by Bonetus, Morgagni, Kerkringius and other old writers. Dr. Baillie, in his Morbid Anatomy, speaks of the thyroid gland being sometimes converted, in old people, into a bony mass. In this respect the disease nearly resembles other sarcomatous tumours, - in which we are accustomed to meet with cartilaginous and ossified productions. Calcareous concretions are said to have been discovered, in the substance of the thyroid gland, affected with goitre.* Pieces of tuft stone have been removed from the thyroid gland, in several instances, by a Swiss surgeon.t The substance of bronchocele is seldom converted into puru- lent matter. But cases have been recorded by Petit and Hev*in, where spontaneous cures were effected in this way. Severinus relates a case in which purulent matter was discharged from a bronchocele mixed with a substance resembling charcoal.J Dr. Baillie has given a drawing of a preparation contained in the Hunterian cabinet, where an abcess formed in the right side of .the thyroid gland and afterwards communicated by ulceration with the trachea, so as to suffocate the patient.§ Alibert re- lates the case of a patient in the hospital of St Louis, who laboured for years under an enormous bronchocele, and was eventually relieved of his burden by suppuration taking place in its substance. Ulceration was spontaneously established, and upwards of five pounds of purulent matter discharged.|| Burns .gives an instance, where suppuration took place in both lobes of the thyroid gland. The matter was slowly se- creted and the integuments became gradually distended, until they formed a large pouch which hung over the sternum, and contained several pounds of pus. The sides of the cyst united, and the patient was ultimately cured.1T In speaking of abscess, • Haller's Elementa Physiologic, Vol. III. p, 400. | Coxe's Travels. $ De Recondita Abscessum Natura, p. 194. § Series of Engravings, p. 27. || Nosologic Naturelle, p. 467. K Surgical Anatomy, p. 188. 68 Bronchocele, or Goitre. following bronchocele, Portal remarks, that the cartilages of the larynx and rings of the trachea, are sometimes eroded by caries. " On a trouve dans des sujets qui etaient morts de suffocation, les cartilages thyroide, cricoide, et les anneux cartilagineux de la trachee arteVe, rouge's par la carie, a la suite d'un abscess dans la thyroide. Valsalva, Morgagni, Lieutaud ont cite de pareils exemples dans leurs ouvrages."* I have had three opportunities of dissecting goitrous tumours. The first was in a man upwards of sixty years of age, who had laboured under a very large and tuberculated swelling of the thyroid, almost from infancy. The tumour occupied both sides of the trachea, and was very solid, and insensible to the touch. it produced very little inconvenience, and the patient died of another complaint. Upon dissection, I found each of the en- larged lobes completely sarcomatous, without any membranous vesicles, or fluid, except a thick yellowish, lardaceous or olea- ginous matter, in small quantity, which could be pressed, by force, from the diseased mass. Fibrous bands, similar to those which occur in the scirrhous breast or testicle, intersected the tumour in various directions. The larynx and trachea were not altered in structure, but the mouths of the small muciparous ducts, which open on the lining membrane of the trachea, were not perceptible, and the tracheo-thyroideal passages of Bordeu appeared less conspicuous than usual. Some years^igo I had an opportunity of inspecting the body of a woman thirty-five years of age, who died of apoplexy. A large tumour occupied the left side of the thyroid gland. Upon turning aside the sterno-thyroidei and omo-hyoidei mus- cles the gland was brought into view, and presented an immense number of varicose veins distributed over its surface; all the parts in the neighbourhood, seemed vascular in the extreme. Upon opening the gland a considerable quantity of thin greenish fluid was discharged, and the small cells which contained it were distinctly perceived. The right side of the gland, to- gether with the isthmus, was slightly enlarged; but in other re- spects appeared to possess its natural structure. This woman, as her husband informed me, had suffered occasionally from inor- dinate pulsation in the tumour, and from its pressure on the tra- • Cours d'Anatomie Medicate, tome iv. p. 564. Bronchocele, or Goitre. 69 thea, but in general, experienced little inconvenienoe. She was a native of Holland, where the disease commenced about the tenth year of her age, and had slowly increased. It appeared to have had no connexion with the complaint of which she died. With the history of the third subject, I am unacquainted. It was a girl about fourteen years old, who was much emaciated, and had laboured, apparently, for a considerable time, under constitutional disease. Both sides of the thyroid were involved; but the disease was evidently in its commencement. The vessels of the gland were slightly varicose, and the cellular structure of the interior contained a small quantity of transparent fluid. The larynx and trachea were unaltered, and the small openings of the first cartilaginous ring were distinctly observable. The causes of goitre are involved in much obscurity. This will account for the numerous, diversified and contradictory speculations on the subject. By many, the disease has been at- tributed to the use of particular alimentary substances, especially poor and unwholesome diet;—to the drinking of cold or snow water, or water strongly impregnated with lime-stone, or other calcareous matters; the immoderate use of spirituous and vinous liquors, debauchery, the repulsion of cutaneous diseases, and many similar explanations have likewise been resorted to; all of which are too hypothetical, and so frequently contradicted by facts, as to deserve no attention. It is certain, that goitre pre- vails as an endemic disease chiefly in countries where the at- mosphere is loaded with moisture, in valleys enclosed by lofty mountains, and which are exposed to the direct and reflected heat of a powerful sun. In some of these valleys, the fogs are visible every morning, rise with the sun in a thick body, and seldom disappear entirely, until the afternoon.* It is, however, well ascertained, that those persons who do not reside in or near the valleys where goitre prevails, but live on the sides or tops of the adjacent mountains, do not labour under the disease. Again, it is a fact established beyond all doubt, that the mere removal of a goitrous person from the valley where he acquired his disease, to the top of the contiguous mountain, will diminish * Marsden's History of Sumatra. Vol. II. 10 tO Bronchocele, or Goitre. the size of the tumour, and in time, remove it entirely. The same observations, perhaps, to a limited extent, may be applied to cretinism, a disease so often concomitant, but probably inde- pendent of goitre. " All the cretins, that I saw," says Dr. Reeve, " were in adjoining houses, in the little village called La Batia, situated in a narrow corner of the valley, the houses being built up under ledges of the rocks, and all of them very filthy, very close, very hot and miserable habitations. In villages situated higher up the mountains, no cretins are to be seen, and the mo- ther of one of the children told me of her own accord, without my asking the question, that her child was quite a different being when he -was up the mountain, as she called it, for a feio days."* Frequent opportunities are offered in this country, of observing the effects produced on goitre, by the removal of individuals afflicted with it into districts where the disease is unknown. Numerous cures, of very large goitres, have been effected in persons, who acquired the complaint at Pittsburg— simply by spending a few months in Philadelphia, or other distant places. These circumstances indicate, beyond doubt, something peculiar in the atmosphere or in the exhalations from valleys or other places where goitre is found. That the disease, at all events, is not owing to poor living or to the drinking of snow water, is sufficiently proved by the circumstance of its not pre- vailing in certain countries where the inhabitants are accustomed to subsist on a very meager and scanty diet. Besides,—the rich inhabitants of the Vallais and of the state of New York, are equally subject to the complaint with the poorer people. In Greenland, and Lapland, where the inhabitants use snow water almost entirely, there is no goitre, while in Sumatra, in Bambarra, and in many other warm countries, where snow is never seen, the disease is very common.f In those parts of the state of New York, New Hampshire and Vermont,^particularly along the course of the Connecticut river, where goitre prevails, it is remarkable that the disease is most common in those places which are covered with wood and are uncultivated; but in proportion as the country is settled and the lands cleared, the disease is found to decline, and in many * Account of Cretinism, Edinburgh Journal, vol. v. p. 33. t Vide Marsden, Park's Travels, Humboldt and Bonpland, &c. Bronchocele, or Goitre. 71 places is already nearly extinct.' In 1798, bronchocele was so common at Pittsburg, that, out of 1400 inhabitants, not less than 150 had the disease.t Since that period, the complaint has so much declined, in the same place, that it is said very few now labour under it. The change is usually attributed by the citizens of the town, to the general introduction of coal fires. All these circumstances tend to show that bronchocele is produced by a peculiar atmosphere, or by certain morbid exhalations from marshes or other grounds. What the peculiar nature of this exhalation is, we have no more means of ascertaining, than we have of finding out the constituents and mode of action, of marsh miasma, or of the agents which create yellow fever, or any similar disease. The late Professor Barton imagined goitre to arise from the same causes which produce intermittent and bilious fevers.J But it has been ascertained that goitre origi* nates in many districts where intermittents are unknown, and intermittents, on the other hand, are frequent where goitre has never been seen. Along the shores of the Delaware and Che- sapeak bays, intermittent and bilious fevers universally prevail, and goitre is seldom found. It is possible, however, that the cause of goitre may be allied to that of intermittent, but so mo- dified by particular circumstances, which we shall probably never be able to ascertain, as to produce very different effects. But those who are anxious for information, respecting all the supposed causes of goitre, should consult the work of Fodere, Coxe's Travels, Saussure's Voyages, Gautieri de Tyrolensium Struma, &c. Whatever may be the remote physical causes of goitre, I am inclined to believe, that the disease arises immediately from an obstruction of the tracheo-thyroideal passages of Bordeu, of the openings, communicating with the sacculus laryngcus and the thyroid gland, of which I formerly had occasion to speak, or of other passages with which we are unacquainted. I am inclined to draw this conclusion from the circumstance oT a watery fluid being found to occupy naturally, the cells of the thyroid gland— from this fluid being increased in quantity in almost every goi- trous tumour, and from the passages of Bordeu being much smaller * Mease's Observations. f Uatlon's Memoir. i Vide Uai Ion's Memoir—also, Caldwell's Medical and Physical Memoirs, p. 279. 72 bronchocele, or Goitre. in the first dissection I made of bronchocele, than they are usually met with in subjects without such disease. This is a mere conjecture. Neither is it original—but was advanced by one of the older writers on surgery. I mention it, merely to induce those who have frequent opportunities of investigating the structure of bronchocele by dissection, to attend to the appear- ances of these passages and to endeavour to discover other com- munications with the gland. Treatment of Bronchocele. The remedies proposed for the removal of this disease are countless—the strongest proof of their inefficiency. It will be sufficient to enumerate the principal—burnt sponge, mercury, pumice stone, muriate of barytes, sulphuret of pot-ash, egg-shells, muriate of lime, digitalis, muriate of iron, belladonna, electricity, pressure, friction, issues, setons, blisters, caustic, excision, and ligature of the thyroideal arteries. In the commencement of my practice, I employed the burnt sponge in the form of powder, mixed with honey and other materials,—the lozenges of Ring, which consist of cinnamon, gum Arabic, sirup and burnt sponge mixed—the simple decoction of the sponge, as recommended by HerrenschwTard of Berne, in Switzerland,—but generally with- out any decided effect.* In two instances, I succeeded in re- moving small goitres by the use of sulphate of potash, continued for several weeks in large doses. This remedy is said to have effected many cures, in the hands of Fodere and other practition- ers. The different preparations of mercury and antimony, muri- ates of lime and barytes, I have tried without the slightest advan- tage. In one case, after the inefficacious exhibition of many of the remedies mentioned, the late Dr. Cromwell, of Maryland, ef- fected a complete cure in a patient upwards of twenty years of * For an account of the use of these remedies, see Fodere, p. 110. Ring, in 4th, 5th, and 11th volumes of the London Medical and Physical Journal. Bronchocele, or Goitre. 73 age, who had laboured for some time under a goitre,—by the repeated application of blisters* Mr. Benjamin Bell says, that he arrested the progress of a very large bronchocele by the same means. Stimulating frictions with flannels, immersed in campho- rated liniments, and other applications of a similar nature, are commended by Underwood. Foder6 remarks that he frequently cured small Spanish dogs of goitre by the same means, at Mau- rice, where these animals are very subject to the complaint.* Frictions with mercurial ointment and various stimulating plas- ters, have been likewise extolled by different writers. Boyer has employed, for many years, cataplasms, or bags of emollient herbs, applied directly to the tumour, and worn night and day for weeks or months, and often with success. Compression has sometimes been found serviceable by Fodere; and the late Dr. Physick once succeeded in effecting a complete cure of the dis- ease, in a lady of this city, by keeping up a continued but mo- derate pressure by means of a bandage for several months. Mr. Holbrook, a surgeon of Monmouth in England, where goi- tre is endemic, has cured a number of patients, by the use of steady pressure, after the failure of other remedies, f But I have found no general or local remedies so efficacious as the extract of cicuta. Indeed, for several years, I have de- pended chiefly upon the use of this medicine, and may declare that I have seldom had recourse to it in the early stage of bron- chocele, without some benefit. I found by experience, that from the age of ten or twelve years up to twenty, and in cases where the goitre was large and spongy to the touch, and had not existed very long, that the cicuta was almost a certain reme- dy ; but, on the other hand, when it occurred in adults beyond the age mentioned, and in old people, that although it sometimes diminished the size of the swelling, yet, in general, it was pro- ductive of no advantage. The seton, employed so frequently by the older surgeons, and recommended a few years since, by Quadri of Naples, I tried repeatedly in the case of a German hoy from Lancaster, whose neck was covered with a lobulated goitre of enormous dimensions—without any other benefit than the copious discharge of a thin greenish fluid, which diminished * Fodere, p. 115. f London Medical Repository, vol. 8, p. 288. 74 Bronchocele, or Goitre. the tumour for a time, and relieved the patient of the uneasiness occasioned by its pressure on the windpipe. Within the last fifteen years, a remedy for goitre has been intro- duced into practice, by Dr. Coindet of Geneva, which has ex- cited, in a great degree, the attention of the profession in almost every European country, and in America. I allude to the pre- paration termed iodine. The reports of Coindet in favour of this medicine were soon fully confirmed by many other conti- nental surgeons; and its reputation rose speedily to the highest pitch; strange as it may seem, however, its decline has been al- most as rapid as its rise, being now considered, in the estimation of many practitioners nearly inert, and by others pronounced a most virulent poison. But from all the statements made on the subject, we have, I think, fairly a right to infer, that it is a me- dicine of great power, calculated, in some cases, to produce a very strong impression on goitrous and other tumours, as many well attested cases decidedly show; and that, on the other hand, it is followed occasionally by tremendous symptoms, and even death. Again, it is equally certain, that upon other patients not the slightest impression has been made by its use, either upon the tumour or upon the constitution of the individuals who have taken it, sometimes for months together, and in the largest doses. My own experience in its use is very limited, but judging from this and from the reports made to me concerning it by my colleagues in the Alms House Infirmary, I should feel inclined to doubt its efficacy. Still it is possible we may have been deceived, either by the bad quality of the medicine, or by other circumstances. Lastly, it may be stated, that Dr. Coindet himself, has abandoned the internal use of the remedy, and mere- ly employs it in the form of inunction, from which he stales that he has derived very beneficial results. Bronchocele sometimes disappears spontaneously. Occasion- ally, the tumour is removed suddenly. Several examples of the sort are related by Alibcrt. In one instance, during the French revolution, a woman was seized with a fit of melancho- ly, and a large bronchocele, from which she had suffered ex- ceedingly, disappeared with the utmost rapidity.* Bronchocele may become so large as to endanger suffocation. * Alibert's Noveaux Elemens de Therapeutique. Bronchocele, or Goitre. 75 In this case, extirpation, an operation first recommended by Celsus, has been resorted to, and sometimes with success. But such favourable terminations are extremely rare—as many of the older, and some of the modern French and English surgeons have sufficiently proved. Palfin, in his Surgical Anatomy, relates the case of a lady of rank in Paris, who perished from hemorrhage, in consequence of the removal of a large goitrous tumour, by an adventurous surgeon, who undertook the opera- tion in spite of the remonstrances of some of the most experi- enced practitioners. The operator had scarcely left the house, before the hemorrhage broke out, with tremendous violence, and destroyed the patient in a few minutes.* Gooch mentions three cases, in which the operation was performed contrary to his advice, and that of some other surgeons. Two of the pa- tients lost their lives from hemorrhage, and the third was only saved by constant pressure, kept up day and night for the space of a week, by the fingers of several persons employed for the purpose.! Mr. John Bell mentions more than one instance, where surgeons have opened tumours arising from or connected with the thyroid gland, from which the flow of blood has been so copious, as to oblige them to abandon the operation and close the wound as speedily as possible.^ Desault, upon one occasion, undertook to remove a bronchocele from the neck of a woman, but the blood issued with such rapidity, as to force him to stop and endeavour to secure the vessels by throwing a ligature around a considerable portion of the tumour which he had dis- sected up. The patient died in a very short time, in convul- sions, occasioned, it was supposed, by irritation from the liga- tures.§ Another case is recorded of a patient who had a large bronchocele, which was productive of no inconvenience to him, removed by the knife, by the advice of Desault, and contrary to the opinion of Baron Percy and Louis. It was found impos- sible to stop the blood, and the gentleman expired almost im- mediately. Many examples of a similar nature are recorded by Bonetus, Severinus, and others of the older writers. But, perhaps, the most remarkable operation of the kind to be found * Anatomie Chirurgicale, tome ii. p. 313. \ Chirurgical Works, vol. iii. p. 158. \ Principles of Surgery, vol. iii. § Dictionnaire des Sciences Medicales, tome xviii. p. 556. 76 Bronchocele, or Goitre. in the annals of surgery, was executed a few years ago in Paris, by the celebrated Dupuytren, on a young woman who had la- boured for a great length of time under an enormous broncho* cele, which interrupted respiration and deglutition to such a de- gree as almost to destroy her. The patient had presented her- self frequently at the Hotel Dieu, in expectation of having the tumour removed by the knife. At several consultations held on her case by the most distinguished surgeons of Paris, it was unanimously determined, that no operation could be performed with any prospect of success. The tumour, however, still con- tinuing to increase in size, and the entreaties of the patient for its removal becoming more urgent, Dupuytren, at last, con- sented to engage in the undertaking. By slow and cautious dissection he succeeded in detaching the left side of the tumour, without dividing any of the large arteries, veins or nerves of the neck. The thyroid arteries, in particular, which were very much enlarged, were each drawn out and tied with two ligatures before they were cut. The right portion of the tumour was then removed, in a similar manner, and the whole operation completed, with the loss only of a few spoonsful of blood. But the patient suffered extremely, as the operation was necessarily protracted, and the dissection carried on among parts of the ut- most delicacy and sensibility. She never recovered from the shock communicated to the nervous system, and expired in thirty-five hours after the operation.* " The Archives Gen. de Med. for January, 183G, contains an - account by M. Rufz of a case in which Professor Roux extir- pated the thyroid gland of a young man 22 years of age, affected with goitre for 12 years. The tumour did not produce any se- rious inconvenience to the patient; nevertheless, it was deter- mined to extirpate it. The operator seemed to have succeeded; that is, it was not followed by any of the serious primary symp- toms which accompany serious wounds; but the patient died about 5G hours after the operation, after a short struggle. The post mortem examination revealed no appreciable cause of death independent of the wounds produced by the operation, except lo- bular pneumonia of the left lung."f In 1836, a surgeon in this * Dictionnaire des Sciences Medicales; also, Pelletan's Clinique Chirurgicale, vol. 1, p. 215. f Hay's Journal of American Medical Science; No. xxxviii. p. 515. Bronchocele, or Goitre. 77 city, performed a similar operation, without necessity, upon a young woman, who died in a short time, from hemorrhage and irritation. It would appear, from these details, that the extirpation of even a small tumour of the thyroid gland, is attended with diffi- culties which should dismay the most expert and enterprising surgeon. Cases are recorded, however, where operations of the kind have been attended with success. Foder6 states that a barber relieved his wife of a very large bronchocele by excision. The same author mentions two other instances within his own knowledge, where Giraudi, an adventurous surgeon of Mar- seilles, succeeded in curing his patient, by the same means.* Desault dissected out the right side of an enlarged thyroid gland of a female patient in the Hotel Dieu, who recovered without a bad symptom in a month after the operation.! Two cases of successful extirpation of bronchocele are detailed by Dr. Harris, of New York. In the first case the tumour was not larger than a pullet's egg, in the second it was of considerable size. " About three months since," says Dr. Harris, "an application was made to me by a lady from South Carolina. I think the bronchocele was full as large as any I had ever seen. The tumour had been increasing for twenty-two years. It extended from the chin, which it buoyed up, along the trachea, until it descended an inch, or perhaps more, under the breast bone, and spread la- terally a medial distance to each ear."J No hemorrhage of con- sequence followed either operation, and both patients recovered in a very short time. There is great reason, however, to be- lieve, from the histories of these cases, that the tumours neither constituted a part of the thyroid, nor were connected with it. But, from all the information I have been able to collect, on the subject of the removal of this gland by the knife, I am inclined to believe that less danger would attend its excision, as respects hemorrhagy, than is commonly imagined. Our knowledge of the means of arresting hemorrhage has been greatly improved within a few years; and it will be seen, that Dupuytren, by adopting a practice long ago recommended and employed with the greatest success, in this country, by Dr. Physick (the tying of * Traitc du Goitre, &c. p. 148. ■{- Surgical Works, vol. 1, p. 257. t New York Medical Repository, vol. 11, p. 242. Vol.11. 11 78 Bronchocele, or Goitre. large arteries before they are cut) was enabled to extirpate an enormous bronchocele, with the loss of only a small quanti- ty of blood. But I very much question the propriety of at- tempting the removal of the goitrous tumour, in any case, inas- much as 1 conceive that hemorrhage is less to be dreaded than the inflammation and irritation which follow the operation. Under ordinary circumstances, the tumour may attain a very large magnitude, without endangering the patient's life or pro- ducing much inconvenience; and if it should increase to such a degree as to render death inevitable, there is very little proba- bility that the patient can be saved by so severe an operation as must necessarily be encountered. But although I would not recommend the excision of the thyroid gland, there is another operation to which I would not hesitate to resort in case of necessity. I allude to the tying up of the great arteries in the vicinity of the tumour, from which it chiefly derives support. Mr. Thomas Blizzard, of London, was the first, I believe, to execute the operation. The thyroid arteries on each side of the neck, were included in a ligature. and the tumour diminished, in the course of a week, one-third in size. The patient, however, did not recover, but died from repeated secondary hemorrhage, occasioned by an attack of hos- pital gangrene. But he lived long enough to evince the pro- priety and practicability of the operation.* In 1818, a similar operation was performed by Professor Walter, of the University of Landshut, on a man twenty-four years of age, who had an enormous bronchocele, from which he suffered extremely. The inferior thyroideal artery of the left side was taken up, and at the end of a fortnight the left portion of the tumour had diminished so much in bulk as to induce the operator to include the supe- rior thyroid of the right side in a ligature. No inconvenience followed either operation, and the bronchocele, in a short time, almost disappeared, leaving behind only the elongated skin which hung from the neck in the form of an empty sack.t * Burns' Surgical Anatomy, p. 202. \ Bulletin de la Soci^te" Medicale d'Emulation, 1818. r A Torticollis, or Wry Neck. 79 Skction VI. Torticollis, or Wry Neck. From exposure to cold, from rheumatism, twists of the neck, or strains of the platysma-myoides, and sterno-mastoid muscles, from the cicatrices of burns, &c, the head is sometimes drawn to one side, or towards the shoulder or sternum, in such a way as to produce great deformity. Occasionally, the disease arises from paralysis; in other instances, it proceeds from some defect or malformation of the vertebras of the neck. The clavicular is oftener affected than the sternal portion of the sterno-mastoid muscle; each, however, is liable fo be converted into a substance resembling gristle. The whole of the muscle also is shortened, has an indurated, stringy feel, and is painful to the touch. Great pain is frequently experienced upon attempting forcibly to restore the head to its natural position. Treatment of Wry Neck. When the disease depends upon paralysis of the muscles, or upon malformation of the vertebrae, it may be looked upon, ge- nerally, as incurable; but when it arises from morbid contrac- tion of the fibres of the platysma-myoides, or sterno-mastoid mus- cles, an operation will, in many instances, effect a cure. It should be done in the following manner. The patient is seated on a chair, and his head supported by an assistant standing be- 80 Torticollis, or Wry Neck. hind him. An incision is then made two or three inches long, in the course of the muscular fibres, through the integuments; and the contracted portion having been fairly exposed, the han- dle of a knife, (or a small curved spatula,) is carried behind it, in order to protect the vessels beneath. By one or more cuts of a bistoury, the muscle is next separated, and when this is effec- tually done, the head may be immediately,* in most cases, re- stored to its natural situation. Very frequently it happens, that several strings of muscular fibres, in different places, require to be cut across. In such cases, the surgeon must persevere until he has loosened the whole. After the operation, the head should be supported in its proper place by bandages or a stock of leather, and the edges of the wound, for some time, kept separated by lint. Sometimes, especially in females, it may be deemed expedient, in order to obviate deformity arising from the cicatrix, to pinch up the contracted portion of the muscle, along with the skin covering it, and divide it with a narrow and sharp-pointed bistoury. Dupuytren has related a case in which he succeeded perfectly by adopting this plan. Professor Jorg, of Leipsic, has attempted the cure of wry neck by machinery, and sometimes, it is said, with success. On Diseases and Accidents of the (Esophagus and Trachea, consult—Pelletan's Clinique Chirurgicale, torn. 1—DesauWs Works, by Smith, vol. 1—C. Bell's Operative Surgery, vol. 2—C. Bell's Surgical Observations, vol. 1.—Lawrence on some Affections of the Larynx, &c, in Medico-Chirurgical Transactions, vol. 6— Chevalier's Case of Croup, vol. 6, of Medico-Chirurgical Transactions—Monro's Morbid Anatomy of the Gullet and Stomach—Burns'Observations on the Surgical Anatomy of the Head and Neck—Hopkins' Case of a Shot in the Trachea, in Pot- ter's Medical Lycseum. In this case, the shot was removed from the trachea of a young lady, by her mother, who, without apprizing the patient of her intention, suddenly seized her while lying over the edge of a bed, and forced her head and shoulders towards the floor. The shot, being carried by this movement towards the glottis, was instantly discharged. On Bronchocele, consult—A Memoir concerning the Disease of Goitre, &c, by Benjamin Smith Barton—Peeve on Cretinism in Edinburgh Medical and Surgi- cal Journal, vol. 5—Fodere" Traite" du Goitre et du Cretinisme—Dictionnaire des * I performed an operation, several years ago, upon a girl, sixteen years of age, whose head had been drawn for several months towards the right shoulder, from a* contraction of the clavicular portion of the sterno-mastoid muscle. As soon as the muscle was cut across, the head was instantly restored to its natural position, and has so remained ever since. Torticollis, or Wry Neck. 81 Sciences Medicates, vol. 3—Gooch's Chirurgical Works, vol. 2—Baillie's Series of Engravings to illustrate Morbid Anatomy—Alibert's Nosologic Naturelle—Gibson on Bronchocele, in vol. 1, of the Philadelphia Journal of the Medical and Physical Sciences—An Essay on the Effects of Iodine on the Human Constitution, with Prac- tical Observations on its Use'in the Cure of Bronchocele, Scrofula, and the Tuber- culous Diseases of the Chest and Abdomen. By W. Guirdner, M. D. 8vo. Lon- don, 1824—Medical Researches on the Effects of Iodine, in Bronchocele, Paralysis, Chorea, Scrofula, Fistula Lacrymalis, Deafness, Dysphagia, White Swelling, and Distortions of the Spine. By Alexander Manson, M. D. On Wiy Neck, consult—C. BelVs Operative Surgery, vol. 1—Gooch's Chirur- gical Works, vol. 2—Sharp's Treatise on the Operations of Surgery—B. Bell's System of Surgery, vol. 5—Boyer's Traill des Maladies Chirurgicales, torn. 7 — Kirby's Cases, with Observations on Wry Neck, &c.—Cooper's First Lines of the Practice of Surgery, vol. 1, p. 558; in which will be found an Engraving and De- scription ofJorg's Apparatus. 82 Hydrothorax, or Dropsy of the Chest. CHAPTER IV. DISEASES OF THE THORAX. Gun-shot and other wounds of the chest, emphysema, col!ec« tions of purulent matter, and of blood, mammary abscess, car- cinoma of the breast, fractures of the ribs and sternum, aneurism of the aorta, caries of the spine, having been already treated of in other places, it only remains to notice hydrothorax, and to describe the operation necessary for its removal, after the phy- sician has exhausted his skill in the trial of medicines. Section I. Hydrothorax, or Dropsy of the Chest. This disease is either idiopathic or symptomatic. The former is very rare, the latter frequent. Idiopathic hydrothorax gene- rally occupies one side of the chest only, and is frequently unac- companied by dropsy in other parts of the body. The pleura itself is seldom much diseased, and merely contains a serous fluid. The lung of the affected side is collapsed, and the patient com- plains of great difficulty of breathing. Symptomatic hydrothorax is exceedingly common, and is characterized by the following symptoms. The patient finds it difficult, if not impossible, to lie in the horizontal position, or on the unaffected side. His respiration is hurried and la- borious, pulse irregular, thirst incessant, urine diminished and high-coloured. In addition to these symptoms, a troublesome cough and palpitation of the heart usually attend the disease. One of the most certain symptoms, however, is a sensation re- sembling the movement of water within the chest. This par- Hydrothorax, or Dropsy of the Chest. 83 ticular sensation may often be discovered by the surgeon him- self, while the patient *is in the erect position, by forcibly striking the chest, and still better by the use of the stethoscope. A collection of water in the pericardium may give rise to all the symptoms of common hydrothorax. Sometimes both sacs of the pleura are filled with fluid. In other instances, the cavities are occupied by hydatids. The most common causes of symp- tomatic hydrothorax, are intemperance, gout, asthma, anasarca, pleurisy. Paracentesis Thoracis. This operation is seldom resorted to until the case is hope- less—a sufficient explanation of the unfavourable termination that generally awaits it. When performed early, however, and under favourable circumstances, it is calculated to afford great relief, even if it should fail to remove the disease. The situa- tion most favourable for the evacuation of the fluid, is between the sixth and seventh ribs, counting from above downwards. Having placed the patient nearly in an upright position, with his back supported by pillows or by an assistant, and the head and shoulders directed backwards, the surgeon makes an inci- sion three inches long, with a small scalpel or bistoury, through the integuments, cautiously penetrates the layers of the inter- costal muscles (keeping close to the upper edge of the seventh rib to avoid the intercostal artery) and makes an opening through the pleura large enough to admit a full-sized cannula or gum elastic catheter, which should be introduced as soon as the wa- ter begins to flow. Care must be taken, however, not to push the cannula too far, lest its extremity irritate the lungs, and ex- cite coughing. This happened to me during the winter of 1824, in the Alms House Infirmary, in a case of hydrothorax under care of Dr. Jackson, and brought on immediately a most severe cough, that distressed the patient exceedingly. If a very large quantity of fluid has collected, it will be improper to remove the whole of it at a single operation—lest the patient suddenly 84 Hydrothorax, or Dropsy of tlxe Chest. die from the pressure being taken off from the heart and lungs. When both sides of the chest are occupied by the fluid, an ope- ration will be required on each side: but they should never be performed simultaneously, inasmuch as the lungs generally col- lapse as soon as the chest is opened, in which case the patient must necessarily die. After the fluid has been evacuated the lips of the wound should be closed by sticking plaster, and made to unite. Should the water accumulate again, as it often does, the operation may be repeated. " The operation for em- pyema, or paracentesis, is seldom resorted to in this country," says Dr. Jackson, " or England, for the relief of morbid effusions into the chest. Though of greater frequency, on the continent of Europe, yet, in comparison with the practice of former periods, it appears to be falling into disusage. The nature of these ef- fusions, and their causes, are widely different. The operation is not calculated to afford equal benefit in all cases in which they exist, while, in many, it is wholly useless. From a re- currence to it without discrimination, it has, no doubt, often proved of no service, and may have been sometimes of disadvan- tage; and, in consequence, the benefits that may be obtained from the apposite performance of this operation, have been too much underrated. Many striking instances of unequivocal relief, and some complete cures in desperate cases, are on record, as having been obtained by these means; nor can it be questioned, that, employed with judgment, it will seldom fail to afford re- lief from distressing symptoms, will often protract life, and, sometimes, prove auxiliary to the completion of a perfect cure. The operation itself is simple, unattended with much hazard, being but little more formidable than the opening of a large abscess, and, when an effusion into the chest is clearly indicated, may, with perfect propriety, be performed, merely with a view to alleviate the distress and suffering of the patient, even when it holds out no expectation of an ultimate recovery." See B. Belts System of Surgery, vol. 5, p. 188—Laennec on the Diseases of the Chest—S. Cooper's First Lines of the Practice of Surgery, vol. 1, p. 584— Archer's Case of Paracentesis, in vol. 1 of Transactions of the King's and Queen's Colleges of Physicians in Ireland—Jackson's Case of Effusion into the Chest, in which Paracentesis was performed, in the Philadelphia Journal of the Medical and Physical Sciences, vol. 10, p. 19. Discuses of the Abdomen. 85 CHAPTER V. DISEASES OF THE ABDOMEN. With few exceptions, the surgical diseases of the abdomen arc as numerous, diversified and important, as those of any other part of the body. Many of them, too, are extremely intricate, and will require all the student's industry and skill to unravel them. This is strikingly the case with hernia, which, from the complicated anatomical relations of that disease, its extraordinary frequency, the numerous varieties of the complaint, the distinct modes of treating each, recommended by some surgeons, and condemned by others equally eminent, the necessity, upon many occasions, for delicate operations, called for, often, upon the spur of the occasion, and without a moment's warning, should be sufficient, as a distinguished writer has remarked, " to infuse fear into the heart, and agitation into the conscience of all who pre- sume to call themselves qualified surgeons, without having first duly considered every thing relating to so important a branch of their profession." In the ensuing sections, I propose to consider dropsy of the belly, poisons in the stomach, and the principal varieties of hernia. Abscess of the liver, aneurism of the abdominal aorta, lumbar abscess, and wounds of the abdomen, have been already treated of in their proper places. Vol. II. 1'2 8G Ascites, or Dropsy of the Abdomen. Section I. Ascites, or Dropsy of the Abdomen. In the commencement, this disease is marked by difficulty of breathing, cough, dryness of the skin, constipation of the bowels, diminished secretion of urine, loss of appetite, prostration of strength. These symptoms are soon succeeded by general ful- ness of the abdomen, and by a sense of fluctuation easily per- ceived by laying one hand on the belly, and striking it with the other. Ascites, for the most part, is the consequence of organic dis- ease of the viscera of the abdomen, particularly scirrhus of the liver, pancreas, or spleen. Sometimes it arises from an accu- mulation of water in the cavities of the pleura or pericardium, at other times it follows an enlargement of the mesenteric glands. In general, the fluid is contained in the sac of the peritoneum, and sometimes accumulates in prodigious quantity. Paracentesis Abdominis. By the internal use of volatile tincture of guaiacum, squill, gamboge, calomel, digitalis, elaterium, and other similar medi- cines, I have frequently succeeded in removing, entirely, dropsy of the belly. The disease, however, often terminates fatally for want of a timely operation. There are two situations in which Ascites, or Dropsy of the Abdomen. 87 this may be performed—mid-way between the spine of the ilium and umbilicus, or in the linea alba. The former has of late years been mostly abandoned, owing to the thickness of the mus- cular parietes, and to the epigastric artery, from irregular distri- bution, having sometimes been wounded. A trocar, either round- ed or flat, is the instrument commonly used in this operation; or a common lancet may be employed, as advised by Dr. Phy- sick. Preparatory to the operation, the abdomen should be sur- rounded by a piece of flannel, broad enough to cover its whole surface, and sufficiently long to go twice round, the ends of which are split in three or four places. The middle of the ban- dage is placed over the front of the abdomen, and the ends arc crossed upon each other, and left hanging on each side. Having marked the spot in the linea alba best adapted to the operation— about two or three inches below the umbilicus—the surgeon makes a slit in the flannel, corresponding to the part, and through this penetrates with the trocar or lancet, the integuments, tendons and peritoneum. The instrument being withdrawn, the water instantaneously follows the puncture, and in proportion as it flows, assistants placed on each side of the patient tighten the flannel by pulling at its ends. This serves the purpose of keep- ing up the general support of the abdomen, and prevents the pa- tient from fainting. If a very large quantity of fluid has accu- mulated, it may, perhaps, be imprudent to draw it all off at once, lest the patient be too much exhausted. On the contrary, the better plan will be to close the orifice from time to time, until the whole is evacuated; after which, the opening may be permit- ted to heal. Should the surgeon prefer a common lancet for the operation, he must be prepared with a flat cannula, corresponding to the size of the instrument, and introduce it into the open- ing immediately after the lancet is withdrawn. Sometimes the flow of water is suddenly interrupted by the intrusion of a par- ticle of fat within the cannula. When this happeus, the obstacle should be removed by a probe. The operation of paracentesis abdominis, is one which in general requires frequent repetition. Incredible quantities of fluid have been drawn from some patients at once, or at separate operations. Many patients sink under the disease in a few weeks or months; others live for as many years, and experience temporary relief from operations. A few recover perfectly. 88 Ascites, or Dropsy of the Abdomen. It sometimes happens that pregnancy so closely resembles abdominal dropsy as to be mistaken for it, and cases are related in which the uterus has actually been tapped. The following remarks on this subject by Sir Astley Cooper are well calculated to put the young surgeon on his guard. Speaking of encysted dropsy, he says, " I will here mention two circumstances, in one of which my character was exposed to considerable risk ; of the other I was informed by a medical man who was invited to wit- ness the operation. In the first case I was desired to see a lady who I was told laboured under dropsy. When I entered the room I saw a tall delicate female, with an immense abdominal swelling, giving a distinct sense of fluctuation. 1 requested the physician accoucheur, whom I met, to examine if the lady was not with child; he said he thought it was unnecessary, as the fluctuation was very distinct, but that he would do so and let me know the result in a few days. I heard no more of her for a week, and then I learned that she had been put to bed on the morning following my visit. I would not have performed the operation of paracentesis for the universe. The circumstances which were told me of the other case were as follows: a surgeon in a country town called upon another surgeon, and said, ' I am going to tap a woman to-morrow; perhaps your young gentle- men would like to be present. As it was an operation they had never witnessed, they most readily accepted the invitation: they were shown into a room in which the patient was already prepared to undergo the operation; she was sitting at one end with her abdomen bare. The surgeon, then, taking his trocar and cannula, went to some distance, and walking up to the pa- tient with the trocar presented, he charged, as it were with a bayonet, and plunged it into the abdomen; then withdrawing the trocar with an air of triumph, it was with no small chagrin he found not a drop of water escape; but, however, still undis- mayed, he withdrew the cannula, and again renewing his attack, he a second time introduced the trocar into the abdomen, but was equally as unfortunate as before, in finding that no water followed. Waiting a few moments, he withdrew the cannula, and turning round to the gentlemen, he said," You may do\her up;" by which he meant they might apply the bandages; and he added, « This, gentlemen, is an operation.which you probably Ascites, or Dropsy of the Abdomen. 89 never saw before, and which most likely you may never see again. This is what we call the operation of dry tapping!"* The encysted, or ovarian dropsy, differs essentially in cha- racter and situation from common ascites. The latter is con- tained in the bag of the peritoneum, in the greater number of in- stances, in contact with the intestines; the former is confined to the ovarium, and originally contained in separate cells, the par- titions of which are afterwards broken down or absorbed. A few of these cells, however, generally remain. The fluid of ovarian dropsy, also, is not commonly so thin and transparent as that of ascites. It is generally thick, tenacious and turbid, of a brown or yellow colour, and often resembles sero-purulent mat- ter. From an enormous tumour of this description, which I opened some years ago, were discharged several gallons of fluid, of the consistence and colour of honey. But, in other cases, I have drawn off large quantities of perfectly transparent serum. When the ovarian dropsy becomes so extensive as to occupy the abdomen, it is very difficult to distinguish it from ascites; but after an operation the walls of the ovarium can be distinctly felt, in shape of a tumour large as a child's head, on one side of the abdomen. See C. Bell's Operative Surgery, vol. 1, p. 318—Dorsey's Surgery, vol. 2, p. 364. * Sir A. Cooper's Lectures on Surgery, by Tyrrell, Vol. II. p. 378. 90 Poisons in the Stomach. Section II. Poisons in the Stomach. Accidentally, or by design, poisons are often taken into the stomach, and, according to their particular quality and quantity, produce, in greater or less time, violent symptoms or death. Poisons from the mineral, vegetable, and animal kingdoms, are all capable of these effects. With few exceptions, however, mineral poisons are more active and deleterious than either ve- getable or animal. The principal mineral poisons are arsenic, corrosive sublimate and some other preparations of mercury, acids, and alkalies, lead, tartrite of antimony, and lunar caus- tic. These, when taken into the stomach, operate by exciting violent inflammation, or by producing excessive vomiting, pal- sy, or convulsions. Arsenic and corrosive sublimate give rise nearly to the same symptoms: these are swelling of the tongue, extreme thirst, a burning sensation throughout the gullet, violent spasmodic pain in the stomach and intestines, incessant vomiting and purging, and the evacuation of viscid mucus mixed with blood. If relief be not speedily afforded, cold sweats, faintings, twitchings of the limbs succeed and destroy the patient in a few hours. When examined after death, the stomach and oesophagus exhibit marks of violent inflammation, and are sometimes perfo- rated with numerous holes. Among the vegetable poisons most deleterious, may be enume- rated opium, cicuta, aconitum, hyoscyamus, digitalis, belladonna, hellebore, savin, laurus cerasus, and many varieties of fungus or mushroom. These, when introduced" into the stomach in large quantity, occasion palpitation of the heart, stertorous breathing, vertigo, dimness of sight, torpor, distention of the stomach, con- vulsions and death. In addition to these symptoms, opium and laudanum, in large doses, have the peculiar power of inducing Poisons in the Stomach. 91 profound sleep, which generally terminates in apoplexy, para- lysis, or death. The animal poisons capable of producing violent symptoms, or fatal consequences, by being taken into the stomach, are com- paratively few in number. The principal are cantharides, and certain varieties of fish. Prussic acid, which belongs both to the animal and vegetable kingdoms, is a most subtle poison, and, sometimes, even in very small quantity, produces instan- taneous death. Cantharides is more protracted in its operation, but is capable of inducing tremendous symptoms, and not un- frequently proves fatal. Some poisonous fish, when eaten, de- stroy life in a few hours. Such fish are by no means uncom- mon in some parts of the West Indies. Those reputed the most deleterious are the yellow billed sprat, dolphin, the rock fish, barracuda, smooth bottle fish, the king fish, gray snapper, the white land crab, and the conger eel. Treatment of Poisons in the Stomach. m When the nature of the poison taken in the stomach can be ascertained, it may be possible sometimes, by antidotes, to ob- viate its deleterious effects. A large quantity of albumen, or white of eggs, for example, is looked upon as the proper cor- rective for corrdsive sublimate; lime water, charcoal, or carbo- nate of magnesia for arsenic; muriate of soda for lunar caustic; calcined magnesia for the mineral acids; acetic acid for the al- kalies. It must be understood, however, that in general neither these nor any other articles* of similar description are calculated to produce very beneficial effects, and that our reliance must be placed, mainly, upon speedy and copious vomiting, and upon the removal of the poison by means of the gum elastic tube and syringe. The last is a remedy of modern origin, and one of * From experiments, recently made on the human subject, and other animals, there is great reason to hope that the hydrated per oxide of iron, will be found a perfect antidote to arsenic. 92 Poisons in the Stomach. immense importance. By whom the idea was first suggested, is) not positively known. Renault, however, in his work on poi« sons,* expressly recommends an apparatus (somewhat similar to the one now in use) for removing arsenic fromj the stomach. Dr. Monro, afterwards, in his thesis,t gave drawings of instru- ments for the removal of laudanum from the stomach, and at the same time published a case in which the experiment had been tried—though without success. Quo laudani effectus leniores essent ei in vetriculum, instrumento in tab. XIV. depicto, per magnam aquae tepidae quantitatem injeci, faucibusrsimul perori- speculum diductis.''J It remained, however, there is reason to believe, for Dr. Physick to prove the utility of the invention; for until the successful issue of the experiment performed by him' in 1812, on a child of three months old, poisoned by laudanum,§ little importance was attached by the profession either to Re- nault's or Monro's proposal. Since that period every apothecary's boy in Philadelphia has become fully acquainted with the ope- ration, which, perhaps, has been performed hundreds of times with the most favourable result. Strange as it may appear, European, or at least British, surgeons are just becoming ac- quainted with the practicability of the operation, for we find from the statements of a Mr. Read, and from remarks in the periodical work called the "Lancet," that the proposal has been considered by Sir Astley Cooper, Messrs. Scott, Jukes, and other surgeons, as perfectly novel, and this so late as the year 1822!! When called to a patient suffering from poison, whether cor- rosive sublimate, arsenic, or any other article of the kind, the surgeon should resort immediately tQ a powerful emetic, and, if this does not answer, to the gum elastic tube, (an instrument about two feet in length, and three-eighths of an inch in diameter,) and by means of a common pewter syringe applied to its upper extremity, inject into the stomach a quantity of tepid water. The water, mixed with the contents of the stomach, should be * Experiences sur les contre Poisons de PArsenic, 8vo. j- De Dysphagia, p. 95. Edin. 1797. $ De Dysphagia, p. 95. § See Eclectic Repertory, vol. 3, p. 111. Poisons in the Stomach. 93 immediately afterward withdrawn, and a fresh supply thrown in, and by this alternate injection and evacuation, the stomach may in a little time be thoroughly scoured out, the poison re- moved, and the patient recovered—provided there has not been T too great delay. The common syringe and tube I prefer to the more complicated and expensive instruments of Jukes and Read —after repeated comparative trials with each. Of late years, however, several instruments for pumping out the stomach have been invented, less complicated and more effectual than the ones just referred to. In particular, a syringe invented by Dr. C. Mathews,* of this city, is worthy of the praise which has been bestowed upon it. English surgeons, especially, I presume, must have been pleased with it; for soon after an account had been published of it in the London periodicals, Mr. Weiss, a celebrated cutler, manufactured one upon the same principle exactly, but without reference to the source from which he, probably, derived it. Mr. Weiss' pump has since been intro- duced into general practice, and is, certainly, a very beautiful, simple, and useful instrument. Consult Monro's Morbid Anatomy of the Human Gullet, Stomach, and Intes- tines, p. 79—Thomas' Modern Practice of Physic, edit. 7, p. 311—Dlctlmnaire des Sciences Medicates, torn. 43, p. 525—Orfila on Poisons—Chhholm on the Poi- sons of Fish, in vol. 4, of the Edinburgh Medical and Surgical Journal, p. 393— Brodie's Observations on the Action of Poisons on the Animal System, in Trans- actions of the Royal Society of London, 1812—Bosioch's Experiments, showing that a Mineral Poison may produce sudden and violent Death, and yet be incapa- ble of Detection in the Contents of the Stomach, in Edinburgh Medical and Sur- gical Journal, vol. 5, p. 14—Account of a new mode of extracting poisonous Sub- stances from the Stomach, by P. S. Physick, in the Eclectic Repertory, vol. 3, p. Ill and 381—Read's Appeal to the Medical Profession, on the Utility of the Im- proved Patent Syringe, &c.—The Lancet, vol. 1, No. 8. * See American Medical Recorder for 1826. Vol. 11 13 9* Hernia. Skction III. Hernia. A protrusion of any of the abdominal viscera, covered by the peritoneum, through natural or preternatural apertures in the tendinous or muscular parietes, may be denominated hernia. The term has been extended, though improperly, to several other diseases bearing no analogy to the one under present con- sideration. Hernia is a very common disease; so much so, that one-eighth of mankind, it has been imagined, is troubled with it—a pro- portion, however, immensely overrated. Certain general ap- pellations expressive of the particular condition or contents of a hernial tumour, are employed by most modern surgeons__ reducible, irreducible, and strangulated hernia, enterocele, epi- plocele, and entero-cpiplocele. By reducible hernia is under- stood a tumour easily replaced by pressure, or by laying the patient in the horizontal position, but descending again as soon as the pressure is discontinued, or the upright, posture resumed. The term irreducible hernia implies permanent protrusion from adhesion between the sac and its contents, or from extraordinary bulk. Strangulated hernia is that state of the disease in which the parts are confined by stricture, and are liable to mortify, unless the stricture be speedily removed. When the protru- sion consists of intestine alone, the disease is denominated en- terocele; when it contains omentum merely, it is called epiplo- cele; and, if intestine and omentum together, enlero-epiplocele. Hernias are, also, designated according to the situation they happen to occupy. Thus, we have bubonocele or inguinal hernia, oscheocele or scrotal hernia, merocele or crural or femoral her- nia, exomphalos or umbilical hernia, congenital hernia, ventral Hernia. 95 hernia, ventro-inguinal hernia, and several other varieties of comparatively rare occurrence. Every hernia is furnished with a peritoneal investment, or sac; this is pushed before the protruded viscera, and passes through a natural or preternatural opening, to the margins of which it speedily forms an intimate adhesion. That portion of the sac communicating directly with the abdomen is called its mouth; its lower extremity, or that most remote from the internal sur- face of the belly its fundus, and the part immediately sur- rounded by the aperture in the tendinous parietes, its neck. The sac, although originally thin as the rest of the peritoneum, soon acquires an increased thickness, and in hernia of long standing, is sometimes greatly condensed. On the other hand, it is frequently found attenuated to an extreme degree, or en- tirely wanting—as the result of absorption. That it is suscepti- ble of extreme extension, is proved by those enormous hernial tumours, so common in very warm climates, and sometimes met with in this country. The causes of hernia are very numerous, and are either ex- citing or predisposing. Severe exercise on foot, or on horse- back, lifting heavy weights, playing on wind instruments, vo- miting, costiveness, stricture of the urethra, the hooping-cough, crying, parturition, tight clothes, jumping, often produce the complaint either immediately or remotely. Among the pre- disposing causes of the disease, hereditary conformation and preternatural laxity of the abdominal apertures, may be consi- dered the most common. Reducible hernia is distinguished from other varieties of the disease by the following symptoms. The tumour, as already mentioned, descends in the erect, and retires within the abdomen during the recumbent position, or when pressure is made upon it. If the sac should contain intestine, a peculiar rumbling or guggling noise will be perceived both by the patient and surgeon, at the moment the gut slips into the abdomen. The tumour will also be tense and elastic to the feel. Omentum, on the contrary, communicates to the finger a doughy sensation, and is with great- er difficulty restored to the abdomen. Besides these indications, a reducible hernia may be distinguished from other diseases by the circumstance of its being larger after a meal than when the stomach and intestines are empty, and by an impulse being com- 96 Hernia. municated from the tumour to the surgeon's finger when the pa- tient is directed to cough. If suffered to increase, the reducible hernia may in time become enormously large, and the patient will not only experience great disorder of the digestive organs, but his life will be endangered by strangulation of the gut. Irreducible hernia may arise from three different causes— from adhesion between the sac and its contents—from the for- mation of membranous bands across the sac—and from an ex- traordinary enlargement of the omentum, or great increase in volume of the intestines. The last two causes are more common than the first. Effusion of lymph upon the inner surface of the sac, and upon the outer surface of its contents, gives rise to the bands that intersect the intestine and omentum, and fasten them at different points to each other. When the omentum has re- sided for a long time in a hernial sac, it is apt to become en- larged and indurated, and in this state cannot pass through the neck of the sac and be restored to the abdomen. Sometimes a mass of hardened omentum serves as a truss, and prevents the descent of the intestines. Slow inflammation, from neglect, from blows upon the tumour, and other injuries, is the most fre- quent cause of hernia being changed from the reducible to the irreducible state. The symptoms of strangulated or incarcerated hernia, are, in most instances, so strongly marked, as to admit of no decep- tion ; yet it happens, now and then, that the disease is confound- ed with ileus and other intestinal affections. If, from irregu- larities of diet, violent corporeal exertions, injuries, or other causes, the contents of a reducible or irreducible hernia should become constricted, the faecal evacuations will be suppressed, the patient will complain of general soreness of the abdomen, of pain round the navel, resembling the sensation produced by a tight cord, of sickness of the stomach, and of severe pain in the tumour itself. To these symptoms are speedily added, vomiting of bilious, or stercoraceous, matter, hiccup, a quick, hard pulse, an increase of tension in the abdomen, cold sweats, and great anxiety of countenance. If by this time the patient does not experience relief, a remarkable change in the symptoms will soon take place. The pulse becomes small and thready, the patient feels suddenly easy, the tumour when pressed upon crackles beneath the fingers, and assumes a leaden colour. To these succeed Hernia. 97 enormous distention of the abdomen, a fluttering, intermittent pulse, and death. When examined by dissection, the intestine will be found of a dark brown or chocolate colour, interspersed with black or mortified spots, and coated in particular places with a brownish or bloody lymph. The omentum is seldom altered in appearance. The sac contains, in proportion to its size, and the duration of the strangulation, more or less of a bloody fluid. At the strictured part, the intestine is generally ulcerated or detached. Throughout, the peritoneum exhibits marks of high inflammation, and in numerous places the intes- tines are glued together, and their surface streaked with red vessels. It might, perhaps, be supposed that a stricture upon the omentum merely, would not give rise to constipation and the other symptoms of strangulation above enumerated. Expe- rience, however, proves the contrary. With regard to the length of time strangulation may continue, much will depend upon the age and size of the tumour, and upon its contents. Re- cent and small herniae, generally speaking, are more dangerous, and terminate sooner, when strangulated, than the old and large. An intestinal hernia, also, runs its course quicker, and is more violent in its symptoms than an omental hernia. Some stran- gulated herniae prove fatal in six or eight hours; others continue for as many days. The disease, when left to itself, is not inva- riably mortal. On the contrary, the parts exterior to the stric- ture, in some instances, mortify, and are thrown off in the form of slough, an artificial anus is established, and the patient reco- vers. The seat of the stricture in strangulated hernia must de- pend upon the particular situation the hernia happens to occupy. General Treatment of Hernia. Reducible, irreducible, and strangulated hernias all require distinct and particular modes of treatment. For reducible hernia, an appropriate truss is the only remedy, and the sooner this is applied the better. Formerly an opinion 98 Hernia. prevailed that such instruments were not adapted to infants; the error has been amply rectified by modern experience, and much mischief thereby prevented. Trusses are either elastic, or non- elastic : the latter are now seldom employed, and never can be to advantage. A well constructed steel truss often effects a per- fect cure, especially in children and young subjects, by exciting a degree of inflammation sufficient to agglutinate the sides of the sac, or the edges of the opening through which the hernia has passed. To accomplish this purpose, great attention must be paid by the surgeon in adapting the instrument to the parts, and by the patient in wearing it without intermission. The best mode of fitting a patient with a truss, is to try a number of instruments, and select the one that adapts itself best to the hol- lows and projections about the abdomen and pelvis, and can be worn with the least inconvenience. When no opportunity of selection offers, a measure may be taken by means of annealed wire, doubled and passed around the body, taking care to leave the wire an inch or two longer than the size of the patient—to allow for the stuffing of the instrument. A well contrived truss will fit accurately in every part, and set closely to the body, neither bulging in particular places, nor binding too closely. Every patient should be provided with a spare truss—in case of accident. To prevent the pad of the truss from imbibing per- spiration and becoming hard, a bit of calico, muslin, or rabbit skin should be placed between it and the tumour. With a view, also, of obviating rust, to which the spring is very liable, the instrument may be thickly covered with durable leather, or some similar material, and with oil-cloth, or gum elastic, when the pa- tient has occasion to bathe. A truss, to derive full benefit from it, must be worn night and day, and for months and years to- gether. Particular varieties of truss will be noticed when the different species of hernia are described. Irreducible hernia, particularly that variety of it dependent upon adhesion between the sac and its contents, very seldom admits of relief. Cases are recorded, however, by Arnaud, Le- dran, and Hey, of the diminution and final restoration to the ab- domen, of immense hernial tumours, by low diet, blood-letting, purging, and confinement, for many months together, to the horizontal position. In most cases, a suspension of the tumour Hernia. 99 by a bag truss, and strict attention to diet, are all that can be done. For strangulated hernia, various remedies have been em- ployed—such as blood-letting, purging, the cold and warm baths, opium, fomentations, and poultices, the application of cold, the taxis, tobacco injections, and an operation. The three last only are to be relied upon. By taxis is understood an effort to restore the protruded intestine or omentum, by manual pressure, to the cavity of the abdomen. This should be attempt- ed always before any other plan, and is frequently successful. To increase the chance of success, the surgeon must endeavour to relax the abdominal muscles as much as possible'—by ele- vating the shoulders and pelvis with pillows, bending the pa- tient's legs on his thighs, and his thighs on the pelvis, and at the same time drawing them towards each other. Upon the tu- mour, steady, but not violent pressure, should then be exerted and kept up unremittingly with the fingers or hands for half an hour. If this fail, the taxis must be discontinued, lest it increase the inflammation in the protruded parts. The surgeon may next have recourse to the tobacco enema, which, (as it is a very powerful and dangerous medicine, if incautiously administered,) should be carefully prepared by infusing a dram of tobacco in a pint of boiling water for a quarter of an hour. When cool, the liquor may be strained, and one-half of it thrown up the rec- tum by a syringe, and the remainder half an hour afterwards, should the first prove inefficient. The effect of tobacco, thus administered, is to prostrate the system, excite the action of the intestines, and relax the abdominal muscles. As soon as these ends are accomplished, a slight effort, in the way of taxis, will often succeed in overcoming the stricture, and in restoring the parts to the abdomen. If the tobacco fail, the knife is our only resource; but in the use of this, the surgeon must be governed by the particular seat of the hernia—as will be explained in the ensuing sections. J 00 Inguinal Hernia. Section IV. Inguinal Hernia. After the general account given of hernia and its treatment, it will be proper to consider the varieties of the disease, the principal of which are inguinal, crural, umbilical, and congenital hernia. To each of these, it will be necessary to prefix a short account of the anatomy of the parts. When the integuments of the abdomen are turned back, a thin but compact sheet of cellular substance, described by mo- dern anatomists under the name of superficial fascia, will be found to cover the whole surface of the abdominal muscles. Not only does it cover these muscles, and their tendons, but extends upwards to the chest, and downwards to the thighs, and, in fact, may with propriety, perhaps, be said to form a sort of general investment to the body. Its attachment to Poupart's ligament, and to the surface of the spermatic cord, is particular- ly close. On the surface of the fascia, and running over Pou- part's ligament towards the umbilicus, an artery and vein may be observed. These are branches of the external pudic, and from being concerned in the operations for strangulated inguinal and crural hernia, should be noticed in the dissection of the parts. Besides these vessels, numerous inguinal glands will be seen lying beneath the fascia, and intermingled with its fibres. Under the superficial fascia, lies the tendon of the external ob- lique muscle. The lower margin of this constitutes Poupart's ligament, which extends from the anterior superior spinous process of the ileum to ihe pubes; and as it approaches that part, splits into two columns, the upper of which is inserted into the symphysis, the lower into the tuberosity of the bone; • Inguinal Hernia. 101 leaving between them a triangular space, called the external ab- dominal ring, out of which emerges the spermatic cord. When the tendon of the external oblique is cut away, or turned down upon the thigh, the internal oblique muscle is brought into view. The lower margin of this arises from the outer half and inner surface of Poupart's ligament, and passing above the spermatic cord, in a vaulted form, is fixed by a ten- don into the symphysis pubis. From the edge of the internal oblique, the cremasler muscle arises, is inserted into the sper- matic cord, and descends with it into the scrotum. The lower edge of the transversalis muscle, like that of the internal oblique, arises from the outer portion of Poupart's liga- ment, crosses over the spermatic cord, and uniting its tendon with that of the internal oblique, is inserted into the pubes. These three muscles—the external oblique, the internal ob- lique, and the transversalis—serve to cover the abdomen, and support the viscera. From the manner, however, in which the last two are formed, (being deficient as it were in part, or not wholly inserted into Poupart's ligament,) this support would be very inadequate, were it not for the co-operation of an addi- tional structure—the fascia transversalis. This fascia consists of condensed cellular membrane, lines the internal surface of the transversalis muscle, and is interposed between it and the peritoneum. Its extent is very considerable, for it not only covers the whole of the lower part of the abdo- men and passes out along with the femoral vessels upon the thigh, but ascends to the diaphragm. In this fascia, an opening is left for the passage of the spermatic cord—called the internal abdominal ring. The spermatic cord, consisting of arteries, veins, lymphatics, nerves, the vas deferens, and a membranous sheath, enters the internal abdominal ring—which is situated about half an inch above Poupart's ligament, and midway between the spine of the ileum and symphysis pubis—and taking a course inwards and downwards, passes along the edges of the internal oblique and transversalis, and finally emerging at the external ring, de- scends nearly in a perpendicular direction into the scrotum. Along the under and inner side of the spermatic cord, and be- tween it and (he pubes, passes the epigastric artery, a vessel Vol. II. M 102 Inguinal Hernia. materially concerned in the operation for strangulated inguinal hernia. From the above account of the structure of the parts imme- diately concerned in inguinal hernia, it will appear—that there are two abdominal rings, the external, formed by a splitting of the fibres of the external oblique tendon, the internal, by an opening in the fascia of the transversalis muscle. To make this structure more intelligible to the student it will be proper to observe that these rings are distant from each other, in most full-grown subjects, about an inch and a half, that between them there is a canal for the passage of the cord, that the cord enters the internal ring, passes obliquely downwards under the internal oblique and transversalis muscles, (not through them, as formerly supposed,) until it reaches the external ring, after which its course is perpendicular. To understand the reason of the cord not perforating the internal oblique and transversalis, it will only be necessary to remember that these muscles are not at- tached to the whole of Poupart's ligament, but only to the outer half of it, and consequently that they may be said to be want- ing from that part as far as the symphysis pubis. In most instances, the hernial sac and its contents enter the internal abdominal ring anterior to the spermatic cord, and having reached the origin of the cremaster muscle, passes be- tween it and the cord. Sometimes, however, the cord is placed on the side of the sac, at other times on its front. The epigas- tric artery runs along the under and inner side of the sac, and between its mouth and the symphysis pubis. In immediate con- tact with the sac, and on its anterior surface, is spread out, from pressure, the cremaster muscle, which forms one of the coverings of the sac. Above the cremaster is the superficial fascia, and next to it the integuments. If a dissection, therefore, is made of the coverings and contents of the inguinal hernia, commencing at the skin, the parts will be presented in the following suc- cession—the integuments, superficial fascia, the cremaster muscle, the hernial sac, omentum or intestine, and perhaps both. The symptoms of reducible, irreducible, and strangulated inguinal hernia do not differ from those of hernia in general, and these have been already pointed out in the preceding section. But it is important to distinguish between this disease, and others Inguinal Hernia. 103 bearing to it some similitude. Inguinal, or rather scrotal her- nia, may be confounded with hydrocele, cirsocele, enlarged tes- tis, and some other affections. From hydrocele, it may be dis- tinguished by the circumstance of the tumour commencing above the abdominal ring, and descending towards the scrotum, where- as hydrocele always begins in the lower part of the scrotum, and gradually ascends. Cirsocele sometimes bears a striking re- semblance to scrotal hernia, but it may be distinguished from it by placing the patient in a recumbent position, pressing firm- ly upon the upper part of the ring, and then directing him to rise, when, if it be cirsocele, the tumour will reappear, and of an increased size; if hernia, it will be retained within the ring until the finger be removed. An inguinal hernia is sometimes contained within the canal leading from the internal to the external ring. It is then called concealed inguinal hernia. As in cases of this description there is commonly no.external tumour, the surgeon should be on his guard, and suspect the existence of this disease, if the symptoms of strangulation be present. The hernial sac in such cases is generally covered, in addition to the usual investments, by the tendon of the external oblique, and edges of the internal oblique and transversalis. Scrotal hernia in shape is commonly pyriform, and in size is very various, descending in some instances to the patient's knees, at other times is not much larger than a natural scrotum. Occasionally, the disease is met with on both sides. Males are more subject to the disease than females, and when it occurs in the latter the tumour bears the same relation to the round ligament that it does to the spermatic cord in the male. Treatment of Inguinal Hernia. For reducible inguinal, or scrotal hernia, an appropriate elas- tic truss should be selected. Above most instruments of this 104 Inguitial Hernia. description, I prefer that of Wright of Liverpool, formed upon the principle of Whitford's truss, described in the work of Mr. Lawrence on hernia. The peculiarity of these instruments consists in their not forming a perfect oval, but in being straight or nearly so behind, where they cross the small of the back, and rising from the posterior part of the pelvis, and descending in front towards the groin. Of the truss of Salmon and Ody, (com- monly called Hull's truss,) I have also a favourable opinion. This, instead of passing entirely around the pelvis, is formed of a semicircle of steel, with a pad at each extremity—one of which is adapted to the groin, the other to the back. In fitting a pa- tient with a truss for inguinal hernia, the surgeon should take care to adapt the instrument to the lower part of the internal ring; for if it be placed, as is too often done, upon the external ring, it not only presses upon the cord, gives unnecessary pain, and injures the function of the testicle, but does not answer the purpose of supporting the hernia. Every patient should habi- tuate himself to return his o\vn hernia and to apply the truss; and the most convenient.time for effecting this is in the morning before he rises, as the intestines and omentum, during the night, generally retire within the abdomen. The irreducible scrotal rupture subjects the patient, when it attains a large size, to great inconvenience, by impeding copu- lation and by arresting the flow of urine, which, from the penis being buried among the integuments, excoriates the parts and gives rise to small abscesses. To prevent the growth or increase of the swelling, a bag truss is the only remedy. Strangulated inguinal or scrotal hernia, should the taxis and to- bacco injection fail, will require an operation, and the sooner this is performed, after it has been determined upon, the better; for there is reason to believe that many lives have been lost by delay, and few, if any, from the operation itself. The patient be- ing placed upon a table of ordinary height with his thighs some- what separated, and each foot resting upon a chair, the surgeon sits before him, and grasping the tumour with one hand, makes an incision with the other, commencing at the upper part of the tumour, and extending downwards nearly^to its base. Having divided the integuments, a branch of the external pudic artery generally springs, and may require the ligature. Immediately beneath the integuments, lies the superficial fascia: this should Inguinal Hernia. 105 be divided by successive touches of the knife, until the cremaster muscle appears; the fibres of which may be elevated carefully by the dissecting forceps, or by running the directory beneath them, until the whole are cut through, and the sac exposed. To open this without risk of injuring the intestine, a portion of it may be pinched up and rubbed between the fingers previously to its division. As soon as the sac is opened, a quantity of fluid gushes out, and part of the intestine, or omentum, appears at the opening. Fluid, however, is not invariably met with, and it is highly important that the operator should be aware of this, otherwise he might, in expectation of finding it, continue to penetrate with the knife, until he wounds the intestine. The opening in the sac should be enlarged upwards and downwards to the extent of two or three inches, and if its contents are found in a proper condition to be returned into the abdomen, the next step of the operation is to carry the fore-finger of the left hand upwards between the sac and protruded parts, and search for the stricture,_which will be found either at the edges of the ex- ternal ring, the internal ring, or the mouth of the sac. In very old and large herniae, the external ring is the most common seat of the constriction, but, in ordinary cases, the internal ring. By gentle pressure with the fingers upon the intestine or omen- tum, these parts may sometimes be restored without dividing the stricture; if the attempt fail, however, the operator then in- troduces a common curved probe-pointed bistoury, (the edge of which, with the exception of half an inch of its extremity, is co- vered by a piece of riband or muslin,) with its flat surface between the sac and its contents, and with the fore-finger as the guide, carries its point beneath the stricture, turns up the edge of the instrument and divides it. A very slight incision, even the eighth or sixteenth part of an inch in extent, will be often suffi- cient to liberate the parts. The moment this is accomplished, repeated and gentle efforts should be made to return them to the abdomen, after which the edges of the wound must be brought together and retained by adhesive straps. In the course of three or four hours after the operation, should the patient not have a stool within that time, a dose of castor oil must be administered. During the cure the patient should be confined to bed, and not suffered to rise until the parts are so completely cicatrized, as to 106 Inguinal Hernia. bear the pressure of a truss—an instrument still more necessary after an operation for strangulated hernia, than before. In dividing the stricture, in all cases of strangulated inguinal hernia, whether seated at the external or internal ring, or at the mouth of the sac, there is one rule extremely important to ob- serve—to carry the knife directly upwards, (a practice first sug- gested by Rougemont, and afterwards adopted by Sir Astley Cooper,) by which we avoid wounding the epigastric artery. If, in the ordinary situation, for example, of this variety of her- nia, the stricture be divided upwards and inwards, or towards the linea alba, and the incision prolonged to any extent, the epi- gastric will, almost to a certainty, be cut across. On the other hand, if the knife be carried upwards and outwards towards the ilium, and the hernial sac should descend, as it sometimes does, on the inner side of the epigastric, (constituting the variety of hernia called Ventro-inguinal,) this vessel may possibly be divided. It is proper to observe, however, notwithstanding these precautions, that there are few examples of fatal hemor- rhage from wounds of the epigastric, although the vessel has been cut in numerous instances by awkward and careless ope- rators. With regard to the condition of the intestine or omentum, it may be observed—that if mortified spots appear on the former, they should be included in a fine ligature before returning them to the belly; and that if the omentum be in an indurated state, and form too large a protuberance to admit of repassing the ring, it should be retrenched, taking care to tie up any particular ves- sels that may spring, instead of including the whole mass in a ligature, as was formerly practised. Sir Astley Cooper, and some other surgeons have recommended, in large herniae especially, to divide the stricture on the outside of the sac—leaving the sac unopened. To this plan, however, there are many objections. The operation for small, or concealed inguinal hernia, does not differ materially from that of the common variety of the disease. If the operation for strangulated inguinal hernia has been so long delayed as to permit the parts to fall into gangrene, and they are found in this condition by the surgeon after having Inguinal Hernia. 107 opened the sac, he should not think of pushing them, in this state, into the abdomen, even if he could effect it, because they would then act as extraneous bodies, and excite irritation. By the time, however, the process of sloughing is completed in the parts exterior to the stricture, it generally happens that the parts within the abdomen or its immediate vicinity are united by ad- hesion to the internal surface of the ring, and therefore, that the protrusion could not be returned without previously breaking up those adhesions, upon which, indeed, the safety of the patient must now in a great measure depend. Some surgeons have attempted to cure inguinal and other va- rieties of hernia radically—by relieving the stricture, returning the protruded parts, and afterwards dissecting up the hernial sac, and either restoring it to the abdomen, or removing it entirely, and tying its mouth with a ligature. The practice, I conceive, is seldom justifiable. Many years ago I performed the operation, but the case terminated fatally. Experience proves, moreover, that a new sac, even if the patient recover, is almost sure to form. 108 Femoral Hernia. Section V. Femoral Hernia. The contents of a femoral or crural hernia, instead of passing through the abdominal rings, are protruded beneath Poupart's ligament through an opening termed the crural ring. This ring is bounded on the outer or iliac side, by the femoral vein, on the inner or pubic side, by Gimbernat's ligament, anteriorly, by Pou- part's ligament, and posteriorly by the pubes. Poupart's liga- ment arises from the spine of the ilium, and is implanted by a broad insertion into the symphysis pubis, into the tuberosity of the pubes and into the ligament of the pubes over the linea-ileo pectinea. By this last insertion a sharp crescentic edge is formed, the concavity of which looks towards the crural vein, and is sup- posed by most writers, to contribute mainly to the constriction in cases of strangulated crural hernia. From having been par- ticularly described by Gimbernat, a Spanish surgeon, it is fre- quently called Gimbernat's ligament. There are two margins to Poupart's ligament, an anterior and posterior, the former of which is straight, the latter concave, in the vicinity of the pubes. The fascia lata of the thigh, as it approaches Poupart's liga- ment, divides into two portions—the iliac (sometimes called sar- torial) and pectineal. The former is connected to Poupart's li- gament throughout the greater part of its extent; the latter is attached to the pubes, covers the muscles that spring from that bone, and unites with the iliac portion below, at the spot where the vena saphena major enters the femoral vein. In thickness and strength the iliac portion of the fascia lata greatly exceeds the pectineal portion. It lies, moreover, conside- rably above the plane of the latter, and covers the femoral vessels, the anterior crural nerve, and the iliacusinternus and psoas mus- cles. Towards the pubes its edge is concave, and on this account Femoral Hernia. 109 was denominated by Burns, of Glasgow, ihefalciform process. Its superior horn received from Mr. Hey the appellation of femoral ligament, and is at the present day commonly known under the name of Hey's ligament. " It has already been stated," says Colles, " that the iliac portion of the fascia lata passes before the femoral vessels. We observe, in this part of its course, that it loses somewhat of its strength and firmness of texture; however, it generally retains a good deal of its ligamentous nature even when it has reached the pubic side of these vessels; except in the immediate neighbourhood of the vena saphena, where it dif- fers but little from the cellular substance. Having passed before the femoral vessels, we find it now to descend on their pubic side; and here we see it attach itself very intimately to the pec- tineal fascia. This attachment is made in a straight line along the pubic side of the vein, from the place of insertion of the sa- phena to within a quarter of an inch of Poupart's ligament. At this place we observe that the line of attachment is curved ; and having here formed a sweep towards the pubes, that the attach- ment now takes place in a line across the top of the thigh."* In most subjects, I have found the iliac portion of the fascia lata to consist of two layers, the innermost of which passed backwards behind the femoral vessels and united with the pectineal portion— leaving the falciform process double, like the margin of the cuff of a coat, and forming a round instead of a sharp edge.t Beneath the fascia lata, and in immediate contact with the femoral vessels, lies the fascia transversalis. This fascia, as for- merly mentioned, under the head of inguinal hernia, not only lines the internal surface of the abdomen, but passes out upon the thigh under the posterior edge of Poupart's ligament. De- scending in front of the crural artery and vein, it becomes united to their sheath and forms for them an additional investment. On the inner side of the crural vessels numerous absorbents may be observed passing through, the transversalis fascia, on their way to the abdomen. The fascia iliaca is but a continuation of the fascia trans- versalis, and differs from it only in situation. It lines the sur- face of Ihe iliacus internus and psoas muscles, adheres to the • Surgical Anatomy, p. 68. | My observations have been lately confirmed by modern European authority .of great respectability Vol.. II. 1 J 110 Femoral Hernia. posterior margin of Poupart's ligament, descends with the cru- ral vessels to the thigh, and affords them posteriorly a strong investment. The union of the fascia transversalis and iliaca has been compared,* not unaptly, to a compressed funnel, the ex- panded part of which may be said to occupy the lower part of the abdomen and hollow of the ilium, while the pipe is repre- sented by the prolongation which covers the femoral vessels and forms their anterior and posterior sheaths. Although the space between the os innominatum and Pou- part's ligament is filled up by the iliacus internus and psoae mus- cles, these would not prove a sufficient barrier to the-descent of a femoral hernia in various situations between the spine of the ilium and symphysis pubis. Such descent, however, is effectu- ally guarded against, except at the crural ring itself, by the the union of the fascia transversalis and iliaca. These fascial, indeed, are so closely connected with each other, with the pos- terior edge of Poupart's ligament, and with the surface of the psoas and iliacus internus muscle, and send off so many parti- tions between the crural artery and vein, and the adjoining parts, as to preclude effectually the escape of any of the viscera between them. In dissecting the parts concerned in crural hernia, it is im- portant to notice particularly the situation of the spermatic cord and epigastric artery. The former lies about half an inch from the mouth of the sac, above Poupart's ligament; the latter runs upon the outside of the hernial sac, and talces a course upwards and inwards on its way to the rectus muscle. Sometimes the obturator artery is sent off by the epigastric, and, running along the inner margin of the sac, and sometimes encircling it, is liable to be wounded, in performing the operation for strangulated fe- moral hernia, if the incision be prolonged too far inwards or to- wards the pubes. A portion of omentum, or intestine, surrounded by the pe- ritoneum, having entered the sheath of the femoral vessels, formed by the union of the iliac and transversalis fasciae, passes alon«- the inner edge of the crural vein, and carries before it the loose cellular membrane that naturally occupies the orifice of the crural ring. This membrane, (which has received from Sir Astley Cooper the name of fascia propria?) being pushed for- • Colles p. 63. Femoral Hernia. Ill ward by the hernial sac, is carried along with it through one or more of the holes on the inner side of the crural sheath, and uniting with that sheath, the two fasciae are " consolidated into one." Above the fascia propria will be found the superficial fascia and the integuments. If a dissection, therefore, be made of a femoral hernia, commencing at the surface of the bend of the thigh, the parts will be presented jn the following order:— the integuments, superficial fascia, fascia propria,-hernial sac. This last will be found resting in the hollow between the iliac and pectineal portions of the fascia lata, and, consequently, on the outer surface of that aponeurotic expansion. There is a variety, however, of femoral hernia, (in which the sac and its contents, not passing through the absorbent holes, is continued along the sheath of the femoral vessels,) covered by the fascia lata. Women are more subject to femoral hernia than men, owing partly to the great breadth of the female pelvis, compared with that of the male. In shape, femoral hernia differs entirely from inguinal—its longest diameter being placed transversely with respect to the thigh. In general, moreover, the tumour is much smaller than that of the inguinal. On this account it is par- ticularly liable to be confounded wiih other diseases, especially with enlargement of one or more glands of the groin, with vari- cose enlargement of the crural vein, psoas abscess, &c. In one patient, however, an old man in the Aims-House Infirmary, in 1833, I found the tumour as large as a child's head. Not un- frequently it is mistaken for inguinal hernia—owing to the tu- mour rising, from the oval space in the fascia lata, upon Poupart's ligament. The edge of this ligament may, however, in femoral hernia, always be traced above the tumour, while in bubonocele, it is below it. A very common symptom of reducible femoral hernia, is pain in the groin, from extending the thigh, which is sometimes so severe as to produce nausea and vomiting. Treatment of Femoral Hernia. The truss for reducible inguinal hernia, will answer also for femoral, provided the pad of the instrument be bent downwards 112 Femoral Hernia. about an inch, in order that it may rest on the top of the thigh instead of the groin. Irreducible femoral hernia, when its con- tents consist chiefly of omentum, sometimes attains such a bulk as to prove very inconvenient to the patient. Under these cir- cumstances, it has been advised by Sir Astley Cooper to apply a hollow truss to the tumour, (taking care previously to reduce the intestine,) with a view of promoting, by pressure, the ab- sorption of the protruded parts. Strangulated femoral hernia must be treated upon the prin- ciples formerly laid down. Instead, however, (in performing the operation of taxis,) of pressing the tumour directly upwards, as in strangulated inguinal hernia, the surgeon should first en- deavour to disengage it from the edge of Poupart's ligament, by pressing it downwards and inwards; after which a slight pres- sure upwards will often succeed in restoring the omentum or in- testine to the abdomen. If the taxis should fail, and an opera- tion become necessary, there should be the least possible delay; for the disease runs its course with much greater rapidity than most other varieties of strangulated hernia. The patient being placed horizontally on a table, the shoulders elevated by a pillow, the thighs somewhat relaxed and brought near to each other, the diseased parts shaved, and the bladder emptied, an incision is made, commencing about an inch above Poupart's ligament, and extending downwards to the middle of the tumour, through the integuments. At right angles with this another cut is made—the two representing in form the letter T reversed. The superficial fascia being exposed and careful- ly divided, the fascia propria is brought into view. This being likewise divided, more or less adipose substance will be ge- nerally found between it and the sac. To open the sac, which should next be done, without risk of injuring the intestine, (for in this variety of hernia there is seldom much fluid in the sac,) a portion of it should be carefully pinched up and rubbed be- tween the finger, and divided by carrying the knife horizontal- ly through it. As soon as the intestine, or omentum, is dis- covered, a finger may be introduced into the opening, and upon this a curved bistoury, with which the sac may be enlarged, to the extent, if necessary, of several inches. The next object of the operator will be to ascertain the seat of the stricture. This will be found either at Hey's ligament, in the crural sheath, at Femoral Hernia* 113 Gimbernat's ligament, or in the mouth of the sac. When the hernial tumour is large, more or less constriction will always be made upon it by the falciform process of the fascia lata, and particularly by that portion of it called Hey's ligament. In or- dinary cases, however, I am inclined to believe that the sharp posterior border of Poupart's ligament, or the ligament of Gim- bernat, as it is called, contributes more than any other part to keep up the symptoms of strangulation. But be this as it mayr the surgeon must proceed in his operation until he has removed every obstacle. With this view, passing the fore-finger of his left hand gently between the sac and its contents, he carries it upwards until he meets resistance. The bistoury should then be passed, with its flat edge towards the finger, until it is fairly within the strictured part, when its edge may be turned up and pressed lightly against the obstruction. If the parts are not suf- ficiently liberated to be returned by moderate pressure, the fin- ger should be carried higher, and other obstructions sought for. These, if found, must likewise be divided, taking care in making each incision to carry the bistoury upwards and slightly inwards. The operator, if regardless of this rule, might, by prolonging his incision outwards, or upwards and outwards, in- jure the crural vein and epigastric artery. On the contrary, by directing the knife too far inwards or towards the pubes, the obturator artery, in case it should happen to spring from the epigastric and take an inward course, would be endangered. By the inward incision, moreover, there is great risk of wound- ing the intestines. Having relieved the stricture and restored the contents of the sac to the abdomen, the after treatment will not differ from that pointed out in some of the preceding sections. 114 Umbilical Hernia. Section VI. Umbilical Hernia. The umbilical vein, and its two arteries, in the foetus, perfo- rate the tendons of the abdominal muscles about the centre of the linea alba, and leave an opening called the umbilical ring. Soon after birth these parts are consolidated, and a firm cicatrix is formed, externally, by the contraction of the integuments, in- ternally by the peritoneum, and between the two, by the re- mains of the umbilical vessels. The ring being thus closed and fortified, protrusions of the abdominal viscera, in most subjects, are guarded against. Sometimes, however, it happens, that the ring is imperfectly closed, or its edges so weak, as readily to yield to any force the viscera may.exert against it. Under these circumstances, an umbilical hernia will be produced. It is still a disputed point whether the protrusion takes place at the centre of the umbilical ring, or at its edges. Sir Astley Cooper inclines to the former opinion. There is reason to be- lieve, however, that both occurrences are not unfrequent. Many of the older writers believed the umbilical hernia to be destitute of a sac or peritoneal covering, erroneously supposing that the umbilical vessels were naturally situated behind that membrane, and, consequently, that the abdominal contents were protruded through the imaginary opening, in the peritoneum, for the transmission of these vessels. The fact, however, that the ar- teries and vein, while on their way to the umbilical cord, lie between the abdominal tendons and peritoneum, has long been known. The inference, therefore, is not less plain than true,— that the umbilical, like most other varieties of hernia, is covered by a peritoneal sac. There is some variety in umbilical hernia, according as it occurs in the infant at birth, in the young subject, or the adult. Umbilical Hernia. 115 The congenital umbilical hernia, as it is called, is often com- plicated with spina bifida, and with extraordinary enlargement of the liver and other abdominal viscera. The contents of the abdomen are protruded through the umbilical ring into a trans- parent bag, formed out of the cellular membrane that connects the vessels of the cord. So transparent, indeed, is this invest- ment, that throughout the greater part of the tumour, the hernial sac may be distinctly seen. The umbilical hernia of young subjects is, unlike the con- genital variety, covered by the common integuments of the ab- domen, and generally makes its appearance about the third or fourth month after birth. It seldom attains, unless very much neglected, a large size; indeed, in many instances, the tumour scarcely exceeds a common marble in bulk, and when pressed upon, readily retires into the abdomen; returning again, however, as soon as the pressure is discontinued. Its figure is commonly round. A fold of intestine generally occupies the hernial sac, and omentum is scarcely ever met with. The disease is often accompanied by disorder of the bowels and digestive organs. Amongst adults, the most common causes of umbilical hernia are, pregnancy, laborious parturition, and inordinate fatness. Hence, women, and especially those who have borne many children, are most subject to the disease. The tumour may, perhaps, remain stationary, or nearly so, for years; in the end, however, it is almost sure to attain considerable bulk, and some- times exceeds in magnitude the patient's head. Nausea, eruc- tations, constipation of the bowels, are very common attendants upon this variety of hernia. In general, the omentum consti- tutes a very large proportion of the contents of an old umbilical hernia, and the colon is oftener found in the sac than any other intestine. Treatment of Umbilical Hernia. Congenital umbilical hernia, provided there be no extraordi- nary deficiency of the tendinous parietes, or other morbid com- 110 Umbilical Hernia. plication, may be cured, frequently, by a well contrived ban- dage, or by surrounding the sac and integuments, (having pre- viously reduced the intestine,) with a ligature—drawn with suf- ficient firmness to occasion the parts included in its embrace to slough, and the edges of the umbilical ring to cicatrize. The last is the most certain and expeditious mode of effecting a cure. Instead of the simple ligature, Dr. Hamilton, of Edinburgh, ap- proximates the edges of the ring by silver pins and adhesive straps. His example, however, should not, I conceive, be imi- tated. The ligature was frequently employed by the ancients, in the cure of umbilical hernia of young subjects, and, in modern times, has been extensively used and highly extolled by Desault. In several instances I have performed the operation with complete success, and with little pain or inconvenience to the patient. There is no risk in the operation, provided the surgeon succeeds perfectly in restoring the protruded parts to the abdomen, before he ventures to apply the ligature; which should be of considera- ble thickness and strength, and drawn so firmly as to ensure the speedy destruction of the part surrounded by it. After the slough is detached, the sore that remains may be dressed with dry lint or some mild ointment until perfectly healed. For two or three months afterwards it will be proper to support the new- formed cicatrix by a compress or truss, to guard against its laceration and the consequent reproduction of the disease. The disease sometimes disappears of its own accord. To the reducible umbilical hernia of adults the ligature is not adapted. In such cases the surgeon must depend upon a truss, which, so long as it keeps the intestine or omentum within •the abdomen, will at least prevent the increase of the tumour, and may eventually, perhaps, by exciting a slow inflammation, effect a cure. Sir Astley Cooper, in small herniae, prefers the common inguinal truss, which, if it form a perfect oval, will without difficulty adapt itself to the body, and furnish the re- quisite support to the tumour. For large umbilical herniae, however, the trusses invented by Morrison, or Eagland, of Leeds, and described in most modern systems of surgery, will be found to answer a better purpose than any others. When the hernia is irreducible, and of very large dimensions, a hollow Umbilical Hernia. 117 truss, or a wide belt, carried under the tumour and over the pa- tient's shoulders, may be resorted to advantageously. Strangulated umbilical hernia very frequently proves fatal, as much from disorder of the intestinal functions, as from the strangulation. When the usual remedies fail, an operation should be resorted to. This may be done in the following way. An incision, several inches long, is made, very cautiously, through the integuments and superficial fascia, when the sac, if not absorbed, as it often is, will appear. Into this a small opening should be made, from which fluid in considerable quan- tity generally issiles. The opening may then be enlarged, and a finger carried upwards between the omentum and intestine as high as the umbilical ring. Upon the finger a bistoury is next carried through the linea alba, to the extent of an inch, which, in most cases, will relieve the stricture sufficiently to enable the operator without much difficulty to restore the parts to their former situation. To guard against peritoneal inflammation, which is sometimes apt to follow the operation just described, Sir Astley Cooper, in two instances, adopted the following mode of procedure. "As the opening," says he, " into the abdomen is placed towards the upper part of the tumour, 1 began the incision a little below it, that is, at the middle of the swelling, and extended it to its lowest part. I then made a second incision at the upper part of the first, and at right angles with it, so that the double incision was in the form of the letter T, the top of which crossed the middle of the tumour. The integuments being thus divided, the angles of the incision were turned down, which exposed a considerable portion of the hernial sac. This being then care- fully opened, the finger was passed below the intestine to the orifice of the sac at the umbilicus, and the probe-pointed bis- toury being introduced upon it, I directed it into the opening at the navel, and divided the linea alba downwards to the requi- site degree, instead of upwards." Dr. Physick has proposed, in strangulated umbilical hernia, to make a crucial incision through the integuments, as far as the neck of the sac, then open the sac at its upper part to an extent sufficient to enable the operator to examine its contents, and re- duce them, if possible, without dilating the umbilical ring. Vol. II. 16 118 Umbilical Hernia. Should the latter expedient, however, become necessary, the stricture must be divided on the outside of the sac. After the omentum and intestine are restored to the abdomen, a ligature should be drawn around the neck of the sac with a view of closing the cavity and obviating peritoneal inflammation. The late Dr. Wistar once performed the operation with success. In the case of a Mrs. N., a very respectable Jewish lady, I performed a similar operation about thirteen years ago. The tumour, how- ever, was as large as a child's head, and had been strangulated se- veral days before I saw the patient, and, on this account, the ope- ration did not succeed. The patient, too, was advanced in years, extremely corpulent, and had long suffered from derangement of the functions of the stomach and intestines. Under these circumstances, no operation, probably, would have answered the purpose, even if performed in the very commencement of stran- gulation. Congenital Hernia. 119 Section VII. Congenital Hernia. This, as its name implies, is met with at birth, or, as general- ly happens, a short time after birth. It differs from common inguinal hernia, in being destitute of a distinct peritoneal sac, and in being lodged in the tunica vaginalis, in contact with the testicle. " In a common rupture," says Mr. Samuel Cooper, " the viscera push out with them a portion of the great bag of the peritoneum, which thus forming one of the most regular in- vestments of the displaced bowels, is called the hernial sac. But in the congenital inguinal hernia, the sac, in which the vis- cera lie, is not thrust forth in this manner, by the displaced bowels; on the contrary, it is a production of peritoneum origi- nally formed and placed ready for the reception of the testes on their descent from the loins, but into which the bowels are sometimes accidentally propelled, before the passage leading into it from the belly is duly closed. The congenital inguinal hernia, therefore, differs from the generality of ruptures in having no hernial sac, formed and produced by the peritoneum being thrust forth from the belly by the displaced bowels them- selves. There is, indeed, one very uncommon species of scrotal hernia, contained in the tunica vaginalis, yet included, also, in a common hernial sac, so that the protruded bowels neither lie in contact with the preceding membrane, nor with the albuginea. This particular case was first noticed and described by the late Mr. Hey. It seems to be formed after the communication of the cavity of the peritoneum with that of the tunica vaginalis has been obliterated, but previously to the closure of the pas- sage lower down."* In most respects, the anatomy of congeni- • First Lines of the Practice of Surgery, vol. ii. p. 23, edit. 4th. 120 Congenital Hernia. tal hernia resembles that of the inguinal. The spermatic cord, and the spermatic artery lie behind the hernia. The tes- ticle, from being surrounded by the intestine or omentum, can seldom be distinctly felt. Congenital hernia sometimes resembles hydrocele so closely as to be mistaken for that disease—owing to water accumulating in the abdomen and passing along with the hernia into the tu- nica vaginalis. It is very important to distinguish the one dis- ease from the other; which may generally be done by placing the patient in the horizontal position, returning the hernial con- tents to the abdomen, and there retaining them by a finger pressed upon the abdominal ring. In the mean time, the water alone remaining in the tunica vaginalis may be easily distin- guished by its transparency and peculiar feel. Treatment of Congenital Hernia. The reducible congenital hernia, if attended to soon after the disease is discovered, may be readily cured by a well construct- ed truss—inasmuch as there is a strong disposition in the tunica vaginalis at the ring to close of itself after the descent of the testicle. A spring truss can seldom be used in a child imme- diately after birth, but a linen compress, covered by a bandage, if well applied, will generally answer every purpose; and after the lapse of a few months a truss with a weak spring may be employed. It sometimes happens that the testicle is detained at the ring, and that the omentum or intestine is placed above or along side of it. In such a case a truss should not be applied, as it will either prevent the descent of the testicle, or bruise the hernial contents. Strangulated congenital hernia, if not relieved by the usual remedies, will require an operation, which differs from that of pommon inguinal hernia, chiefly in this particular—that the in- Congenital Hernia. 121 cision of the sac should never be prolonged further than the up- per part of the testicle, in order to obviate inflammation of the tunica vaginalis, to which this membrane is particularly prone. That inflammation is propagated, more readily, to the peri- toneum within the abdomen, after the operation for strangulated congenital hernia than for that of castration, is owing to the tunica vaginalis, in the former case, being continuous with the peritoneum, whereas in the latter it is closed immediately af- ter the descent of the testicle. In certain quadrupeds * (as in the horse) the tunica vaginalis communicates directly with the abdomen and is continuous with the peritoneum. If, therefore, in castrating such animals, care be not taken to sear the cord and edges of the tunica vaginalis, by hot irons, as practised, with pro- priety, by farriers, death will be very apt to follow. Twenty years ago, I performed the operation, to oblige a friend, on a colt, and tied up the vessels as I would have done in the human sub- ject. Violent inflammation followed and the animal was saved with great difficulty. Sir A. Cooper mentions a similar in- stance. Searing obliterates the passage between the abdomen and tunica vaginalis, and produces the same effect as natural adhesion in the human subject. In large congenital herniae that have long remained irreduci- ble, Sir Astley Cooper advises the return of the parts without in- spection, provided the stricture can be removed without opening the tunica vaginalis. 122 Artificial Anus. Section VIII. Artificial Anus. When the operation for strangulated hernia has been too long delayed, and the intestine has mortified, it sometimes happens that an artificial anus is formed. In such cases the inflamma- tion, instead of extending throughout the peritoneum and pro- ducing the patient's death, is limited to the neighbourhood of the stricture, and, terminating in the adhesive stage, glues the sound portions of intestine to the hernial sac. This adhesion becomes firmer and firmer, in proportion as the sloughing pro- cess, going on in the protruded parts, advances, until the sloughs are th^vn off and faeces are discharged externally. By this provision of nature, effusions into the cavity of the abdomen are, in nine cases out of ten, effectually guarded against. As in every case of hernia the intestine is doubled upon itself, it fol- lows that the two portions must lie parallel, or nearly so, with each other, and that when an artificial anus is formed, an inter- mediate ridge or projection will be the result. To the free ad- mission of the faeces from the upper to the lower part of the canal this ridge will prove, in general, a serious obstacle; in most cases, indeed, there is a total cessation of faecal discharge by the rectum; so much so that the intestine is constantly empty, or, at most, contains only a glairy mucus. After a time, how- ever, faeces in small quantity occasionally pass through the low- er part of the canal, and are discharged from the rectum. This is owing, in part, to the contraction of the external orifice of the artificial anus, and at the same time, to an enlargement of the passage between it and the orifice of each gut. As soon, therefore, as the faeces leave the upper intestine, they fall into a " funnel-shaped" cavity, and meeting with some resistance from the contracted mouth of the opening in the integuments, are propelled by a circuitous route towards the orifice of the lower gut. Jirtificia I Anus. \ 23 An artificial anus, whether induced by a wound of the abdo- men, or by hernia, is a very grievous disease, not only subject- ing the patient to great inconvenience, but endangering his life. Most patients, labouring under the infirmity, are troubled with colic and other derangement .of the intestinal functions. Be- sides, they have no control, for want of a sphincter, over the faecal discharge. A prolapsus from one or both openings of the intestine, is by no means uncommon, and is sometimes exqui- sitely sensible. Artificial anus, when situated high up, or among the small intestines, is apt to terminate fatally—from inanition. Treatment of Artificial Anus. Nature will often make surprising efforts towards restoration, .and is sometimes abundantly successful. Aware of this, the susr geon must not be officious, but patiently wait, so long as there is any prospect of a favourable termination. In the mean time, the patient should be supplied with a common truss, the pad of which must be broader than usual, and covered with a piece of bladder or oiled skin. This serves the purpose of restraining the fasces, and at the same time contributes, by blocking up the external opening, to direct them to the lower intestine. If it should be found, however, after the lapse of months, that there is no prospect of amendment, an operation may be attempted for the relief of the sufferer. The indication to be fulfilled by this is to overcome the ridge-like barrier situated between the two intestines, and which prevents the direct descent of the excre- ment from one to the other. Desault, with this view, introduced, into each orifice of the gut, plugs of lint or linen, and by these means frequently succeeded. A more expeditious, effectual, and less troublesome operation, was proposed and executed by the late Dr. Physick, between the years 1808 and 1809. , A crooked needle armed with a ligature, was passed for som£ distance within the orifice of one gut, and brought out at the other— 124 Artificial Anus. traversing in its passage the coats of each. The ends of the ligature were then tied at the external opening, and formed a loose loop. This being suffered to remain for a week, caused the sides of the intestines to adhere to each other. Through the consolidated ridge, thus formed, an incision was afterwards made, and a direct communication established between the up- per and lower intestine. An operation, similar to that of Dr. Physick, was afterwards performed by the late Baron Dupuytren, in Paris, and to him the merit of the proposal is awarded by European witers—without the slightest foundation. Dr. Physick's claim to priority, as respects the operation for artificial anus above described, having, as just mentioned, been contested by European surgeons, the following statement on the subject from the able pen of Dr. Benjamin H. Coates of this city, must carry conviction to the mind of every unprejudiced person. "John Exilius, a Swedish sailor, aged nineteen years, was ad- mitted into the Pennsylvania Hospital on the morning of the 20th of October, 1808, affected with a congenital hernia. He stated that he had passed the last fourteen days without having had a stool, and that on the 29th, he had been affected with ster- coraceous vomitings. These were renewed after his admission. After several other means had been employed to produce a re- duction of the hernia, the operation was proceeded to at half past three o'clock the same afternoon, by the late Professor Wistar, in the presence of Dr. Physick. The sac being opened, the in- testines were found firmly adherent to the testicle, and partially so, but with equal firmness to the abdominal ring, so as to ac- count for the impossibility of effecting a reduction by the taxis— they appeared to be a part of the ilium. A perforation existed in the side of one of them, of sufficient magnitude to permit the dis- charge of a considerable amount of faeces. There were, however, * no marks of mortification found, and the opening appeared to be the product of mere ulceration. After the removal of the stric- ture and the application of a dressing, a dose of laudanum was administered, and the patient was returned to his bed. Much enlargement of the abdomen continued, accompanied with great general restlessness, and but a small quantity of the faeces was discharged from the wound, though various means were em- ployed to procure their expulsion. On the 22d and 23d, ster- coraceous vomiting returned, and it was not till the 23d, that Artifikal Anus. 125 much relief was obtained. This was the result of a copious dis- charge produced by the injection into the bowel of an infusion of senna. On the 24th, Dr. Wistar divided a small portion of the ten- don of the transversalis abdominis, as well as of the neck of the sac, from which ensued much greater facility for the escape of the faeces. On the 30th of October, the patient, by the regulations of the hospital, came under the care of Dr. Physick. On the 24th of December, the projecting portion of the intestine was cut off close to the ring. This was done under the expectation that the open orifices thus left in the intestine would gradually be retract- ed within the abdomen. On applying a ligature to a divided mesenteric artery, severe pain was produced in that cavity, which was relieved by rhubarb, laudanum, and aniseed. After wait- ing some time, and finding that retraction did not take place, as hoped for, another process was resorted to. A roll of waxed linen, such as is used in making bougies, and of the size of the fore-fin- ger, was bent double and each end introduced into one of the orifices of the intestine. The dresser then pressed the angular part of this tent backwards, in such a manner as to approximate the adherent intestine to a straight position. So much pain, of a kind similar to colic, was produced by this pressure, that the plan was necessarily abandoned. The two ends of the intestine were found, by a careful examination, to adhere to each other for some distance, and the form, thus presented, has been com- pared in this case to that of a double-barrelled gun. The next method proposed by Dr. Physick, was to cut a lateral opening through the sides of the intestine where they were adherent. But not knowing the extent of the adhesion inwards, he thought it necessary to adopt some preliminary measure for ensuring its existence to such a depth as might admit of the contemplated lateral opening without penetrating the cavity of the peritoneum. By introducing his finger into the intestine through one orifice and his thumb through the other, he was enabled to satisfy him- self that nothing intervened between them but the sides of the bowels. He was thus enabled, without risk, to pass a needle, armed with a ligature, from one portion of the intestine into the other, through the sides which were in contact, about an inch within the orifices, which ligature was then secured with a slip- knot. This operation was performed on the 28th of January, 1809. The ligature was merely drawn sufficiently tight to ensure the VoJlI. 17 lliti Artificial Anns. contact of those parts of the peritoneal tunic which were with- in the noose. When drawn tighter, it produced so much pain in the upper part of the abdomen, of a kind resembling colic, that it became necessary immediately to loosen it. The ligature, in this situation, gradually.made its way by ulceration through the parts which it embraced, and thus loosened itself. It was at several periods again drawn to its original tightness. After about three week had elapsed, concluding that the re- quired union between the two folds of peritoneum was sufficient- ly ensured, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature. No unfavourable symptoms occurred in consequence. On the 28th of February, the patient complained of an uneasy sensa- tion in the lower part of the abdomen, and on the 1st of March he extracted with his own fingers some portions of hardened faeces from his rectum. On the 2d of March, two or three evacuations were produced in this manner. On the 3d, an enema, consisting of a solution of common salt, was directed to be given twice every day. The first of these occasioned a na- tural stool, about two hours after its administration. The same effect was produced on the 4th, 5th, and 6th. and the discharges from the orifices in the groin now became inconsiderable. Ad- hesive plasters, aided by compresses were employed, not only to prevent the discharge of faeces from the artificial opening, but with the additional object of procuring the adhesion of the sides. This last effort was unsuccessful. On the twenty fourth of June, an attempt was made to unite them by the twisted suture. Pins were left in for three days, and adhesion was, in fact, effected; but owing to the induration of the adjacent parts, the wound again opened. On the 2?th of July, a truss of the common con- struction, furnished with a very large pad, and surmounted by a large compress, was applied to the wound. By these means the discharge of faeces from the groin was completely prevented, and the patient had regular evacuations per anum, except when from improper diet or cold, he became affected with diarrhoea. At such times, a small portion of the more fluid matter escaped by the sides of the compress. Not satisfied with this state of things, Dr. Physick made several attempts to improve the pa- tient's condition. On the 2d of August, a mould of the parts $/as taken in plaster of Paris, and being covered with buckskin, Artificial Anus. 127 was employed as a pad for the truss. The expedient answered extremely well, as long as the patient continued in the same posture in which the mould was made; but as soon as the form of the parts was altered by a change of position, faeces escaped from the orifice. A bandage was then applied to the body, fur- nished with a thick compress, and having that part of it which crossed the patient's back formed of elastic, extensible wire springs, such as are used in suspenders. This, also, however, proved ineffectual. The truss with a compress and a large pad, stuffed in the common way, was then reapplied, and found to answer completely the purpose of preventing the discharge of faeces, the hope of an entire closure of the orifice being aban- doned. On the 10th of November, he was discharged from the hospital in good health and spirits, and applied himself with very good success, to acquire the profession of an engraver.''-— Dupuytren has invented a forceps of peculiar construction, called enterotome, for the purpose of bruising and breaking down by force the sides of the two intestines, and in this way opening a passage from one to the other. Dr. Physick's operation, it ap- pears to me, in every respect, merits the preference. Dr. Lotz of New-Berlin, Pennsylvania, has succeeded, lately, in curing a case of artificial anus, by an ingenious improvement on the me- thods of Physick and Dupuytren. On Hernia, Consult— Pott's Works, by Earle, vol. 2—Hey's Practical Observa- tions in Surgery, edit. 3—The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia, by Astley Cooper, fol. Loud. 1804—Ditto the Anatomy and Swgical Treatment of Crural and Umbilical Hernia, part 2, 180/—Laurence on Ruptures, edit. 3—Scarpa's Treatise on Hernia, translated from Hie Italian, by John Henry Wishart, Edinburgh, 1814—/. Cluquel, Recherclics Anaiomiques sur les Hernies, 1817—.1 Treatise on Surgical Anatomy, part the frit, by Abraham Collees, Philadelphia, 1820—C. Bell's Surgical Observations —Drawings of the Anatomy of the Groin, by William E. Darrah,fol. Philadelphia, 1830. On Artificial Anus—Desault's Works, by Smith, vol. 1, article Preternatural Ani, p. 306—Travers on the Intestines, p. 295 —Scarpa on Iltrnia, Memoir 4th p. 288—Hennen's Military Surgery, 2d edit. p. 407—Dorsey's Surgery, vol. 1, p. 96—Reybard&ur Its Traitement des Anus Artificial, 8vo.—Account of a Case in which a new and peculiar Operation for Artificial Anus, performed, in 1809, by Philip Syng Physick, M. 1)., then Professor of Surgery in ilie University of Penn- sylvania. Drawn up for pull cation by B. II. Coates, M. I)., in North American Medical and Surgical Journal, vol. 2, p. 260—Lo'z on Artificial Anus, in Ame- rican Journal, No. xxxvi. p. 367. 128 Diseases of the Rectum. CHAPTER VI. DISEASES OF THE RECTUM. It is but too common for students to pay particular attention to favourite subjects, and neglect others not less important. The diseases of the rectum, I have frequently perceived, are little relished; being considered not only loathsome and uninteresting, but very simple in their nature, and easily cured. Experience teaches the reverse. Many a patient has lost his life from an ill-managed fistula in ano, or from an operation upon it, unneces- sarily, or improperly performed. A small portion of dissecting- room labour, (too often wasted upon the muscles,) is the proper corrective for this error. The principal diseases of the rectum are prolapsus ani, tu^ mours within the rectum, hemorrhoids, and fistula in ano: those less frequently met with, are imperforate anus, foreign bodies in the rectum, neuralgia and spasms of the anus, atony and inju- ries of the anus, blenorrhagia, strictures and fissures of the rec- tum. The latter disease, (fissure,) I have never met with, nor do I find, upon inquiry,-that it is much known, to other sur- geons in this country. On this account, I shall not treat of it, but refer, for information on the subject, to European writers. Section I. Prolapsus Ani. From habitual eostiveness, straining at stool, diarrhoea, dy- sentery, hemorrhoids, strictures in the urethra, stone in the Prolapsus Ani. 129 bladder, drastic purgatives, irritation from ascarides, and vari- ous other causes, the lining membrane of the rectum, immediate- ly above the internal sphincter, is sometimes inverted, and pro- truded to a greater or less distance beyond the verge of the anus. Infants and very old people, are most liable to the com- plaint, which, if the tumour be large, recent, and accompanied by much inflammation, may terminate in gangrene, or give rise to symptoms of strangulated^hernia. In general, however, this re- sult is not to be apprehended, and the disease must be considered as rather inconvenient and troublesome than dangerous. In some cases there is reason to believe that there is an intussusception of the gut itself, instead of an eversion of its lining membrane. In other instances, the sigmoid flexure, and other portions of the colon, may be invaginated and finally protruded at the anus.' Even the caecum may undergo a similar displacement. Not un- frequently, the upper part of the rectum descends and lodges in the pouch of the same intestine. But these affections differ, in toto, from genuine prolapsus ani. To understand the true na- ture of prolapsus, it should be recollected that perpetual strain- ing from irritation, however induced, may give rise to infiltra- tion in the cellular tissue, beneath the villous coat, and that this congestion must have the effect, finally, of causing protrusion of the lining membrane of the gut. In chronic cases of the disease, or where unusually large protrusions have taken place, there is reason to believe that the folds of the inner coat, which line the pouch or natural sinus, above the internal sphincter, and which are uncommonly numerous and relaxed, are forced by the action of the abdominal muscles from their lurking-place, and carried in volumes beyond the verge of the anus. Several cases of the kind I have seen, and one especially during the winter of 1835, at the Aims-House Infirmary, in a man 36 years of age, named Dubois, in whom the protrusion, equal in bulk to the fist, and of a dark red colour covered with irregular ridges and furrows, not unfrequently descended five or six inches, beyond the margin of the anus. According to Mr. Mayo, of London, not only the mucous and submucous coats of the rectum are liable to eversion, but the muscular coat also—as is proved by a preparation in the Mu- seum of King's College, of which Mr. Mayo has furnished a drawing. 130 Prolapsus Ani. Treatment of Prolapsus Ani. In the treatment of this disease, it is highly important to re- turn the protruded parts as speedily as possible. This is best accomplished by placing the patient on his back, elevating the hips and shoulders, and pressing gently with the fingers, (pre- viously oiled,) upon the tumour. Should the parts be very tender and inflamed, and offer much resistance, the efforts to- wards reduction must be discontinued, until full benefit has been derived from general and local blood-letting, mild purgatives, cold poultices, astringent washes, &c. To support the protru- sion, after it has been reduced, and to prevent its recurrence, a piece of lint, covered with some mild ointment, should be ap- plied to the anus, and over it a soft sponge and bandage. Rest, also, for some time in the horizontal position, will prove essential. Dr. Physick has sometimes cured prolapsus ani by confining the patient for a considerable time to a diet of rye mush and sugar. It must be obvious, however, from what has been stated, that much will depend upon the cause of the disease, as respects the prospect of a permanent cure; and that so long as many of the causes pointed out continue to operate, little advantage can be gained by any mode of treatment that may be instituted. The protruded parts, now and then, become in- durated and incapable of reduction. Under such circumstances, it may be necessary to remove them, either with the ligature or knife. When the tumour appears to be very vascular, and is small, I should prefer removing it by the double cannula and wire, as used by Dr. Physick for hemorrhoids. But when it has long remained protruded, is disorganized, and has, apparently, very little connexion with the parts within the rectum, I should re- sort to the operation long ago practised by Hey—the removal of one or more flaps, or of the whole mass, by excision. This I have practised successfully, in several cases, without incon- venience. At other times, considerable hemorrhage has fol- lowed the operation. The young surgeon should be on his guard, therefore, and take care how he ventures to cut off a large re- ducible prolapsus of the mucous membrane; and, above all, that Prolapsus Ani. 131 he docs not amputate an invaginatcd colon or coxum, under the idea that he is merely removing folds of the lining membrane of the rectum. An ingenious operation, first suggested and practised by Du- puytren, (and for which, in a former edition of this work, I have failed to award him the credit he deserves,) is better calculated so far as I can determine, by a few trials of it, to effect a cure of prolapsus ani than any other ever invented. Instead of cut- ting away the mucous membrane of the gut, Dupuytren seizes with a pair of small forceps a greater or less number of the ra- diating folds of skin which naturally surround the outside of the anus, and with a pair of curved scissors, cutting from with- out inwards, removes them. When the prolapsus is large, these folds should be pinched up in two or three different places and cut off: but in small tumours of the kind, such as are generally met with in children, the removal of two or three folds at a sin- gle spot will commonly prove sufficient. Occasionally, it is ne- cessary to prolong the incision into the rectum as far as the point where the radiating folds are fused insensibly into the mucous membrane of that gut. The object of this operation, as will be understood immediately, is to contract (through the medium of a cicatrix, which must necessarily form when the wound made by the scissors has healed up,) the margin of the anus, or to diminish the size of that opening, and thereby to af- ford a support to the loose folds of the mucous membrane of the gut they were destitute of in the relaxed condition of the parts, as usually found in cases of prolapsus. In an obstinate case of this disease in a girl three years old at the Blockley Hospital, during the winter of 1835, {and where the protrusion, the size of an egg, had been partially removed, previously, by dissecting off ribands of the lining membrane with a view of exciting the adhesive inflammation,) I succeeded in effecting a perfect cure of the prolapsus, merely by cutting away, in two places, the converging folds of skin, in the manner described. In the case of Dubois, referred to above, I performed a simi- lar operation; but the long standing of the disease, and the ex- traordinary bulk of the tumour, prevented me from succeeding. However, as regards both the operations of Hey and Dupuy- tren, it should be remarked, that, if carried too far, there may be a possibility of producing such a contraction of the parts, 132 Prolapsus Ani. within the rectum and at the anus, as to interfere, ever after- wards, with the evacuation of the faeces. Cases of the kind have been reported by Chesselden, and by the old anatomist Keil, where the patients could never procure a stool without the assistance of a clyster, and, even with that alternative, suffered immensely. It must not be supposed, from the remarks already made, that an operation will be required, necessarily, for the cure of pro- lapsus ani. On the contrary, many cases occur, in children espe- cially, where by early attention to the disease, the use of sa- turnine and astringent injections, keeping the bowels in a solu- ble state, and, above all, by obliging the child to evacuate the faeces whilst in a standing position, perfect cures will be effected in a few weeks or months. Perforated ivory balls, gum elastic and other pessaries, the craw of a turkey, lint plugs, sponges, steel trusses, and other contrivances have been resorted to for sustaining the prolapsed parts, or for effecting radical cures through the medium of adhe- sive inflammation, but generally without effect. As some pa- tients, however, have derived benefit, undoubtedly, from them, they should in certain cases be tried. But if, upon trial, they are found, as is generally the case, to act as suppositories, they will do more harm than good, and should be abandoned. •On Prolapsus Ani, consult Monro's Essay on Procidentia Ani, in Edinburgh Physical and Literary Essays, vol. 2d, p. 353—Chesselden's Anatomy of the Hu- man Body, 1792—Chevalier on relaxed Pedum, in Medico-Chirurgical Transac- tions, vol. 10, p. 401, 1819—Sabatitr, Memoires sur les Anus contre Nature, in Memoires de la Acadamie Boy ale de Chirurgie, torn. 15, 12 mo. edit.—Hey's Practical Observations in Surgery, p. 438, London, 1814—A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum, by C. Bell, with Notes, by J. Shaw, p. 324. London, 1820—Dupuytren on Prolapsus of the Rec- tum, in Clinical Lectures on Svrgery at Hotel Dieu, &c, translated by Doane, p. 99—Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, p. 28, London, 1833—American Cyclopaedia of Practical Medicine and Surgery, Edited by Isaac Hays, M. D., Part 6, p. 96. Philadelphia, 1835—Colles' Surgi- cal Anatomy, p. 139. Tumours within the Rectum. 133 Section II. Tumours within the Rectum. Sarcomatous and other tumours occasionally sprout from the surface of the lining membrane of the rectum, and according to their bulk and figure, excite more or less irritation, diarrhoea, &.c. Sometimes they originate between the coats of the intestine. Mr. John Bell* speaks of enormous tumours of the rectum, soft, woolly, lubricous, of a shining red colour, involving the whole cir- cle of the anus, extending beyond it many inches, and retiring deeply within the cavity of the gut. Such I have not seen. Treatment of Tumours within the Rectum. When the tumour originates by a very narrow pedicle, and moves freely about, it may sometimes be pulled away with a pair of forceps; but when its base is broad, the ligature will prove the safest and most effectual remedy. It will answer no purpose, however, merely to encircle the swelling with a single cord. Many years ago, I was consulted by a gentleman of Maryland, on account of a fleshy excrescence, about the size of an egg, which arose from the walls of the rectum an inch and a half above the sphincter ani. A surgeon of eminence had undertaken to re- • Principle* of Surgery, vol. iii. p. 188. Vol. II. 18 134 Tumours within the Rectum. move the tumour by a single ligature; but, unable to noose the base of the swelling, the anterior part only was destroyed, and the operation proved fruitless. I determined to proceed in a different way. Directing the patient to sit for half an hour over a tub of warm water, and by straining, to force the tumour as far as possible below the sphincter, I passed a crooked needle, armed with two ligatures, through its substance, as near as pos- sible to the coats of the bowel, and tied one on each side. In four or five days the diseased mass sloughed away, and a per- fect cure followed. By similar means I have removed, repeatedly, since, both large and small tumours, and almost invariably with success. The knife, upon such occasions, should never, I think, be em- ployed, on account of the hemorrhage which would be almost certain to follow the extirpation of a vascular tumour within the walls of the rectum, and the difficulty which the surgeon would experience, necessarily, in securing the vessels in that situation. The advantage possessed by the double, over the single ligature, is, that two portions of the tumour being embraced, at the same moment, the sloughing will be accomplished with greater ra- pidity than if the whole mass were encircled. Besides, the li- gatures having been passed through the substance of the tumour, cannot be detached until the tumour is removed. On Tumours of the Rectum, consult C. Bell's Operative Surgery, vol. 1st—/ Bell's Principles of Surgery, vol. 3d, p. 191—1 Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate and Rectum, by C. Bell, p. 323. Hemorrhoids. 135 Section III. Hemorrhoids. Hemorrhage, occasional, or periodical, from the verge of the anus, or from the cavity of the rectum, is very common among persons of indolent and sedentary lives, and of full habits of body. Costiveness, pregnancy, severe exercise on horse-back, and many other causes may give rise to the complaint. It is still a disputed point whether the blood proceeds from varicose dis- tention of the hemorrhoidal veins, or is poured into cysts formed of the cellular membrane, between the coats of the bowel, or be- neath the integuments of the anus. Both opinions are, I am sure, well founded. In by far, however, the greater number of in- stances, hemorrhoidal tumours are formed by enlargement of the veins of the rectum. This varicose condition of the veins is brought about, there is reason to believe, by repeated strain- ing at stool, during which the sphincters are of necessity re- laxed, so that a column of blood, unsupported by valves, and driven by the action of the abdominal muscles against the me- senteric veins, dilates, and, not unfrequently, bursts them. In the course of time, from repeated attacks of inflammation, co- agulablc lymph is thrown around the distended veins, their coats are thickened, and fleshy tumours created, which enclose the veins in their substance, and either diminish, or obliterate, altogether, their cavities. But more or less of the cavity of the vein generally remains, concealed within the tumour, and often this cavity is much larger than the original vessel, and, if opened, will shed blood profusely. Hemorrhoidal tumours, so long as they remain within the cavity of the rectum, are mostly free from pain; when they protrude, however, beyond the anus, and are compressed by its sphincter, they frequently beceom ex- 13fr Hemorrhoids. quisitely sensible, and greatly enlarged. The margin of the anus is sometimes surrounded by a cluster of tumours of a dark red or purple colour; at other times only a single protuberance is visible. Treatment of Hemorrhoids. The remedies for this disease are either palliative or radical. Among the former may be enumerated leeches, cold astringent washes, astringent ointments, rest in the horizontal position, mild laxatives, general blood-letting. In several instances I have de- rived great benefit from a poultice made of the pulp of the green persimmon, and also from a decoction of the bark of the per- simmon tree. The extracts of stramonium, and belladonna, I have used for twenty years, and have found, in particular cases, extremely soothing, and useful. Internally administered, there is nothing better than the old remedy extolled by Benjamin Bell— the balsam copaibae. When hemorrhoids become large and troublesome, or irredu- cible, an operation will be required. The knife, or ligature, will prove equally successful. The use of the former, however, is sometimes followed by profuse hemorrhage, violent inflam- mation, and. even death. Three instances of fatal termination are related by Sir Astley Cooper. The first was that of a lady, who died in a week from peritoneal inflammation, induced by the removal of a single pile by the scissors; the second that of a gentleman who died from hemorrhage on the second day after the operation. In the third case, Sir Astley removed a large hemorrhoid by the scissors from the anus of a nobleman. " In about ten minutes after the operation, he said,l I must relieve my bowels,' and he rose from his bed and discharged into the close stool what he thought to be faeces, but which proved to be blood. In twenty minutes he had the same sensation and evacuated more blood than before, in about the same lapse of time: he again rose, and soon became very faint from the free Hemorrhoids. 137 hemorrhage. 1 therefore opened the rectum with a speculum, and saw an artery throwing out its blood with freedom. I there- fore requested him to force down the intestine as much as he could, and raising the orifice of the bleeding vessel, with a tenacu- lum, secured it in a ligature and also compressed the artery with a piece of sponge. His lordship bled no more. On the follow- ing day he was low, his pulse very quick, and he had a shiver- ing ; on the next day he complained of pain in his abdomen; he had sickness and tenderness upon pressure, and in four days he died." Similar cases have been reported by other writers, both in this country and in Europe. When we recollect, indeed, that piles consist, in nine cases out of ten, of dilated veins, and that there are no valves from the anus to the liver, so that the whole column of blood must press upon the rectum, it is only sur- prising that surgeons, knowing these facts, should undertake to operate as often as they do, with the knife, and scissors, and that a much greater number of accidents have not been met with. The latter circumstance can only be accounted for by the fact that tumours, which were originally varicose veins, have become obliterated by adhesive inflammation, or been con- verted into disorganized masses of cellular membrane, veins and skin, and that when, under these circumstances, clipped off' by a cutting instrument, have shed little or no blood. Such being the case, it is important to draw a distinction between a cluster of dilated veins, within the sphincter, or projecting beyond the margin of the anus, and those lifeless indurated growths, which so often occupy the same situations. The latter may be safely cut away; but the former never can, without imminent risk of the patient's life. It is true that whilst most eminent surgeons are adverse to the removal of venous hemorrhoids by the knife, one or two others, equally eminent, have advocated the practice when con- joined with collateral means. Thus, Dupuytren, the magnus Apollo of French surgery, has boldly recommended and prac- tised not only the removal of piles by cutting instruments, but the application of the actual cautery, immediately afterwards, for stemming the torrents of blood. His own mouth has suffi- ciently condemned, we think, both the operator, and the opera- tion. " I have seen you," says he in his Lectures, " shudder 138 Hemorrhoids. more than once at the sight of the red hot iron, and at the cloud of smoke which arises from the cauterized part: you may judge what an impression such a preparation would produce on the friends and relations of the patient, who are not, like you, accus- tomed to such scenes." Again: " It is also to avoid this disastrous occurrence—hemorrhage—that we make it a rule not to apply the dressings for some hours after the operation, because it is to be feared that the dressings would only hinder the blood from flowing out, and thus cause it to flow back into the superior in- testines." What we apprehended happened the next day: an in- ternal hemorrhage manifested itself; the pupil of the ward was not mistaken. He gave him (speaking of a particular patient,) an enema, which brought away a great quantity of blood ; a second enema brought a considerable clot. He then made the patient strain first to expel any blood that might remain, and, secondly, to cause relaxation of the sphincter, and exhibit the surface of the divided arteries; then he applied to the bleeding parts two red hot iron instruments. The quantity of blood lost in this opera- tion has been estimated to be three, four, and five pounds. It flows into the descending, the transverse, and the ascending, colon, and as far as the caecum, but never beyond this. From the effects of the cauterization he experienced a retention of urine, and it was necessary to use the catheter. After the eva- cuation of a great quantity of urine, he felt violent pain, which did not cease until the organ returned to its usual state." A^ain: a very wealthy banker is attended by Dupuytren, who, with a pair of large forceps, pulls down the hemorrhoids and cuts them off. " At the end of a quarter of an hour, the patient became pale, fell into a state of extreme weakness, the pulse small and hard, a cold perspiration covered his body, and he felt a sensation of heat in the abdomen, continually ascending. The Professor immediate- ly recommended the patient to make expulsatory efforts, and a great quantity of scarcely coagulated blood was discharged, Cold injections were useless; the hemorrhage was not stopped: then a pig's bladder, stuffed with lint, was introduced. This succeeded completely: but it was not without great difficulty it could be kept in its place; involuntary expulsatory efforts tend- ed incessantly to displace it, and actually did so several times. This hemorrhage weakened the patient very much, and would undoubtedly have been fatal, if it had not been arrested so Hemorrhoids. 139 promptly." The banker's brother had a similar disease, is treat- ed in a similar manner, and would certainly have died, but for the presence of mind of another brother, who, in the absence of the surgeon, introduces the pig's bladder, and stops the blood. " But the loss of blood was so great that the patient was a long time before he recovered^ In another instance, a Scotchman, an officer of dragoons, is subjected to excision. " There were three tumours not very voluminous, and as there was but a trifling ef- fusion of blood, M. Dupuytren thought that cauterization might be dispensed with. About five hours after the excision, all the characteristic symptoms of hemorrhage in the rectum were ma- nifested: anxiety, rigors, inclination to vomit, cold perspira- tion, sinking of the pulse, convulsive contraction of the limbs, inexplicable agony, vertigo, syncope, tremors increasing, the patient went to stool, and the expulsion of a considerable quan- tity of partly coagulated blood, gave him visible relief. At the expiration of about an hour the symptoms returned -with in- creasing intensity; they produced complete collapse. The pa- tient requested a notary should be sent for, and hastened to ar- range his affairs, preferring death, which he thought inevitable, to cauterization. With the aid of the speculum, the place from whence the blood flowed was easily found, and the effusion stopped by the application of a bent cauterie en haricot heated to a white heat; a wick was kept in the rectum, and in a few days the patient was perfectly cured." Other cases are report- ed, in favour of excisio?i, and the cautery; but the details corres- pond so exactly with each other, that it is superfluous to state them. Besides, the disastrous effects of excision and the cautery, already pointed out, it should be mentioned, (and the fact is ad- mitted by Dupuytren,) that contraction of the anus, to such a degree as greatly to interfere with the patient having a stool, not unfrequently follows. Under all these circumstance, may we not exclaim, Cui bono 1 Why subject an unfortunate indivi- dual to such torture? Why give rise to hemorrhage, merely for the sake, apparently, of showing our dexterity in stopping it 1 The ligature, then, in our estimation, is the only safe opera- tion, for the generality of hemorrhoidal tumours. As prac- tised by the older surgeons, and by most of the moderns, there can be no doubt that inconvenience, and sometimes very severe pain, and other unpleasant symptoms, follow its application; but 140 Hemorrhoids. that any thing like the consequence spoken of by old Petit, and handed down from one generation to another,—symptoms of strangulated hernia, and death—ever follow from performing the operation, as it ought to be performed, or even when performed in the most bungling manner, I am very far from believing. To the late Dr. Physick we are indebted for the best mode of performing this operation. A double cannula of the ordinary form, but only two inches long, is selected, and " a piece of tough, flexible, pure iron wire, one twenty-fourth part of an inch, or rather less, in diameter, having firmness enough to allow of its being pushed backwards and forwards in the cannula," is passed through both barrels of that instrument, and whilst one end is secured at the ring of the cannula, the other remains loose. A loop being formed adapted to the size of the hemorrhoid, is passed around it, and then drawn as firmly as possible, by pull- ing upon the extremity of the wire projecting from the lower end of the cannula with a pair of flat pliers, and then securing its end to the opposite wing. In twenty-four hours, or some- times twelve, the wire is loosened from the wing of the instru- ment, straightened by the pliers and cautiously pushed back, and its loop disengaged from the tumour, which by that time is commonly found black, shrivelled, and free from pain. A poultice is then applied, and in a few days the tumour is entire- ly separated. The peculiarity, it will be perceived, of the above operation, consists in the unusual firmness with which the wire is drawn, and its being removed in a few hours, instead of being suffered to remain for several days. " No one can pro- perly appreciate," says Dr. Physick, " the advantages result- ing from the above method of removing hemorrhoidal tu- mours, who has not seen them treated, by allowing the ligature to remain during the separation of the part. Under that mode of operating, the patient is never at ease during the whole time ; the discharge of the faeces is often excruciating, even moving in bed is dreaded, and in the last case in which I performed the operation in that manner, the convulsive twitchings of the lower extremities, which were induced, became so frequent and vio- lent, that I was uneasy, through an apprehension of tetanus be- ing the consequence. It seerns to me probable, that one rea- son of the difference between the effect of the wire, and a com- Hemorrhoids. 141 mon ligature may be, that, however firmly the waxed ligature may be drawn and tied on the base of the tumour, before a se- cond knot can be tied to secure the first, the elasticity of the parts compressed opens the first knot a little, and of course the exclusion of blood, and nervous influence is not so complete as when the wire is used, which can be fastened on the arm of the instrument at the time when it is drawn round the swell- ing as tightly as possible. The pinch given by the wire is soon destructive, and any degree of restoration is rendered impos- sible. " It might be supposed, if a thread were used, it could be cut off after a short time; but the swelling comes on so speedily, the parts retract so much within the anus, and are so extremely tender to the touch, that it is difficult to find the noose: when found, the operation of dividing it either with knife or scissors, is productive of so much pain, that I have known some patients refuse to submit to it. The removal of the wire occasions no pain. It may be proper to mention, that when the tumour hap- pens to be attached to the inside of the anus, anteriorly, some difficulty in voiding urine is often complained of; but this symptom, always, in my patients, has subsided immediately af- ter the removal of the wire. " Where," Dr. Physick further re- marks, " hemorrhoidal tumours are only protruded in the act of evacuating the faeces, then their excision would be attended with great risk of hemorrhage. This some have denied, but having twice witnessed the fact to a very alarming extent, I wish, on all such occasions, to guard against it." For many years I have practised the operation just described, both on small, and large hemorrhoidal tumours, and in a great many instances, and can positively declare, that, although I have often known very sharp, and severe pain to follow the tighten- ing of the ligature in some, that in others very little complaint has been made, and that in all very perfect and speedy cures have been accomplished. In proof of this, I shall relate a case which, I think, will be acknowledged to be equal in extent to any reported by Dupuytren. Mr. B., a respectable merchant of Danville, on the Susque- hannah, had suffered for fifteen years with internal hemorrhoids. His constitution was naturally very fine and vigorous, but from repeated hemorrhages from the rectum, he had become ema- Vol. II. 19 142 Hemorrhoids. ciated, and so debilitated, and suffered so much pain from the pro- trusion of the tumours, that he could scarcely attend to his busi- ness, and life had almost become a burden to him. When I saw him, his skin was of a pale yellowish hue and his whole aspect cadaverous. After resting a few days, to recover from the fa- tigue of his journey, he was directed to sit for half an hour over a bucket of warm water, and force down gradually the tumours. They came out, and as they descended became ravelled up into rolls, each as thick as the thumb, covered with blood and sero- purulent matter. There were two or three masses which com- pletely surrounded the verge of the anus, but which presented, when superficially examined, an irregular, tuberculated, dark purple, very vascular, highly sensitive tumour, as large as the fist. The patient was put to bed, a gentle aperient ordered, and the next day, immediately after the tumours, (by straining over warm water) had been forced down, was laid on his side over the edge of a bed, and the largest and most painful mass selected, included in the iron wire ligature, as near its base as possible, and the wire drawn with all the force I was master of. The pain, for an instant, was agonizing; but soon subsided—owing to the death of the tumour, thus so suddenly brought about. In fifteen or twenty hours, the wire was removed, and a warm poultice applied to the parts. In four days the remains of the tumour were completely separated, and the patient returned home in a fortnight, perfectly cured of the protrusion and of the hemorrhagies, and in a few months recovered his health. Seven or eight years have now elapsed since the operation; and I have never heard of his having had a return of this complaint. It may be asked what became of the remaining tumours. They were obliterated, by the supervention of the adhesive inflam- mation—a fact very important to be known, and an occurrence by no means uncommon. Aware of this, the surgeon should al- ways make it a rule never to include numerous hemorrhoids, or a very large mass, in a ligature, at a single operation, (in or- der to guard against violent symptoms,) but take his chance of curing all by one operation, and of repeating it, subsequently, should the remaining tumour require it. A case, in some re- spects similar to that of Mr. B., I operated on, in presence of Dr. Physick, five years ago, and with the same happy result. The patient, Mr. W., long before and since the operation, a Hemorrhoids. 143 most valuable officer of the government at Washington, had de- termined to abandon his office, unless he could have obtained re- lief. In conclusion I may remark, that no surgeon can properly ap- preciate the value of the ligature unless he use it according to the principles first pointed out, and unless he fulfil the most im- portant indication—to draw the wire with very great firmness. On Hemorrhoids, consult Abernethy, on Hemorrhoidal Diseases, in Surgical Works, vol. 2d—Earle on Hemorrhoidal Excrescences, 1807—Exrbyon the Treat- ment of Hemorrhoidal Excrescences—Ware on the Treatment of Hemorrhoids—A Practical Treatise on Hemorrhoids, &c, by George Calvert—The double Cannula and Wire recommended in the Operation of Extirpating Scirrhous Tonsils, and Hemorrhoidal Tumours, by Philip Syng Physick, M. D., in Philadelphia Journal of Medical and Physical Sciences, vol. 1, p. 17, 1820—Excision of Hemorrhoidal Ihmours, in Clinical Lectures on Surgery, by Dupuytren, translated by Doane, p. 105, Phil. 1833—Observations on Injuries and Diseases of the Rectum, by Her- bert Mayo, London, 1833,/?. 53. 144 Fistula in Ano. Section IV. Fistula in Ano. When an abscess forms in the cellular membrane surround- ing the rectum, or about the verge of the anus, and leaves, after its contents are discharged, one or more small openings com- municating with its cavity, the disease is denominated fistula in ano. Other appellations have also been invented, expressive of the particular situation of the fistulous orifice, and the extent of the disease. If the fistula opens upon the surface of the in- teguments, it is called an incomplete fistula; if it communicates with the rectum, and not with the integuments, an internal fis- tula ; and when there is an opening in the gut and another through the skin, a complete fistula. The formation of a fistula in ano is often denoted by rigors, a painful swelling about the ischium or perineum, difficulty of passing urine, and by irritation of the rectum and neck of the bladder. During the progress of the disease, the patient, in many instances, suffers immensely; at other times, the abscess forms and breaks almost without the patient being aware of its existence. Generally the abscess communicates with the inte- guments by a single opening; occasionally, three or four are met with; and I once attended a case of long standing, in which there were no less than fifteen. In healthy constitutions the abscess does not differ from that of the common phlegmon, met with in other parts of the cellular tissue. In consumptive and scrofulous patients, however, the disease often assumes a different shape. The surface of the integuments is covered with an erysipelatous inflammation, the fever, sickness, and pain are very considera- ble, the matter is discharged in small quantity, and from a sloughy, ill-conditioned opening, or from a ragged unhealthy Fistula in Ano. 145 surface. The origin of fistula in ano cannot be always satisfac- torily traced. Sometimes it arises from irritation about the rectum, from local injury, from the lodgement of undissolved articles of food taken into the stomach, and passed through the intestines as far as the rectum, such as the bones of fish or fowls. Severe and long-continued exercise, on rough-going horses, I have sometimes known to lay the foundation of the complaint. Hemorrhoids, there is reason to believe, often contribute to the disease. The same may be said of severe colds and coughs. Treatment of Fistula in Ano. An opinion very generally prevails that every fistula in ano requires an operation. There cannot be a greater mistake. So far from it, almost every sinus, I am inclined to think, in a pa- tient tolerably healthy, might be healed, if attended to in the commencement, and judiciously managed. Nothing will con- tribute more to this end than absolute rest, simple dressings, moderate diet, and mild laxatives. I have known a fistula, (protracted and kept open for months while the patient walked about,) healed in a week by perfect quietude, and the horizontal position. It frequently happens, however, that the surgeon is not called until the disease is firmly established, and an operation urgently demanded. But, before he undertakes it, the operator would do well to soothe the parts, and reduce the inflammation and callosity about the sinus by emollient poultices, and after the irritation has subsided, gradually enlarge the fistulous orifice by bougies, (if necessary,) before an examination with the probe is entered upon. If these precautions arc neglected, and the fistula probed at once, the patient will suffer, as I have often witnessed, immensely, and, indeed, will experience infinitely greater pain than from the operation itself. It will still remain to inquire concerning the patient's general health. If consump- tive, the operation can answer, generally, no good purpose; on 146 Fislida in Ano. the contrary, it will aggravate, if the fistula should be healed, all the pectoral symptoms. When determined upon, the operation may be performed by a common probe-pointed bistoury, by the sheathed bistoury of Dr. Physick, or by the knife of Cruikshank. The objection to the probe bistoury is, that it will sometimes be necessary, when there is no opening between the gut and sinus, to make one. For this purpose, an instrument with a sharp point will be re- quired. Dr. Physick's instrument was constructed with this view, and possesses the additional advantage, from being co- vered by a silver sheath, blunt on its edges, of not cutting the tract of the sinus whilst passing along, until the operator de- sires so to do. Cruikshank's bistoury is constructed with a moveable stilet that can be pushed forward or retracted at plea- sure, the point of which is intended to pierce the gut, and then to be withdrawn, that the surgeon's finger may rest on the blunt extremity of the knife. Previous to the operation, the rectum is emptied by a clyster, and the buttocks being turned towards the light, are held asun- der by assistants, while the patient stoops forward and rests his body and arms upon a table. The surgeon introduces a fore- finger, oiled, into the rectum, passes the probe into the sinus, examines carefully its situation and extent, and having satisfied himself thoroughly in this respect, carries the sheathed bistoury, (for example,) as high as the naked outer surface of the intes- tine, then disengages the sheath from the bistoury, and removes it from the sinus. The point of the bistoury is next pushed through the gut, and made to rest on the finger within the rec- tum. Both the finger and knife are next withdrawn, the latter dividing in its passage downwards the whole tract of the sinus, the intestine, sphincter ani muscle, and integuments, and leaving a chasm of considerable extent. A dossil of lint should be next introduced between the lips of the wound, and the patient put to bed. The cure is afterwards completed by mild dressings. When there is an opening in the gut and another at the mar- gin of the anus, or on the buttock, with an intermediate commu- nication by a sinus, constituting complete fistula, no other in- strument than the common probe-pointed bistoury will be re- quired for the operation. In performing the operation for fistula in ano, simple as it is Fistula in Ano. 147 considered, the operator must remember, that if he prolongs his incision too far upwards from an over anxiety to trace every ramification of the sinus, (a very unnecessary piece of work,) he may wound the peritoneum, lay open the cavity of the abdo- men, and also divide the internal hemorrhoidal artery. The ligature, is frequently employed, instead of the knife, for the cure of fistula in ano. As it requires, however, a much longer time to effect its purpose, and is, withal, sometimes pain- ful and inconvenient, there are many patients unwilling to sub- mit to the operation. But cases present themselves now and then, in which the knife could not be employed without risk of hemorrhage, or in which from the number and depth of the si- nuses, it would be impossible to trace them, or if traced, diffi- culty would afterwards be experienced in making them heal from the bottom or in preventing the formation of new sinuses. Under these, and some other circumstances, it has been custo- mary, particularly among the French, from time immemorial, to resort to the ligature. The material of which it is made, as well as the instruments for conveying it, have varied exceeding- ly in different ages. Hippocrates used a linen thread wound upon a horse-hair, others employed silver or iron wire, and many preferred leaden wire to any other kind of ligature. Some con- veyed the ligature by means of a silver probe, others by a can- nula. Forceps for seizing the wire within the gut, and stilets for making an opening into the gut for the transmission of the ligature, have also been used. But, in many instances, it will only be necessary, when this operation is determined on, to pur- sue the following simple plan, one which has been practised for a great many years by Dr. Physick, and which experience has taught him to be almost always successful. A common pocket case probe, of the same thickness throughout, is slightly ragged at one end with a knife or file, and a piece of braid secured to it by thread, in the same way that the line is fastened to a fish- hook, is introduced into the fistulous orifice and conveyed along the sinus into the gut. The probe is next bent upon a finger, (pre- viously passed into the rectum,) and brought out along with the* ligature at the anus. The latter is then removed from the probe and its ends loosely tied. After the lapse of a few days the liga- ture is moderately tightened, and occasionally afterwards, (once a week, for example,) the constriction is repeated and increased, 148 Fistula in Ano. until the parts within its embrace arc completely destroyed, and the cord, sua sponte, detached. The small ulcer left soon heals up. Sometimes the ligature comes away in four or five weeks; at other times, eight or ten months elapse before the loop sepa- rates. In the mean time, however, the patient is generally per- mitted to walk about and attend to his business. In cases where no communication exists between the rectum and fistula, Dr. Physick has been, in the habit of making one, by means of a sharp-pointed sheathed knife, previously to the introduction of the probe and ligature. In peculiarly irritable patients, however, I have found it very difficult to carry jthe eyed-probe and ligature through the orifice in the gut without producing excessive pain in the act of bending the probe within the rectum, and which must al- ways be done before it can be brought out at the anus. To ob- viate this difficulty, I invented, seven years ago, the following in- strument, which I have employed ever since, upon all occa- sions, where I have thought it necessary to use the ligature in preference to the knife, both in hospital and in private prac- tice, and with the greatest success and least possible inconve- nience to the patient. A silver cannula, moderately curved, about five inches long, the eighth of an inch wide in its longest, and the sixteenth of an inch in its shortest diameter, is intend- ed to convey a narrow watch-spring, ten inches long, having at the extremity next the handle of the cannula an eye, and at the other a small bulbous silver point. An additional spring, dif- fering only from the first in the silver end being small enough to pass along with the spring through the cannula, knd intend- ed for incomplete fistula, accompanies the instrument. A steel stilet, which fills up the cannula, and projects in the form of a small lancet, just beyond the extremity, completes the contri- vance. See Plate 3. If it be intended to operate on a case of incomplete fistula— that in which there is no opening in the gut—the cannula, armed with the stilet, and its point retracted, is entered at • the fistulous orifice, conveyed carefully along the sinus until that portion of the side of the rectum is reached where it is intended to make the perforation. The stilet is then pushed through the walls of the gut, and is felt within by the finger, previously introduced into the rectum. Having withdrawn riaU ;i.Vol? Fistula in Ano. 140 the stilet, the spring with the flattened silver end, armed with very narrow braid, is conveyed through the cannula, ancr, guided by the finger in the rectum, brought out" at the anus along with the ligature, which is then separated from the eye of the spring, and its ends loosely tied. In cases of complete fistula, the stilet will not be required, and the spring, with the bulbous end, previously placed in the cannula, and armed, as already described, with braid, may be employed. In either case, it must be obvious that the pressure which gives the pa- tient so much pain when the probe is used, is taken off the fis- tulous orifice and borne by the cannula; and, besides, that the spring has a natural tendency, by forming a curve as it is pushed onwards, to avoid pressure, and to reach the anus with the greatest facility. The ligature is often adapted to those cases in which a fistula follows, or is conjoined with phthisis pulmonalis. Under an im- pression that the pulmonary affection is dependent upon, or aggravated by the fistula, many patients are extremely anx- ious to have an operation. I have invariably refused to em- ploy the knife upon such occasions, but have sometimes grati- fied them by operating with the ligature, which, by being worn for months together, is sometimes so far serviceable as to pre- vent the formation of other abscesses in the neighbourhood of the rectum, and by keeping up a steady drain throughout a sin- gle track, to relieve the cough and other constitutional symp- toms. The worst case of fistula in ano I ever saw, I attended, along with Dr. Physick, about five years ago,—that of a Mr. \V.' from the neighbourhood of Lynchburg, Virginia. The pa- tient's whole family had been carried off by phthisis, and seve- ral of them had also laboured under fistula in ano. In Mr. W., the only remaining one of his race, there were strong premo- nitory symptoms of consumption, and for months he had suf- fered from profuse discharges of sanious, gleety, offensive mat- ter from the rectum, all the parts about which I found indu- rated, covered will! sinuses, and fistulous openings, with exten- sive ulcerations within the gut, destruction of all its coats in particular spots, and the whole rectum more or less insulated by the destruction of the surrounding cellular membrane, ,o that it might have been said to have floated loosely in a large bag of matter. I trimmed away many of the loose-hanging por- Vol. II. 20 150 Fistula in Ano. tions of the rectum and disorganized cellular tissue, and en- deavoured to reach by the finger and by probes the bottom of the sinuses; but found it impossible, owing to their great depth. In consultation it was determined that there was every proba- bility of the patient sinking under his disease, and that all that could be done for his relief would be to introduce a large cord high up the gut, and let it remain for several months. This was accordingly done by Dr. Physick, and the patient returned home. The seton, thus left, had the effect of consolidating, through the medium of adhesive inflammation, all the loose parts, and, finally, contrary to our expectations, the external fis- tulous openings were obliterated, the sinuses healed up, and the patient now enjoys, comparatively, good health. When the knife is employed for the cure of fistula in ano, it effects its purpose by promoting the granulating process, by first dividing the sinus, which, so long as it remained lined by a secreting membrane, would never have been obliterated, and lastly, by dividing the sphincters of the gut, thereby rendering them quiescent, and preventing that incessant motion about the anus, so well calculated to interfere with and to break up the granulations as soon as they are formed. Rest, then, so essential in the treatment of many other, diseases, is peculiarly so in fistula in ano. Though the sphincters unite very readily, in most cases, after the operation by the knife, it sometimes happens that they remain separated, a deep fissure is left, and the patient cannot retain his faeces as perfectly as he had been accustomed to. It is extremely difficult, under these circumstances, to restore the use of the parts. In obstinate cases of the kind, I should think the surgeon justified in cutting away the edges of the chasm, as in hare-lip, and endeavouring to unite them by suture. On Fistula in Ano, consult Desaull's Works, by Smiih, vol. l,p. 330—Pott's Works, by Earle, vol. 3, p. 45—A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum, by Charles Bell, with Notes, &c. by John Shaw, Surgeon; Demonstrator of Anatomy, in the Schoolof Great Windmill Slreet,Lon- don 1820, 8vo. page 297—Copeland's Observations on some of the Principal Diseases of the Rectum and Anus, Philadelphia, 1811—Practical Observations on the Symptoms, Discrimination and Treatment of some of the most Common Diseases of. the Lower Intestines and Anus, by John Howship. London, 1820— Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, p. 28. London, 1833—Sir Astley Cooper's Lectures, by Tyrrell, vol. 2d, p. 336. Encysted Rectum- 151 Section V. Encysted Rectum. Within the cavity of the rectum, between the internal and external sphincters, commencing at the margin of the former, are, naturally situated, a number of small sacs, or pockets, the orifices of which look upwards, while the bodies of the sacs de- scend towards the anus, perpendicularly, are about a quarter of an inch in length, and have a cul de sac termination. The num- ber of these minute pockets is in proportion to the number of grooves, situated between the columns of the rectum, and each groove terminates in its corresponding pocket. In general, from seven to thirteen sacs are found, all of which are covered and lined, by the mucous membrane of the gut. These sacs are filled, there is reason to believe, with mucus (poured out by the numerous adjoining follicles) which is pressed out of their cavi- ties during the passage of the faeces, and serves, probably, to lubricate that portion of the anus covered by cuticle. Accord- ing to Ribes, such sacs had been noticed by lluysch, Morgagni, and Glisson, as being accidentally met with in the rectum upon certain occasions. Ribes himself was unable to find them, al- though he had made numerous dissections for the purpose, during the period of twenty-five years. Subsequently, he was more for- tunate, and was able to find in one subject three, and, in another, four of these lacunae, but which he has not described with per- fect accuracy. It remained for Dr. Horner to establish the fact, by numerous and most satisfactory examinations, that (what the anatomists, referred to, considered as accidental occurrences) these sacs exist invariably, and form a portion of the natural ap- paratus of the rectum. So far back as the year 17i)->, Dr. Physick met with a peculiar 1 52 Encysted Rectum. disease of the rectum, which had never been described or noticed by writers. It consisted of one or more sacs, of different di- mensions, which, by bending a probe upon itself, introducing it into the rectum, and hooking it into the mouth of the sac, could be drawn down and made to appear on the outside of the anus. From that period he was accustomed to speak of this case (and others, which he subsequently met with) in his surgical lectures in the University of Pennsylvania. From 1792 to the present time, (1835,) his experience in the complaint has been very con- siderable, a great number of cases having occurred in his own practice, and in the practice of others by whom he has been consulted. From what has been said, it will be readily inferred that this disease to which the attention of Dr. Physick was originally drawn, must consist in an expansion, or dilatation, of the small natural sacs of the rectum, described in the commencement of this section. Such, we have every reason to believe, to be the fact, though, strange as it may seem, no dissection has ever yet been made, so far as we are acquainted, calculated to demon- strate that the preternatural pouch is an actual enlargement of the natural one. From the circumstance, however, of small portions of faeces, or foreign bodies, such as seeds, &c. having been found in the dilated sacs at the time of operation, it is mere than probable that these articles, by finding their way occasionally into the natural pockets, may, by irritating them, cause their expansion and elongation, and produce the disease in question. Dr. Physick, himself, seems inclined to believe that "they commence in the same manner with one of the forms of hemorrhoidal tumour. The constriction o[ the sphincters which embarrasses the venous circulation of the part, aided by the pres- sure exerted in passing different stools, frequently give rise to ecchymosis beneath the integuments. The effused blood pro- duces no irritation of the cellular tissue in which it is placed, but forms for itself a simple inert receptacle. If the blood is neither absorbed nor discharged, but remains or becomes en- larged by successive ecchymoscs, it constitutes (certain authori- ties to the contrary, notwithstanding,) one form of hemorrhoid. If, on the other hand, some accident, or the absorption of the in- tegument, gives exit to the blood, after the cavity has become Encysted Rectum. 153 accustomed to its presence, the cellular tissue shows little dis- position to reunite, no obvious marks of inflammation appear, and a preternatural cavity is established. In support of this ex- planation, which is urged with characteristic caution, as an hy- pothesis, Dr. Physick states that in the early part of his practice, he has, in several instances, operated on hemorrhoidal tumours of the same part, in which after the removal of the coagula, the part presented precisely the same aspect with the preternatural cavities, wanting only the orifice. He refers, also, to the existence of similar cavities after the discharge of ecchymoses of the scalp, such as most surgeons must have seen, particularly in children, and which often prove tedious and difficult of cure: he has also witnessed the same accident in other parts of the body. In most cases the first appearance of the cavities was preceded by trou- blesome piles."* It generally happens that patients troubled with sacculated rectum, have complained for weeks, or months, of uneasy, dis- agreeable sensations, (resembling those created by the nestling of ascarides, within the gut,) or of extraordinary itching about the anus. Others complain of a sense of pressure or weight upon the extremity of the rectum. Pain is seldom felt until the disease has existed for some time, and even then, is not general- ly noticed until a short time after the passage of the faeces. It does not, however, follow every evacuation, and the patient may be free from it for whole days together. Sometimes it is extreme- ly severe. For the most part there is more or less smarting shortly after each stool—owing, in all probability, to small por- tions of faeces finding their way into the pouches, and there ex- citing irritation. The secretion of mucus within the rectum is usually increased, but pus, except in the advanced stages of the complaint, or when inflammation has supervened, is rarely no- ticed. Upon the whole, it may be stated that this affection is of- ten confounded with neuralgia of the rectum, and that, not un- frequently, even after examination, the patient's complaints have been pronounced, by practitioners, imaginary. • Hays' Cycloped. of Pract. Med. and Surg. Part 6, p. 125. 154 Encysted Rectum. Treatment of Encysted Rectum. When the surgeon has reason to believe, from the absence of inflammation, or of free discharge of mucus and pus, from the want of spasm about the sphincters, that there is no internal, or occult fistula, in the rectum, and no neuralgic affection, and, above all, when the symptoms enumerated have been strongly marked, especially uneasiness and pain, a short time after stool, he will naturally suspect enlargement of the rectal pouches, and proceed accordingly. The mere introduction of the finger into the rectum will not enable the surgeon to detect this disease. Dr. Physick, as al- ready mentioned, takes a probe with about half an inch of its extremity bent back upon itself, and by moving it upwards and downwards, throughout that portion of the circumference of the rectum situated between the two sphincters, is able by patience to explore successfully every part of the surface of the mucous membrane. Wrhen the dilated pouches exist, the reverted ex- tremity of the probe drops readily into them, and each cyst may be drawn down to the verge of the anus, and distinctly seen—though not without producing severe pain to the patient. That the portion drawn down is really one of the rectal pouches may be known by its transparency, for the probe shines dis- tinctly through it—and by the exquisite pain which the bare admission of the probe into its cavity occasions. Several of the enlarged pouches often exist simultaneously; at other times, they enlarge in succession, and months may elapse before a complete cure can be accomplished. Having drawn the cyst down by the hooked probe, Dr. Physick then cuts off the whole of it, including the orifice where the probe entered, by a pair of scissors, so that its edges retract and are soon obliterated and blended insensibly with the smooth surface of the rectum. Should other sacs exist, or form subsequently, they must be treated in a similar manner, until a radical cure is effected. In the hands of Dr. Physick, the practice has invariably proved successful, and the remark is confirmed by my own experience. So far Encysted Rectum. 155 back as 1812, I attended the late Dr. S. of Baltimore, with this complaint. It was the first case of the kind I ever saw. The nature of the disease, in this particular case, had been previously detected by Dr. Physick, and by operating in the manner he advised, I soon effected a perfect cure. I have operated subse- quently, and successfully, in numerous instances. For further observations on this subject, the reader is referred to an article by Dr. R. Coates, (drawn up under the superintendence of Dr. Physick,) in the seventh number of a^ecent valuable publication —the American Cyclopaedia of Practical Medicine and Surgery by Dr. Hays. 156 Stricture of the Rectum. Section Vf. m Stricture of the Rectum. Simple stricture of the rectum, like that of the oesophagus and urethra, may be either spasmodic or permanent. The former, however, is not very common, and, when it does occur, is the result, probably, of disordered action of the sphincter muscles, of the levator ani, and also, not unfrequently, of the muscles of the perinaeum and of those surrounding the urethra. But the permanent or organic stricture of the rectum, if it be not so common as some other affections of that intestine, is, nevertheless, by no means rare. It may occupy any part of the rectum, but is, commonly, met with at the upper margin of the internal sphincter; and consists of a fold of the mucous membrane or coat of the gut, which in the form of a tumid ring hangs, at first, loose into the bowel, but in proportion as it acquires, from repeated straining, and irritation, firmness, projects horizontally towards the centre of the rectum, to a greater or lesser distance, so as to resemble in some cases a septum with a hole in its mid- dle. Sometimes there are two or three of these folds, or ridges, within a short distance of each other, which either continue separate, or, in the course of time, approximate, and form an indurated tube which diminishes the capacity of the bowel and subverts its texture. In either case, or in that of a single ridge protruded into the caliber of the gut from its walls, the effect must be a girding, or coarctation, well calculated to interfere with the passage of the faeces, or to produce wire-drawn-like stools. Hence, all patients complain of their excrement being contracted; and this, indeed, will be found to be an almost cer- tain accompaniment of the disease, though not infallible diag- nostic, or criterion. As the stricture increases, other symptoms Stricture of the Rectum. I57 are developed; there is perpetual straining or nisus, sometimes followed by mucus, sometimes by blood, either from rupture of small vessels about the rectum or from superadded piles. The bladder, also, becomes involved, and great irritation and painful micturition ensue. Eventually, the rectum becomes extremely irritable, and so exquisitely sensitive, that the patient is often afraid to attempt the expulsion of the faeces; or, if they are passed at all, it is through the medium of purgatives, enemata, or diet, calculated to keep the contents of the bowels nearly in a fluid state. If not soon relieved, great distension of the bowels, from flatus and food, takes place, followed by more urgent symp- toms, and the patient dies. Not unfrequently, he has lived for years in a miserable condition, the real nature of his case un- known to himself or his attendant, and has, finally, recovered under the management of some more skilful surgeon. Strictures of the extremity of the rectum, or, rather, coarcta- tions of the orifice of the anus, are occasionally met with. This disease is often the result of operations, improperly performed, for hemorrhoids, prolapsus ani, fistula in ano, &c. Sometimes depositions of coagulable lymph are thrown out either on the outer or inner surfaces of the radiated folds of skin around the anus, or immediately within the termination of the rectum, where the mucous membrane and radiated folds meet. From any of these causes the opening of the anus may be so contract- ed as scarcely to admit the passage of a common-sized urethra bougie. Treatment of Stricture of the Rectum. Before attempting to overcome, by mechanical means, a stric- ture of the rectum, the causes of the disease should be carefully investigated, and, if possible, removed. Great attention should, in particular, be paid to the condition of the patient's stomach and bowels, through the medium of appropriate diet, gentle ape- Vol. II. 21 158 Stricture of the Rectum. rients, and enemata. Repeated ablutions of the rectum by tepid and cold water alone, or holding opium or other similar articles in solution, thrown to some distance up the gut by a well con- trived syringe, will pave the way for bougies and other instru- ments, and sometimes, without the assistance of the latter, will effect perfect cures. But soft, well made gum elastic, or waxen, bougies are more to be relied upon, in the majority of cases, than any other instruments or modes of treatment. The surgeon should take care, however, not to promise to accomplish too speedy a cure; for if, under the impression that he has nothing to do but to break down by force the barrier opposed to him, he introduce at once a large bougie and drive it home, and fol- low it up shortly afterwards by another still larger, he may either destroy the patient at once by tearing the bowel, or re- motely by inducing peritoneal inflammation. Very instructive cases of the kind have been published by Sir Charles Bell, Mayo, and other surgeons. The utmost gentleness, therefore, should be employed during the introduction of such instruments, and caution observed in increasing their size. The more gra- dual the dilatation, the less will be the irritation; and whenever it is found that the patient complains much of soreness or pain, the instrument should be diminished or withdrawn for a day or two. By prudence and discreet management, radical cures may be effected in a few months: by rash and intemperate measures, the disease will be aggravated, or the patient killed in a few weeks. The bougie acts either by dilating the stricture, gra- datim, or by exciting the ulcerative process, and thereby re- moving, through the medium of absorption, the superfluous mass of which it consists. It has been proposed, and by high authority, to introduce a bistoury and cut through the stricture at several points of its circumference. But I am at a loss to conceive what benefit can result from such a measure. If merely divided, will not reunion take place, almost immediately, and the ridge or septum con- tinue as firm as ever ? We cannot cut out the whole of the ridge from its base to its edge, by introducing the knife per anum, without great risk. But I have sometimes thought (should the urgency or peculiarity of the case require it,) that by laying open the muscles of the perineum, as in the lateral operation for lithotomy, and then slitting the rectum, as is too often done Stricture of the Rectum. 159 by ignorant or careless lithotomists, that the strictured portion of the gut might be completely extirpated. This, however, is a mere speculation, and as such must be received. The other operation (notching the stricture) has been performed, and suc- cessfully, it is said. For coarctation of the orifice of the anus, the knife appears to be the best remedy. It must be followed up, however, by the bougie; though the cure is allowed, by all familiar with the disease, to be very difficult and uncertain. Consult Howship on some of the most important Diseases of the lower Intestines and Anus, p. 1, London, 1821—Observations on some ofthe principal Diseases of the Rectum and Anus, particularly Stricture of the Rectum, &c, by T. Copeland, p. 13. London, 1811—A Treatise on Diseases of Urethra, Vesica Urinaria, Pros- tate and Rectum, by Charles Bell. London, 1820, p. 311—A Practical Treatise on Hemorrhoids, Strictures of the Rectum, &c, by Calvert. London, 1824—(Sal- mon's Practical Essay on Stricture of the Rectum. London, 1828—Two- Clini- cal Lectures on Hernia and Strictures of the Rectum and Anus, in Lancet. Lon- don, 1827—Mayo on Injuries and Diseases of the Rectum. London, 1833—Hay's American Cyclopaedia of Medicine and Surgery, Part 6,1835. 160 Imperforate Anus. Section VII. Imperforate Anus. This congenital imperfection is occasionally met with, both in the human subject and among inferior animals. Sometimes it is complicated with other malformations. In my cabinet there is an interesting specimen of imperforate anus, spina bifida, and club feet; all in the same subject—a child at birth. There are three or four varieties of imperforate anus —a mere closure by the common skin of the orifice of the rectum—a membranous septum occupying the same situation, or placed within the gut at a greater or less distance from its extremity—a cul de sac termination of the rectum—an entire oc- clussion of the sides of the rectum, or the conversion of the gut into a solid tumour. Along with these varieties, there is not un- frequently conjoined a communication between the rectum and vagina or between the rectum and uninary bladder, so that the faeces and urine are commingled. An uncommonly fine specimen, of the latter kind, I had an opportunity of witnessing some years ago in a thorough-bred colt, the property of the late Dr. Thornton of Washington. The animal was deficient in a tail, (its rump terminating, as in the human subject, at the os coccygis,) and the anus was completely shut up by integuments, and beneath by an apparently fleshy membrane. Along with the urine were discharged quantities of thick greenish matter, evidently of the nature of faeces. At this time the animal was a week old, sucked freely of its dam, and in other respects was perfectly healthy. Perceiving, at the natural site of the anus, a fluctu- ating tumour, I pushed a double-edged scalpel to the depth of an inch into the part, and immediately there was discharged about a gallon of greenish fluid, similar to that which had been Imperforate Anus. 161 accustomed to pass from the urethra. By means of plugs and tents, the orifice was kept open, by the owner of the colt, for a few weeks; and after that time, the use of them appeared un- necessary. The communication between the rectum and blad- der closed of its own accord in a very short time. The animal, I believe, is now living and in perfect health. This statement is made for the twofold purpose—of recording an interesting fact, and of drawing the attention of students to the diseases of domestic animals, a subject in this country very much neglected and underrated. Country practitioners are often consulted, as friends, by their neighbours and patients, concern- ing epidemics, or local diseases, among their stock. Instead of considering their dignity insulted by such appeals to their feel- ings and humanity, (as too often the case,) they should furnish cheerfully all the information they possess, or prescribe in ob- scure and difficult cases, according to the principles that would guide them in the treatment of a human being—for between the two, as regards mere animal conformation, there is much great- er correspondence than generally imagined, and similarity of texture is commonly associated with similarity of disease. Mon- ro, Hunter, Jenner, Cline, and a host of other European physicians and surgeons, and the late distinguished Dr. Rush, in this coun- try, have not thought it beneath them to investigate the disor- ders of those domestic creatures, upon which so large a share of our comforts, convenience and pleasure depends, nor to recom- mend such studies to their pupils. Treatment of Imperforate Anus. From want of timely aid, from the nature of the disease being undiscovered or misunderstood, many infants have perished that might have been saved. It is incumbent, then, upon the practitioner to investigate, speedily, the variety of the complaint the child may labour under, and to decide, promptly, upon the 162 Imperforate A n us. treatment; for after the lapse of a few hours, meconium and other fluids may accumulate in such quantities as to produce great distention and distress, which may soon be followed by pe- ritoneal inflammation and death. It is true, that a few cases have been reported where recoveries have taken place, although no operation has been performed until the tenth or twelfth day. In by far the greater number of instances, however, the child will not survive beyond the fourth or fifth day. When the anus is merely covered by a common skin, or where a membranous septum is visible, or felt, a short distance within the gut, a bistoury, (wrapped throughout the greater part of its edge,) may be pushed through the skin, or through the septum, guided, in the latter case, by a finger per anum, and the obstruction removed. But where the rectum is obliterated, to any extent, by closure of its sides, or filled up by a fleshy tumour, a more delicate and difficult operation will be demanded. Either a regular dissection in the natural course of the rectum should be made until the open portion of the bowel be reached, or a trocar of large size thrust through the obstruc- tion. Both operations have been performed, and with success in some instances; though in other cases they have failed—owing to the great extent of the obstruction, or the distance of it from the natural situation of the anus. Under such circumstances, it was proposed by Littre to cut through the parietes of the abdo- men, either in the right or left groin, open an intestine and estab- lish an artificial anus—by connecting the gut with sutures to the surrounding parts. The operation was afterwards per- formed, and with partial success, by Duret, a French naval sur- geon. It has since been repeated by Pring, an English surgeon, in the case of a lady, in whom the rectum was closed by a scir- rhous tumour. The operation was performed on the colon near its sigmoid flexure, and proved successful so far as the establish- ment of the artificial anus was concerned, though the patient died a few months afterwards from the scirrhous affection. If the surgeon, in any of the varieties of imperforate anus, should succeed, by the operation described, in making his way through the obstructed rectum, he will find it necessary, in or- der to preserve the track or passage of suitable dimensions, to introduce plugs of lint, sponge tents, gum elastic bougies and other similar instruments, and gradually increase their size, until Imperforate Anus. 163 the requisite degree of dilatation has been effected. This, how- ever, will be found, in many instances, the most difficult part of the treatment; as there will be great irritation from the long continued use of such instruments, and a perpetual tendency, in the artificial passage, to close up. On Imperforate Anus, consult Sabatier's Medecine Operatoire, tom. 4—Calli- sen's Systema Chirurgiac Hodiernae, tom. 2d, edit. 1815—Ford, in Medical Facts and Observations, vol. 1—Richerand's Nosographie Chirurgicale, torn. 3d—Cham- ber laine, in Memoirs of Medical Society of London, vol. 5—Wayte in Edinburgh Medical and Surgical Journal, vol. 17—A. G. Hutchinson's Practical Observations in Surgery, 1826. 164 Foreign Bodies in the Rectum. Section VIII. Foreign Bodies in the Rectum. Indigestible articles often pass from the stomach along the in- testines, and are arrested by the sphincters at the anus. Pieces of gristle, of bone, of sponge, of apple core, of toasted bread, and other similar substances, have been found within the rectum, and the cases reported. Still more numerous examples have been given of the lodgement of pins, needles, fish-bones, chicken- bones, all of which have excited more or less irritation, and, in some instances, laid the foundation of fistula in ano, of extensive ulcerations, and even death. Upon other occasions foreign ar- ticles have been forced into the rectum from without either by design, or by accident, sometimes producing death, at other times most violent symptoms—as exemplified in the case of the unfortunate Edward the Second of England, murdered by a red hot iron being thrust up the rectum, and in the celebrated case reported by Marchetti, where the but-end of a pig's tail was forced up the rectum of a courtesan, and remaining for several days, had nearly destroyed her. " Des etudians avoient projette de jouer quelque mauvais tour a une fille publique; ils s'aviserent de lui mettre dans l'anus une queue de cochon qui dtoitgelee; ils en couperent les poils un peu court, afin qu'ils fussent plus piquans et plus roides; ils la trerriperent dans l'huile, et Pin- troduiserent par l'extremite la plus grosse et a force dans le fondement de cette fille, a la reserve de la longeur d'environ trois doigts qui resta a l'exteriur de l'anus: on fit diverses tentatives pour l'oter; mais comme elle ne pouvoit etre tiree qu'a contre poils, les soyes entroient dans les membranes du rectum, et causoient a cette fille des douleurs inexprimables; pour les appaiser, on fit prendre a la malade divers remedes huileux par la bouche, et on-tacha de dilater l'anus avec un spe- Foreign Bodies in the Rectum. 165 culum, assez pour retirer cette queue sans violence, mais on ne reussir; il. survint des accidens enormes, un vomissement vio- lent, une constipation opiniatre, une fievre, tres ardent, et des douleurs tres vive dans tout l'abdomen."* Although not to be classed, with strict propriety, under the head of foreign bodies, yet great irritation and even extreme distress are not unfrequently occasioned by the lodgement of as- carides, within the rectum—especially in children and old people. These animals, (which probably find their way into the stomach and intestines, through the medium of fruits and unboiled vege- tables, and have been found out of the body by Pallas in the waters of Siberia, and by Dr. Barry in certain springs in Ireland,) are so enveloped in mucus whilst in the rectum, which they sometimes almost choke up, as scarcely to be reached by medi- cine, or the most stimulating injections. That they may be got- ten rid of, however, or the irritation they produce very much alleviated, by means I shall presently point out, I have had fr- quent opportunities of proving for the last twenty years, and on that account I notice them in this place. Removal of Foreign Bodies from the Rectum. When, from more or less irritation, difficulty of passing faeces, a peculiar pricking sensation, within the rectum, whilst at stool, and at other times, a discharge of purulent matter and blood, from the anus, &c, there is reason to believe, that some foreign body occupies the gut, an accurate search should be made both by the finger and by instruments. If discovered, the extraneous article may then be removed by a pair of forceps or scoop. The latter instrument, such as is used commonly for extraction • Memoires de l'Academie Royale de Chirurgie, tom. 3d., p. 78.—Edit, octav. Vol. II. 22 166 Foreign Bodies in the Rectum. of bullets, is peculiarly adapted to the removal of hardened faeces, which often accumulate in the rectum, and become so impacted that the patient is unable to force them out. But pins, needles, fish and chicken-bones, &c, may be removed with more facility by the forceps than any other instrument. In the extraordinary case reported by Marcthetti, and detailed above, a most ingenious and successful expedient for the removal of the pig's tail, and the only one that could have been practised with probable suc- cess, was resorted to—the introduction of the end of the tail, hanging from the rectum into a reed, the reed carried up the gut, made to press down the bristles, that stood like a chevaux- de-frise, and then the removal of the reed with the tail enclosed in its cavity. " Le sixieme jour on eut recours a Marchettis: ce practicien instruit de tout ce qu'on avoit fait, inventa un pro- c6de fort simple, mais fort ingenieux; il prit un roseau creux long d'environ deux pieds, il le prepara par une de ses extre- mites de maniere qu'il put l'introduire facilement dans l'anus, et enfermer entierement la queue de cochon dans ce roseau, pour la tirer ensuite sans causer de douleur; dans ce dessein il at- tacha a cette queue, par le bout qui etoit hors du fondement, un gros fil cire, et le passa dans le roseau; il poussa d'une main cette espece de canule dans le rectum et il retenoit de l'autre, le fil, pour ne pas repousser la queue en enfoncant le roseau dans le fondement: il parvint a enfermer entierement cette queue dans la cavitie du roseau, et delivra promptement la malade, tant du danger de la mort que de l'etat cruel ou elle se trouvoit; elle rendit sur le champ une tres grande quantite de matieres stercorales qui avoient £te" retenues pendant six jours par le corps etranger." In ancient times, when barbed arrows were used instead of fire arms, an instrument somewhat similar to Marchetti's reed, was employed for removing them, in order to prevent the flesh from being torn during the extraction. There are many occasions, even now, when similar contrivances may prove useful. For the removal of ascarides from the rectum, I have em- ployed the bullet scoop, or a small instrument resembling a mustard spoon. I was first led to make the experiment by finding the disease to be exceedingly common, and sometimes productive of so much distress to the patient as to render life almost a burden. The scoop being oiled and introduced Foreign Bodies in the Rectum. 167 into the rectum, was found to bring away one or more of these animals enveloped in its appropriate nidus, and to relieve at once the intolerable itching so annoying to the patient. Adults can use the instrument themselves, with the greatest facility, and are always directed to the spot where the animal is situated, by the itching and pricking sensation which it creates. Chil- dren will require the assistance of a physician or skilful nurse. Incredible quantities of these troublesome insects may be taken away in a short time, by this simple expedient—where me- dicines might be employed for months, and at last fail. Consult Memoires de TAcademie Chirurgie, tom. 3d, Precis Observations sur les Corps Etranger, &c, par M. Hevin, Dictionnaire des Sciences Medicates, tom. 7th, p. 35—On Painful Constipation from indurated Faeces, in Lond. Med. Obs. and lnq. vol 4, p. 123—Case of a Fork thrust up the Anus, and extracted, in Phi- losophical Transactions, abridged, 1725—Harrison's Case of Apple Core, forming a Fistula in Ano eight Months after being eaten, Memoires of Medical Society of London, 1796—Blair's Case of hard Toast arrested in the Anus, in medical Facts and Observations, vol. 6— Gregory's Case in which Death followed from a Fish-bone lodged for Years in the Rectum, in Monro's Morbid Anatomy of Stomach and Gul- let, p. 22, Ed.1811. 168 Diseases of the Tunica Vaginalis and Testis. CHAPTER VII. DISEASES OF THE TUNICA VAGINALIS AND TESTIS. Having treated on a former occasion* of cancer and of fungus haematodes of the testicle, and described the treatment and ope- rations necessary for each, some other affections of these organs will be noticed. These are hydrocele, haematocele, chronic en- largement of the testis, irritable testis, encysted testicle, tumours of the scrotum, &c. Among surgical writers, accounts will be met with, of the oedematous hydrocele or dropsy of the scrotum, of hydrenterocele or hydrocele combined with intestinal her- nia, of encysted hydrocele of the spermatic cord, of the conge- nital hydrocele. These, however, are either the result of other diseases, or are so analagous, in many respects, to common hy- drocele, as not to require minute consideration. Section I. ■Hydrocele. The tunica vaginalis is naturally bedewed with a thin serum, which, by lubricating its surface and that of the testicle, enables them to move freely upon each other. This fluid, when se- creted in undue quantity, constitutes hydrocele—a disease of frequent occurrence, and met with in patients of every age and constitution. If attended to in the commencement, the tumour • Vol. I. pages 191 and 197. Hydrocele. 169 will be found to occupy the lower part of the scrotum, and'gra- dually to extend towards the abdominal ring. In shape it is pyriform, and to the touch elastic—feeling like a bladder dis- tended with water. When pressed upon, little or no pain is experienced by the patient, except at the posterior part of the swelling where the testis is situated. The rugae of the scro- tum generally remain unaltered, even in hydroceles of the greatest magnitude, and sometimes the tumour attains an enor- mous bulk. In ordinary cases, however, the tunica vaginalis seldom contains more than a pint of fluid. This fluid, in colour, is either perfectly limpid, or else yellowish. The disease is usually confined to one side. It is sometimes difficult to dis- tinguish between hydrocele and other complaints that bear a resemblance to it. Much may be learned from the history of the disease. The hydrocele invariably begins below, and very gradually ascends. The swelling in sarcocele, or scirrhous testicle, is uniform throughout, is accompanied with pain, is in- elastic, and heavier when handled than hydrocele. When re- cent, hydrocele is generally transparent, if examined by placing the tumour between a lamp and the surgeon. From hernia it differs materially—the one commencing above, the other below In hernia, moreover, an impulse is communicated to the finger when the patient is directed to cough. This is not the case with hydrocele. The causes of hydrocele are very uncertain. By some the disease is attributed to urethral excitement, by others to varicose enlargement of the spermatic vessels, to blows upon the scrotum, to rheumatism, cold, &c. I have met with it in infants immediately after birth. Hydrocele is often conjoined with enlargement of the testicle—constituting the dis- ease called hydro-sarcocele. It occasionally happens that the cavity of the tunica vagina- lis is occupied by one or more hydatids, or cysts filled with transparent fluid; and that the tumour bears so close a resem- blance to common hydrocele as to be mistaken for it readily. A few cases of the kind I have met with, both in young and old subjects. Sometimes the two diseases exist simultaneously, and occupy the same tunica vaginalis. In other instances the hydatids are connected with the epididymis, or substance of the testicle, and protrude when the tunica vaginalis is opened by a trocar or lancet. 170 Hydrocele. Hydrocele of the spermatic cord is now and then met with. It usually appears as a rounded or oval tumour, in the site of the external abdominal ring; or it may be situated in the abdominal canal, between the internal and external rings. It is elastic to the touch, and retires in such a way, from the finger, as to give the idea of the existence of hernia, with which it is often confounded, even by experienced surgeons. A man forty years of age in the Aims-House Infirmary during the winter of 1833, had a tumour the size and shape of an egg, which occu- pied the left cord below the external ring. It was pronounced by some a hernia, by others, a varicocele. I was satisfied, how- ever, by its not retiring with a guggling noise, by its being free from pain and by its transparency and bluish colour, tha£ it was a hydrocele of the cord, and so it turned out to be; for upon thrusting a lancet into it, nearly an ounce of limpid serum was discharged. Under the title of congenital hydrocele, a variety of that dis- ease was first described by Vigurie and Desault, and was as- certained by them to be owing to the communication being kept up between the abdomen and tunica vaginalis, so that wa- ter accumulating in either of those cavities, might pass freely from one to the other. This form of the complaint is by no means uncommon; but is not confined to children. Hence, the term congenital is not strictly correct. It may be distinguished from common hydrocele by the fluid retiring into the abdomen when the patient is in the recumbent posture, and by its reap- pearing with more or less fluctuation in the erect position. The complaint is sometimes complicated with hernia. Treatment of Hydrocele. In very young subjects, and in recent cases, I have sometimes succeeded in removing the disease by purgatives, and by bath- ing the tumour repeatedly with a mixture of sal ammoniac and Hydrocele. 171 vinegar. Sir Astley Cooper recommends, in similar cases, a sus- pensory bandage moistened with muriate of ammonia and liquor ammoniae acetatis, two drams of the former to six ounces of the latter; and, after using it for awhile, to add to the mixture tinc- tura lyttae, or to apply tincture of iodine, in case the fluid is not absorbed. In the majority of instances, however, an operation will be required. This is either palliative or radical. The former may prove necessary when there is any doubt respecting the na- ture of the disease, or it may be performed to diminish the size of the swelling, and thereby enable a patient to pursue a journey without interruption. In a short time the fluid accumu- lates again; and, if necessary, the operation may be repeated. A common lancet, or a small trocar, answers equally well for the operation. The radical cure of hydrocele has been attempted in various ways—by laying open the tunica vaginalis, by passing a seton through it, by applying caustic to the surface of the tumour, by extirpating a part of the tunica vaginalis, by the introduction of a tent, and by the injection of the cavity of the sac, after having drawn off its contents. The latter operation is the one prac- tised by most modern surgeons, and when properly performed, is generally successful. The patient being seated on the edge of a bed, or table, with his thighs separated, the operator sits before him, and grasps the tumour so firmly with one hand as to render it perfectly tense, while with the other he introduces a trocar of moderate size, covered by its cannula, obliquely upwards and inwards, into the front of the tumour, near its lower part.* The trocar, thus held, is made to penetrate the integuments of the scrotum, and the tunica vaginalis, to the depth of an inch and a half, and is then withdrawn, leaving the cannula behind, through which the fluid is immediately discharged. The nozle of a syringe, or gum elastic bag, is next adapted to the mouth of the cannula, and an * The opening is made in this situation, and the instrument directed obliquely with the view of avoiding the testicle, which is usually situated posteriorly. But it should be remembered that the testicle is sometimes placed in front, and will, there- fore, be wounded if the above direction is followed. To avoid so unpleasant a consequence, the operator must endeavour beforehand to ascertain, if possible, its exact position. 172 Hydrocele. injection, consisting of two parts of port wine, and one of water, thrown into the tunica vaginalis until it is distended to the size of the original tumour. The length of time the injection should be permitted to remain, must depend upon the patient's feelings. In general, a pain will be felt along the cord, extending into the abdomen; and when this becomes very severe, the wine and water must be evacuated ; on the contrary, if the patient, as I have sometimes noticed, should experience no pain whatever, the injection may be renewed, and its strength increased. It only remains to withdraw the cannula, and close the wound by a bit of lint. In a few hours the parts swell, sometimes enor- mously, and may require the application of a poultice, the anti- phlogistic system, and the recumbent posture. But the swell- ing usually subsides in four or five days, and a cure is accom- plished through the medium of adhesion—the tunica vaginalis being made to coalesce with the proper coat of the testicle. This operation, trifling as it is usually considered, is some- times, from inattention on the part of the surgeon, followed by serious consequences, owing to the end of the cannula being permitted to slip from the cavity of the tunica vaginalis, and rest among the cellular membrane of the scrotum, into which the vinous injection will pass, and, by exciting most violent in- flammation, cause gangrene and sloughing of the scrotum, and denudation of the testicles. This has repeatedly happened to surgeons of the first eminence, and should be most carefully guarded against. Sir Astley Cooper mentions an instance in which a patient, from this cause, died in about a week after the operation, and I myself have known of one case of the kind, and heard of another in this country. If the operation of hydrocele, above described, should fail, as sometimes happens, it may be repeated; or the plan of Hunter may be pursued—which is simply to make an incision an inch long, into the upper and front part of the tunica vaginalis, eva- cuate the water, and sprinkle a little flour into the cavity. This generally excites the requisite degree of inflammation; and, after this 'purpose is accomplished, the flour may be washed out, or permitted to escape along with the pus. This operation, however, is followed, sometimes, by violent Hydrocele. 173 inflammation, and, in old people, by gangrene and death. In other cases the suppuration is so profuse that the tunica vagina- lis is filled with matter. But I have known the same to follow, in one instance, the operation by injection. I performed, No- vember 22d, 1835, the operation for hydrocele on a negro fifty years of age, at the Blockley Hospital. Nearly three pints of fluid were drawn off and the vinous injection thrown in. The wound made by the trocar healed up, but the swelling did not subside, and the patient's constitution was rapidly sinking. On the 22d of December, I pushed a lancet into it, and evacuated nearly a quart of thick offensive pus, and in a short time the man recovered perfectly. I have had occasion to repeat the operation by injecting two or three times in the same individual, and, at last, only have succeeded by using spirits of wine, or turpentine, along with the port wine; and although no injurious consequences followed, yet I am not inclined to recommend the practice, but have pre- ferred, latterly, where the injection has failed, not to repeat it, but to resort to the seton, of which, under all circumstances, I entertain a very favourable opinion. The plan I pursue is very simple. The water being drawn off, in the usual way, by a tro- car, I permit the cannula to remain, and pass through its cavity a small narrow seton needle, six inches long, armed with French braid, and, pushing the needle through the tunica vaginalis and scrotum, introduce the braid, and remove the cannula and needle—leaving a space of two or three inches between the ori- fices where the ends of the braid emerge, and tie the ends loose- ly together. Perfect cures having invariably resulted from this practice, in my hands, I have resolved, in future, where I have reason to believe that the requisite degree of inflammation will not be excited by the injection, to employ the seton at once, and from the first. Indeed, I see no good reason why it should not supersede the injection in all cases; for in the hands of the celebrated Pott, and others, it scarcely ever failed; and was never followed, so far as I am acquainted, with serious conse- quences. In general, it will be sufficient to permit the seton to remain ten days, or a fortnight, and during that time no attempt should be made to draw it backwards and forwards, which would only create unnecessary pain and inflammation. Of the other methods of treating hvdrocele—excision, caus- Vol. II. 23 174 Hydrocele. tic, and the tent, I do not speak, because they are acknowledged, by all modern surgeons, to be cither very severe or else inert. Where hydatids occupy the tunica vaginalis, and fill it en- tirely, (a disease which cannot be distinguished, always, pre- vious to operation, from common hydrocele,) the surgeon will discover that very little fluid follows the push of the trocar, and that a membranous bag will protrude immediately afterwards from the opening. In such a case, he will find it necessary to enlarge the orifice an inch or two, and dissect away with the knife, or scissors, the different hydatids he may meet with. The operation is tedious and painful, but generally successful. In cases, however, where ordinary hydrocele is associated with two or three floating hydatids, the water must first be drawn off, and the injection, or seton, introduced, and each hydatid afterwards pulled out as it shows itself, (which it generally does,) at the orifice, and cut off. Should any smaller hydatids remain, the inflammation that follows the injection or seton, will commonly obliterate them. If not, a small separate seton should, afterwards, be passed through them, and suffered to re- main for a few weeks. For hydrocele of the spermatic cord, either incision, or in- jection has been usually employed. The former is painful and apt to be followed by suppuration, and the latter almost sure to fail, even when repeated frequently. The seton is uniform- ly successful, and is decidedly, in every respect, the best reme- dy. Pott and other surgeons have reported cases where death has followed from laying open hydrocele of the cord. Congenital hydrocele, as improperly termed, may be cured, sometimes, by a well contrived truss, which, by obliterating through the medium of adhesion the sides of the tunica vagina- lis, shuts off the communication with the abdomen. Vigurie and Sir Astley Cooper report successful cases of the kind; but Desault, having tried the plan ineffectually, was induced to sub- stitute another proceeding, more complicated, painful, and fraught, I conceive, with considerable danger. He first drew off the water by a trocar, then directing an assistant to make firm pressure at the groin, injected the tunica vaginalis with warm wine, and having afterwards carefully removed every particle of wine, lest it should find its way into the abdomen, by firm compresses over the scrotum and groin, succeeded, in a short Hydrocele. 175 time, in obliterating the passage to the abdomen and in curing, at the same time, a hernia which happened to the conjoined with the hydrocele. This example, however, should not, I conceive, be imitated, on account of the risk of peritoneal inflammation from continuity of surfaces, and from the possibility of escape of the vinous fluid into the abdomen. Should a truss effect a cure, by producing an hour-glass-like contraction between the belly and tunica vaginalis, it may afterwards become necessary to draw off the fluid from the latter by a trocar and perform some one of the operations for ordinary hydrocele. But expe- rience proves that the fluid is sometimes spontaneously absorbed after the communication between the two cavities has been cut off. In cases where ascites and hydrocele are conjoined, the scrotum will be found a convenient place for the operation of paracentesis. Hydrocele is removed, occasionally, by a blow upon the tu- mour, and, in other instances, by ulceration, or sloughing, from slow inflammation, or over-distention. I once performed the pal- liative operation upon a gentleman, and after the lapse of a few weeks, when the fluid accumulated again, ulceration took place at the spot pierced by the trocar, and left for a few days a fistulous orifice, from which the fluid drained off In a few days the fistula closed and the fluid was again secreted, and again discharged, in a similar way; and after the process had been repeated several times, a cure was effected. Something similar occurred in a patient upon whom I operated for stone; for in twelve months after the operation the perineum ulcerated at the place of inci- sion, and a lump of calculous matter was discharged from the bladder along with urine. The ulcer then healed up of its own accord, and the patient never had a return of his complaint. 176 Hematocele. Section II. Hematocele. This disease, as its name implies, is a collection of blood—si- tuated either in the tunica vaginalis testis, within the tunica al^ buginea, or in the cellular membrane of the scrotum. It may arise, according to writers, from several different causes—from wounding one or more of the large veins of the scrotum in per- forming the operation for hydrocele,—from wounds of the ves- sels of the scrotum, during the operations of lithotomy and cas- tration,—from rupture of branches of the spermatic vein,—from spontaneous rupture of a vessel within the tunica vaginalis, after the water of hydrocele has been drawn off,—from blows or inju- ries of the vessels of the testis, and consequent extravasation of blood within the tunica albuginea. The disease may be distinguished, generally, from hydrocele, by its great weight and solid feel, by its want of fluctuation and transparency, by its often following the operation of hydrocele, or arising suddenly from a blow, and sometimes, by the appear- ance of extravasated blood in the cellular membrane of the scrotum. Treatment of Hematocele. Unless the extravasation of blood should be very considerable, it will probably be absorbed in a short time. If, in this respect, Hematocele. 177 however, the surgeon is disappointed, an incision may be made into the part that contains it, and the coagulum extracted; after which, the parts will granulate and fill up. If any particular vessel continue to pour out fresh blood, it must be searched for and secured by ligature. During the winter of 1830,1 attended a patient in the Alms-house Infirmary, whose scrotum was dis- tended to an enormous size. Upon opening the tumour, 1 found a large collection of blood mixed with serum. Three weeks previously, the patient had undergone the operation for hydro- cele, and the surgeon who performed the operation had, in all probability, wounded with the trocar some large artery or vein. The man recovered perfectly in a short time. Effusion of blood under the tunica albuginea, is considered by Pott, and some other writers, as requiring castration; but, as I conceive, without foundation. There is, indeed, more reason to apprehend that the surgeon may be too prompt in performing this operation; for cases have been reported where the testicle has been extirpated and found upon examination perfectly sound. Sir A. Cooper, in particular, mentions an instance where a surgeon mistook a common haema- tocele for a diseased testis, and had so little curiosity, after cas- trating the patient, as not to examine the part. When dissected by Sir Astley, blood only was found in the tunica vaginalis, and the testicle in its natural situation and free from disease. On Hydrocele and Hematocele, consult Pott's Works, by Earle, vol. 3—A Treatise on Hydrocele, by Sir James Earle, 1803—Bell's Operative Surgery, vol. 1, p. 193—Ramsden's Practical Observations on Sclerocele, 1811—Dorseyrs Surge- ry, vol. 2—Richerand's Nosographie Chirurgicale, tom. 4, p. 262 and 258—Scarpa on Hernia, by Wishart—Observations on the Structure and Diseases of the Testis, by Sir Astley Cooper. 4to. London, 1830; 178 Irritable Testis. Section III. Irritable Testis. This disease has been particularly described by Sir Astley Cooper, under the title of irritable testis. It is a most severe and distressing affection, but, fortunately, not very common. Sometimes it follows hernia humoralis, or common inflammation of the testicle induced by injuries, though not, perhaps, un- til the inflammatory symptoms have disappeared for months; at other times it comes on without evident cause, and may occur in persons of vigorous and healthy constitution. But, on the other hand, it is, occasionally, preceded, or followed, by paralysis, or de- rives its origin from the brain or stomach. That one or more of the nerves of the spermatic cord may be materially implicated in this affection is not improbable. The symptoms are excessive pain in coitu, pain in the groin and back, exquisite tenderness in the whole testicle, particularly upon the slightest motion of the testicle or any pressure that may be made upon it, by the clothes in walking. There is scarcely any general swelling, or enlargement, of the testicle, nor is the uneasiness or pain diffused throughout the gland. On the contrary, there is sometimes di- minution of the testis, and the pain occupies a single spot or point and may shift from one part to the other in an instant. The cord is frequently the seat of suffering, and from it to the testicle the pain darts backwards and forwards, like a flash of lightning. The recumbent posture on the side opposite the dis- ease, is the only one the patient can generally bear. Nausea, vomiting, mental dejection, and extreme bodily distress, are apt to follow long-continued attacks of the disease, and in some in- stances months and years wear away without any perceptible amendment or alleviation of the sufferings. When removed and examined by dissection, the testicle is found unaltered in structure, and apparently sound. In other cases, it is entirely Irritable Testis. 179 absorbed, with the exception of the tunica albuginea and tunica vaginalis. This atrophy, however, I have known to follow other affections of the testis, particularly hernia humoralis and that enlargement of the gland produced by cynanche parotidea, or mumps. In all the cases of the kind I have met with, one testis, or both, have wasted away gradually, the pain has subsided and the patient recovered. Treatment of Irritable Testis. If the disease should reach the height I have described, it can seldom be removed except by the operation of castration. When only of a few weeks' duration, and the symptoms are moderate, benefit may be obtained, and a cure sometimes effected, by the in- ternal use of carbonate of iron, arsenic, ammonia, quinine, cam- phor, opium, cicuta, stramonium, belladonna, compound decoc- tion of sarsaparilla, and by the local application of blisters to the groin and thigh, and tincture of iodine, and pyroligneous acid, ice, &c, to the scrotum. Blood-letting, low diet, purgatives, and other parts of the antiphlogistic system, generally aggravate the complaint. Eighteen months ago, I was induced, in an obstinate case of irritable testis, to cut down upon the spermatic cord and divide its nerves, leaving the cremaster muscle and vas de- ferens untouched. The operation proved very difficult, but eventually produced so much relief, that the patient does not re- gret having submitted to it. 180 Chronic Enlargement of the Testis. Section IV. Chronic Enlargement of the Testis. From inordinate indulgence in venery, or masturbation, from any urethral excitement, from exposure to cold, from fatigue or mental inquietude, from -intemperance, and from various constitutional causes, chronic inflammation is set up in one or both testicles, and is so insidious in its approach and so gradual in its advances, as often to escape the notice of the patient and to deceive the surgeon. In particular, even after the disease has existed for weeks, or months, the testicle may be handled roughly without exciting pain or any unpleasant sensation. In- deed, in many instances, the testicle attains a considerable mag- nitude, and yet is entirely devoid of uneasiness. The swelling commences in the epididymis, which slowly hardens and en- larges. From the epididymis it extends to the body of the gland, and both preserve their natural smoothness and shape. Both testes may be simultaneously affected, or the swelling may remain stationary in one and increase in the other. With the swelling a hydrocele is often conjoined. The patient's ge- neral health is apparently good, and he is seldom debarred from exercise or prevented from attending to his business. In this state of the disease, it often happens that a blow, or some other injury, is received, or that the patient has been drinking to ex- cess, or exposed to cold, and from that moment great pain, and swelling, take place in the testicle, which are soon followed by pain in the loins, febrile excitement, &c. By the use of appro- priate remedies these symptoms wholly subside, and for weeks, or months, the patient remains, apparently, well. He is very lia- ble, however, to a repetition of the attack, and should this occur Chronic Enlargement of the Testis. 181 frequently, suppuration is established in the body of the testicle or epidydimis, and the matter, of its own accord, at- last dis- charged through the scrotum, or let out by the surgeon. A sinus ending in a fistulous orifice, soon follows, and from this a discharge of seminal fluid issues, sometimes, in considera- ble quantity, and is kept up, not unfrequently, for many months. From the mouth of the sinus, granulations in a fungous form, sprout forth, and often become very luxuriant. Indeed, in this, and other respects, there is reason to believe that chronic en- largement of the testicle, corresponds with fungus of that organ, described in former editions of this work. Treatment of Chronic Enlargement of the Testis. In the commencement of this disease, or even after consider- able swelling of the testicle has taken place, strict confine- ment for several weeks, to the horizontal position, elevation of the testicle above the pubes, and retention there by a bag truss, the application of leeches, followed up by cold satur- nine solutions, or camphorated mixture, and vinegar, or the acetated liquor of ammonia, together with low diet, occasional purgatives, the internal use of mercury, and avoidance of ve- nereal excitement or indulgence, will often effect a perfect cure. But, should the patient afterwards neglect himself, and have repeated returns of the complaint, and suppuration of the testis, discharge of semen through fistulae, and fungous granulations follow, extirpation of the testicle, will, in many cases, be required, and, indeed, will often be insisted on by the patient. In other cases the fungous granulations may.be re- pressed by canslic, or should be cut away with the knife, or kept down by pressure, whilst injections of solution of sul- phate of copper and other similar articles are thrown into the sinuses, to consolidate their sides and close the fistulae. It should Vol. II. 24 182 Chronic Enlargement of the Testis. be remarked, however, that the operation of castration has of- ten been performed, unnecessarily for chronic enlargement of the testis, under the idea of its being a specific or malignant disease, which, in reality, it is not, as is proved by the circum- stance of the cord not being liable to contamination, as it al- ways is in the advanced stages of cancer of the testicle, &c. Encysted Testicle. 183 Section V. Encysted Testicle. Cysts, containing a yellow, transparent serum, or else a tur- bid gelatinous fluid, are found to occupy, occasionally, the sub- stance of the testicle within the tunica albuginea. They vary in size, some being not larger than a shot, and others equal in bulk to a pistol bullet. The fluid contained in the larger ones is thick and muddy, and in the smaller transparent. Both the tunica vaginalis and albuginea are thickened, and, in cases of long standing, the substance of the testicle in a great measure removed, and its place occupied by the cysts. According to Sir Astley Cooper, these cysts are probably enlargements of the seminiferous tubes, and not animal hydatids. Patients from eighteen to thirty-five years of age are most subject to the complaint, which, however, is rather uncommon than otherwise, and very liable to be confounded with other af- fections of the testicle, particularly with hydrocele. But the most striking symptoms of hydatid testicle are—conspicuous distention of the veins of the scrotum and spermatic cord, no tenderness, or pain, in the commencement "of the disease, or even in the advanced stages, unless the part be forcibly squeezed, and then sickness of the stomach, pain in the groin, and that peculiar sensation which follows pressure on a sound testicle, arise. The testicle, too, retains its natural, or rounded shape, is heavier than usual, has a very obscure and limited sense of fluctuation, and the epidydimis preserves, generally, its natural line of demarcation. In the end the tumour becomes enormously large, but the cord and inguinal glands are never contaminated. Lastly, there is no transparency in the tumour. This, together with absence of distinct fluctuation, and the rounded, instead of" 184 Encysted Testicle. pyriform, shape of the swelling will be sufficient, in most cases, to distinguish the disease from hydrocele. Nevertheless, the most experienced surgeons have been frequently deceived, and have confounded one with the other. Treatment of Encysted Testicle. Before giving a decided opinion, the surgeon should make it a rule to puncture with a lancet every tumour bearing a resem- blance to encysted testicle. In case a few drops of fluid issue mixed with blood, the nature of the disease will, generally, be made manifest. It will then become a question whether cas- tration should be performed or not. When the tumour is im- mensely large and is inconvenient, or so unsightly as to annoy the patient, it may be removed; but, on the contrary, when it remains stationary for years, and the patient's mind is not filled with apprehension as to the termination of the case, he should be advised to submit with Christian resignation to his misfortune and to palliate the complaint as long as possible. On the other hand, should he determine, after mature deliberation, to lose the testicle, the surgeon has it in his power to assure him of the safety of the operation, and that the disease (which is not of a malignant nature,) will not return. It may happen, however, to be conjoined with fungus haemalodes, and in that case an operation will prove fruitless. Tumours of the Scrotum. 185 Section VI. Tumours of the Scrotum. Sarcomatous, and other indurated, growths are met with, occasionally,-in the cellular texture of the scrotum, which some- times are scattered about in the form of small tumours, which feel like a marble or piece of cartilage beneath the skin, being either firmly fixed or moveable; at other times the whole tex- ture of the scrotum seems to undergo a change, becomes unusual- ly corrugated, thickened, and finally converted into enormous indurated masses. Such are often seen in the West Indies and in Egypt, and interesting cases of the kind have been reported by Larrey, Titley and others, but are rarely met with in the United States. When a single sarcomatous, or adipose tumour occupies the scrotum, or the outer surface of the tunica vaginalis, or is imbedded in either of these textures, it often presents the appearance of a third testicle, and has been so considered by ignorant persons. An interesting case of the kind occurred se- veral years ago in the practice of Dr. Heister, an eminent phy- sician of Reading, in this state. The tumour had existed for a long time, was of the shape of a testicle, but much larger, and was so situated between the testes as to inspire a belief on the part of the patient and his friends that it was really a third testis. Upon being removed, however, by Dr. Heister, it was found to be lodged in a cyst between the scrotum and tunica vaginalis, and to consist of adipose and fleshy matter. The preparation, obligingly presented to me by Dr. Heister, is still in my cabinet. 186 Tumours of the Scrotum. Treatment of Thimours of the Scrotum. Those enormous growths described by Larrey, Hendy, Tit- ley, Delonncs, &c, although supposed to derive their origin from an incurable disease—elephantiasis—have been extirpated, never- theless, with success. In particular, Titley removed, effectually, from a West Indian negro, a stupendous tumour, in the interior of which the genitals had long been buried, and which reached nearly to the ground, and weighed seventy pounds. Others of still greater weight and dimensions have been reported, and are said to have been successfully cut away. In performing such operations, the surgeon should endeavour, if possible, to ascertain the condition of the testes and penis, in order not to injure, or remove them unnecessarily. When small tumours occupy the scrotum or surface of the tunica vaginalis, they do not always require extirpation; but, when necessary, the operation is easily performed, and a cure soon effected. I have known, however, very large sarcomatous thickenings of the scrotum, and tunica vaginalis, and also enormous hydro-sarcoceles in West Indians removed in a short time by a change of residence. In Decem- ber, 1816, Captain D----was recommended to my care by Ro- bert Harrison, Esq., United States consul for the Island of St. Thomas, on account of an immense scrotal tumour which in- volved each testicle and spermatic cord, and was complicated with hydrocele. The patient stated that from long residence in Martinique and other islands, where he had been exposed from the nature of his occupations to hardships, and had drunk con- stantly of rain water, which was often in an impure state, his disease, as he believed, was to be attributed. While the patient was arranging his affairs and recruiting his health, to enable him to undergo an operation, the tumour gradually subsided, and in the course of two or three months was entirely absorbed—and all the parts affected restored to their natural state. Tumours of the Scrotum. 187 Consult, on Diseases of the Tunica Vaginalis and Testis, Pott's Works, by Earle, vol. 3d—1 Treatise on Hydrocele, by Sir James Earle, 1803—Bell's Opera- tive Surgery, vol. 1, p. 193—Cooper's Lectures by Tyrrel, vol. 2d, p. 86— Obser- vations on the Structure and Diseases of the Testis, by Sir A. Cooper, p. 165__ Ramsden's Practical Observations on Sclerocele, 1811—Richerand's Nosographie Chirurgicale, tom. 4th, p. 258 and 262 —Observations on a peculiar Affection of the Testis, attended with the Growth of Fungus from that Organ, illustrated with Cases by W. Lawrence, in the Edinburgh Medical and Surgical Journal, vol. A,, p. 257—Wadd's Cases of Diseased Prepuce and Scrotum, 4to. 1817—Larrey's Surgical Memoirs—Case of Extraordinary Enlargement of the Scrotum, by J. M. Titley, Medico Chirurgical Transactions, vol. 6, p. 73—Delonne's Case of Charles Delacroix, in Richerand's Nosographie Chirurgicale, tom. 4th, p. 315. 188 Diseases of the Penis. CHAPTER VIII. Diseases of the Penis. A mistake into which writers, as well as practitioners, are ex- tremely apt to fall,—that the penis, with one or two exceptions, is subject only to specific disease—should be corrected. Possess- ing the same texture and organization, (modified by certain pe- culiarities) as other soft parts, why should it not be liable to the same infirmities? That it is so, experience, our safest guide, has sufficiently proved; for, wounds and other injuries, sim- ple and erysipelatous inflammations,—excoriations,—abscesses, —ulcers, simple, irritable, and indolent,—warts,—tubercles,— tumours, sarcomatous, encysted, steatomatous—herpetic and other eruptions, totally unconnected with syphilitic taint, or with other specific vitiation, sometimes the result of sexual intercourse, at other times entirely independent of it, the consequence often of abrasion, or mere mechanical injury, have been, always, more or less common, in every country and in every age. It is not my intention, however, to treat of all these affections, but chiefly of simple ulcerations, of phymosis, paraphymosis, &c. Chancre, or the true syphilitic sore, has been noticed on a for- mer occasion.'* * See vol. 1, p. 226. Wounds of the Penis. 189 Section VI. Wounds of the Penis. The penis is liable to incised, lacerated, contused, gun-shot and other varieties of wounds. They may be the result either of design or accident, and numerous instances have been report- ed where maniacs, and persons under the influence of religious phrensy or hallucination have removed both the penis and tes- ticles. An extraordinary instance where an attempt was made, under a different feeling, to inflict a punishment of this descrip- tion, occurred not long since, in the practice of an eminent sur- geon of New York. A woman who had long lived unhappily with her husband, and from whom she had been separated for a considerable time, became, apparently, reconciled to him, and through the intervention of friends the parties consented to re- new their nuptial intercourse. Prompted, however, by jealousy and a diabolic spirit, the virago, having provided herself with a razor, took it to her bed, and while her unfortunate Abelard was in the act of consummation, seized the penis, and with her weapon nearly severed it from his body. The penis has been shot off in duels, or swept away by can- non or musket balls or grape-shot, or so bruised and lacerated by these and other missiles, that it has afterwards slOughed and been lost. A severe bruise, or contusion, may likewise pro- duce a different effect or lay the foundation of a specific disease as in the following case. "I. Wallace," says Sir Everard Home, " a married man, thirty-seven years of age, stout-made, subject to no general or particular complaints, and by profession a sailor, was admitted into St. George's Hospital, under my care, November 18th, 1803. About four years since, during a violent storm at sea, the main top-mast was shivered, and °the upper portion was swinging backwards and forwards. It was Vol. II. 25 190 Wounds of the Penis. necessary to cut away the upper piece, and Wallace was sent aloft for that purpose. He had on a pair of loose trousers at the time. The rolling of the ship was very great, which in- creased the motion of the mast, and while he was clinging to the standing part, his glans penis was caught between it, and the loose piece; he immediately fainted away and fell into the round top, from whence he was carried to the deck. On re- covering, he was informed by his companions that when they first took him up his glans penis was as flat as a half crown. The body of the penis and both testicles, as well as the glans, began to inflame and swell, and were extremely painful. He kept his bed for three weeks, at the end of which time the glans had recovered its natural size and figure, having only a small pimple on that part to which the fraenum is attached. This was considered of no consequence, and was not at all trouble- some until his arrival in England, six months afterwards, when it began to ulcerate and become very painful. It is proper to remark that he never had the venereal disease, and from the time of the accident never had intercourse with his wife or any other woman."* From that period the ulceration increased, assumed the cancerous form, involved the greater part of the penis and groin, and after the lapse of a year proved fatal. An interesting case was reported to me, two or three years ago, by Dr. Wm. S. King of Russelville, Chester County, in which a young man, 17 years of age, had the genitals entangled in the machinery of a cotton factory, in such a way, that the skin was completely stripped from the pubes, penis, testicles, and perineum, as far as the verge of the anus, and although replaced by Dr. King, shortly afterwards, finally sloughed away, and endangered the patient's life—by irritative fever, and inflamma- tion. * Home on Cancer. Wounds of the Penis. 191 Treatment of Wounds of the Penis. In cases of incised or lacerated wounds of the penis, the hemorrhage should be arrested by picking out the vessels with the tenaculum, or needle, and tying them, or by introducing a catheter into the urethra and making firm compression with a -—■" bandage on the penis. After the hemorrhage has ceased, the edges of the wound must be drawn together by the interrupted suture, and supported by adhesive straps. The bandage should then be slackened or removed, as, if long continued, it will be apt to cause swelling and to excite erections. When the urethra is divided and the penis nearly cut through, as in the New York case, the catheter must be continued until reunion is established; otherwise, effusion of urine and sloughing may follow. Con- tused wounds of the penis will require poultices and fomenta- tions, and after full benefit has been derived from these, should ulcerations remain, mild dressings, such as are used in simple ulcers in other parts of the body, may be resorted to. But, in all injuries of the penis, an important indication is to repress erections—by the internal use of camphor, dulcamara, &c. 192 Ulcers of the Penis. ", Section II. Ulcers of the Penis. The loose skin eovering the glans, as well as that on the body of the penis, is subject to phlegmonous inflammation and abscess, which seldom, however, forms a large tumour, but upon breaking, or being let out with a lancet, discharges freely, and leaves an ill- conditioned sore, with an indurated margin, and excavated edge. The whole aspect of the ulcer, indeed, is at first so unfavoura- ble as to cause it to be mistaken for chancre; though the rapid progress towards amendment, and the speedy filling up of the sore, will soon evince its true character. The Ulcus Erraticum is met with, almost invariably, in per- sons of bad constitution, in dram drinkers, and in those who have suffered from the abuse of mercury. It may follow sexual intercourse or not, and is distinguished, generally, by this pecu- liarity—that the sore, which usually occupies the body of the penis, ascends in a spiral form, and, while it heals below, breaks new ground above, and in this way may encircle the penis, reach the groin, and pubes, and devastate them. The edges of the ulcer are everted and indurated, the granulations foul, and the pain severe and burning. Psoriasis Preputialis is an affection almost peculiar to those individuals who have the prepuce unnaturally long, tender, and succulent. It appears in the shape of deep fissures, or cracks, which pervade the edges of the prepuce, discharge at first a co- hesive, and afterwards a purulent matter, bleed freely upon being irritated, are excessively tender or painful, and difficult to heal. Herpes Preputialis differs from the foregoing affection in toto. It commences in the form of vesicles, which, upon breaking, leave, when situated on the inner surface of the prepuce, a small round yellowish white ulcer, and when it occupies the outer skin of the prepuce, forms a scab. Each vessicle has its corre- Ulcers of the Penis. 193 sponding sore, which often unites with those adjoining it, until one unbroken surface of ulceration is established. From expe- riments made by Mr. Evans, it appears that the sore is not con- tagious. The same writer imputes the disease to derangement of the digestive organs. Excorialio, or abrasion of the cuticle of the glans penis or pre- puce, may be the result of inordinate friction, of preternatural tenderness of parts, of undue secretion of that whitish, cream- cheese like, sebaceous matter, which seems almost peculiar to certain persons, of filth, or want of accurate ablution, of connex- ion with foul and unwholesome women, particularly such as have laboured for years under fluor albus and other acrimoni- ous discharges, of extraordinary inequality of size between the male and female genitals, &c. From any of these causes, trou- blesome ulcerations may arise, and are often confounded with syphilitic sores. But their external characters are sufficiently marked, in general, to enable a careful surgeon to distinguish them from other ulcerations. In particular, these ulcers are su- perficial, irregular, in separate patches, of a yellowish hue, in the commencement, but surrounded, in the advanced stage, by a red areola. Extraordinary itching, together with undue serous or purulent secretions, followed, in some instances, by sympathe- tic enlargement of the inguinal glands, are the remaining sym- toms. Treatment of Ulcers of the Penis. Phlegmonous inflammation of the penis is rarely susceptible of resolution. The sooner, therefore, the matter is evacuated by a lancet, the better. An emollient poultice of bread and milk, ground flax seed, and particularly of the powdered bark of slippe- ry elm, may then be applied, and renewed frequently for a day or two. Afterwards, the mildest unctuous dressing and lotions may be employed. Should fungous granulations arise, the sul- phate of copper and lunar caustic will be required. 194 Ulcers of the Penis. Ulcus Erraticum, like the common irritable ulcer of other parts, frequently proves refractory. It should be coaxed and humoured by soothing and sedative lotions, such as the acetate of lead and sulphate of zinc blended with gum Arabic and opium. Very weak solutions of argentum nitratum, and nitric acid, ex- tremely diluted, will also prove useful. Acrid and stimulating applications generally fret and annoy it. The blue pill, as an alterative, and great attention to diet, with rigid observance, in plethoric patients, of other parts of the antiphlogistic system, will sometimes do more good than all the local remedies that can be thought of. In patients prostrated by intemperance, or other causes, a system of support, or nourishment, must be in- stituted, and corresponding applications to the sore, and internal medicines employed. For Psoriasis Preputialis, various astringent lotions and ointments are generally used, and, according to Evans, the best application is the unguentum hydrargyri nitrati, reduced to one- half its ordinary strength. Herpes Preputialis is benefited by attention to diet, by the occasional use of gentle purgatives, and by the mildest local ap- plications. Keeping the parts perfectly clean, and suffering them, when disposed so to do, to form a scab, will effect a cure in a very short time. Simple Excoriations, unconnected with specific disease, may be removed speedily, by guarding against erections, by the use of simple ointments perfectly fresh, by moderately astringent lo- tions, and, when the sores become indolent, by gentle, occasion- al, touches of argentum nitratum, and weak solutions of corrosive sublimate mixed with spirit of lavender or alcohol. Phymosis. 195 Section III. Phymosis. There are two varieties of this disease—the natural and preternatural. The former exists at birth, and is therefore congenital; the latter may occur at any period of life, in both cases the prepuce is contracted in front, and cannot be drawn backwards over the glans penis. Natural phymosis is a very common complaint, and met with under two or three different forms. Sometimes, though rarely, the extremity of the prepuce is perfectly closed, and the urine cannot pass off, but collects between the glans and pre- puce, forming a large bag or tumour. The disease is of course discovered a short time after birth, but is often not understood, and from this cause several infants have perished that might have been saved by a trivial operation. Another form of natu- ral phymosis is that in which an opening exists at the extremity of the prepuce, but so small as not to permit the urine to escape from it with the same rapidity it issues from the urethra. Con- sequently, it collects between the prepuce and glans, and dis- tending the former to a great size, is then forced off gradually in a very fine stream, and to a great distance. If the disease should continue in this state for several years, as I have known to happen, pus and calculi may collect within the cavity of the distended prepuce, and keep up a constant irritation. But in most instances, there is no impediment to the flow of urine, no extraordinary elongation of the prepuce; yet the skin is so closely contracted around, as to prevent the patient from unco- vering the glans penis. From this, other inconveniences result. A whitish sebaceous matter collects in large quantity between the glans and prepuce, and excites so much irritation, as to pro- duce a disease resembling gonorrheea—with which it is often confounded. Besides this, the inflammation excited by this, 196 Phymosis. or any other cause, may produce an adhesion between the glans and prepuce, which can only be relieved, and that not always, by a most severe and tedious dissection. Preternatural phymosis is commonly the result of inflammation of the prepuce, by whatever cause induced. The disease often accompanies severe gonorrhoea, extensive chancres, and vene- real warts. Sometimes matter accumulates behind the corona___ glandis, and is followed by ulceration of the prepuce, and a pro- trusion of the glans through the opening. The inflammation at- tending preternatural phymosis, is sometimes of the erysipelatous kind. Extensive sloughing of the prepuce is frequently the con- sequence, in bad constitutions, of the continued exhibition of im- moderate quantities of mercury. Treatment of Phymosis. Natural phymosis, if it exist at birth, and be complete, will re- quire an immediate operation, in order to save the infant's life. A puncture with a common lancet in the most prominent part of the tumour, may answer every purpose, as the stream of urine will afterwards prevent the opening from closing. When the prepuce has become distended, from repeated collections of urine, the small opening in its extremity may be either enlarged, or the superfluous bag amputated. The latter will prove the most effectual, and should be, generally, resorted to. A simple phymosis, when only inconvenient to the patient by impeding copulation, may be relieved by slitting up the pre- puce at its middle as far as the corona glandis. The operation can be performed with a sharp-pointed bistoury, or still better by the sheathed knife employed by Dr. Physick for fistula in ano. Hemorrhage sometimes follows the incision, but in gene- ral is easily suppressed by a dossil of lint. Before the parts are dressed, the surgeon must take care to tack the two lay- ers of skin to each other by a single stitch of the interrupted Phymosis. 197 suture. The edges of the prepuce, thus divided, retire from each other, and after they are healed, become continuous, and resemble the borders of a prepuce naturally formed. This has been denied by some surgeons, who allege that two flaps or angles are left, which afterwards prove very inconvenient to the patient. I have performed the operation very frequently, and never experienced such a result. Preternatural phymosis, when complicated with gonorrhoea or chancres and attended with high inflammation, should never be touched with the knife. The best remedies, under such circumstances, are local blood-letting, emollient poultices, fo- mentations, and accurate ablution of the glans by means of a syringe. The continuance of mercury will prove immensely injurious. After the inflammation has entirely subsided, if ad- hesions should have formed between the glans and prepuce, uniting them firmly to each other, an attempt may be made to separate them by dissection, provided the patient is willing to encounter a most severe operation, (one compared by Petit " to the skinning of an eel,") rather than submit to his misfortune. Vol. II. 26 198 Paraphymosis. Section IV. Paraphymosis. Paraphymosis is the reverse of phymosis—the prepuce be- ing retracted behind the corona, leaving the glans uncovered. The disease may be either congenital or acquired, but the latter is the most common. Sometimes it is the result of the success- ful retraction of the prepuce in cases of phymosis; but generally it proceeds from inflammation induced by syphilis or gonorrhoea. So extensive is the swelling, in some instances, and so great the constriction produced by it, that the glans penis, or prepuce, oc- casionally mortifies and drops off. This termination, however, must be considered as comparatively rare. I have known para- phymosis to proceed, in some instances, from erysipelas, and in other, from collections of sebaceous matter between the prepuce and glans penis. In such cases sero-purulent matter, or ill-con- ditioned pus, very abundant, and very fetid, has collected in the cellular tissue of the skin of the penis, or in the cells of the cor- pus spongiosum, or cavernosum, and has been discharged from one or more fistulous orifices—giving rise, eventually, to con- densations, and adhesions, which may interfere with erections and other functions of the penis. Treatment of Paraphymosis. If called in time, or before the swelling attains a great height, the surgeon may often succeed in restoring, by steady pressure with the fingers, kept up for several minutes without intermis- sion, the prepuce to its natural situation. The application of Paraphymosis. 199 very cold water to the parts will also contribute towards the same end. Punctures, too, when there is much oedema, as generally happens, afford great relief, by evacuating the serum and reducing the swelling. This treatment, together with an observance of the antiphlogistic system, will usually effect a cure in a short time; should this not prove to be the case, and gangrene of the parts be likely to follow, the division of the stric- ture must be attempted. To accomplish this, a fold of the skin should be raised and cut through, a director pushed beneath the stricture, and the latter divided by a bistoury. In cases of erysi- pelas of the prepuce, leeches, cold washes, slight incisions, fol- lowed by poultices, and by mercurial ointment, I have found useful. Steady purging, too, has proved exceedingly useful, espe- cially in corpulent subjects, and those accustomed to luxurious living. On Phymosis, Paraphymosis, and other Diseases of the Penis, consult, Petit's Traitd des Maladies Chirurgicale, et des Operations qui leur Conviennent, tom. 2—Hunter on the Venereal—Cooper and Trovers' Surgical Essays, part 1, p. 145 —Richerand's Nosographie Chirurgicale, tom. 4, p. 328—S. Cooper's First Lines of the Practice of Surgery, vol. 2, p. 176. Wadds Cases of Diseased Prepuce and Scrotum, 4to. London, 1817—Pathological and Practical Remarks on Ulcerations. of the Genital Organs, by James Evans, Surgeon to his Majesty's 57th Regiment. London, 1819. 200 Diseases of the Urethra and Bladder. CHAPTER IX. DISEASES OF THE URETHRA AND BLADDER. Volumes have been written on these subjects; and there is scarcely an eminent surgeon of any age who has not devoted some portion of his writings to their explanation. This will show the importance of these diseases, and the difficulties en- countered in their treatment. In a work professedly elemen- tary, it will not be expected that more than a very general sketch on such topics can be furnished. Ample scope, how- ever, must be taken in the lectures—such, I trust, as will abun- dantly supply any deficiency that may be here met with. The diseases of the urethra and bladder, that remain to be considered, are stricture, fistula in perinaeo, enlarged prostate, retention and incontinence of urine, and stone in the bladder. Section I. Stricture of the Urethra. This is a very common complaint; more common, indeed, than is generally imagined. It may proceed from various Stricture of the Urethra. 201 causes—from gonorrhoea, or the remedies employed in the cure of that disease; from external violence; from irritation within the urethra, produced by the passage of calculi, or the applica- tion of blisters to the perineum or other parts of the body; from excessive indulgence in venery, or unnatural prolongation of the venereal act; from enlargement of the prostate gland; from stone in the bladder, &c. It is somewhat remarkable, however, that the disease seldom makes its appearance until years have elapsed, and the effect of the causes above enumerated has ap- peared to cease. Many surgeons question the propriety of re- ferring the origin of stricture to gonorrhoea, without, I conceive, sufficient foundation ; though it must be acknowledged that the disease is sometimes met with in very young boys, and in adults who have led the most exemplary lives. Strictures have usually been divided into two kinds—the permanent and spasmodic. To these Mr. Hunter added a third variety—which is alleged to consist in a combination of the two. Permanent stricture may be said to consist of a thickening or change of structure in the urethra, induced by preceding inflam- mation. That spasmodic stricture frequently exists, there can- not be the smallest doubt, though it is still a question whether the spasm should be referred to the muscularity of the urethra itself, or to the muscles surrounding that canal; a question, however, in a practical point of view, of comparatively small importance. Yet I must confess my willingness, for various reasons, to subscribe to the latter doctrine. There is seldom much variation in the seat of a stricture; which is usually found behind the bulb of the urethra—about seven inches from the extremity of the glans. At the distance of four or five inches, also, and three inches and a half, mea- suring from the outer orifice of the urethra, strictures may be often discovered. Sometimes the orifice itself is the seat of stricture. Most patients have but one or two strictures, others four or five. Strictures differ from each other in extent and consistence. The most common form of the disease is that which resembles the effect of a thread tied around the canal; it is likewise the most simple variety of stricture. ^Sometimes the canal of the urethra is regularly contracted or thickened, in -one or more places, to the extent of an inch and upwards. The simple 202 Stricture of the Urethra. thread-like stricture, which does not always run in a circular direction, but sometimes splits and branches, may by irritation or bad treatment be converted into a callous induration. When examined by dissection, most permanent strictures will be found to consist of a dense, pure white, fibrous substance, like gristle —the result of previous and repeated depositions of coagulable lymph. The symptoms of stricture of the urethra, are constitutional and local. Among the former may be enumerated, disorder of the digestive functions, general irritability of the system, va- rious mental emotions, severe chills followed by high fever and profuse perspiration. All patients, however, are not subject to the febrile paroxysm. The most common local symptoms are, a slight discharge of matter from the urethra; a frequent desire to evacuate the urine, which issues in drops, or in a forked, twisted, wiry, or thread-like stream; nocturnal emissions; scalding of the urine; uneasiness about the anus and perineum. Persons trou- bled with strictures, are extremely liable to cold, which greatly aggravates the symptoms. Excess in eating or drinking will pro- duce the same result. During copulation, it frequently happens that a stricture, by interrupting the flow of semen, occasions it to be forced backwards into the bladder, from which it is after- wards discharged the first time the patient makes water. Stricture is often confounded with other diseases; especially with gonorrhoea, gleet, stone in the urethra, or bladder, enlarged prostate, spasm of the muscles of the perineum, irritation, or in- flammation, of the lacunae, intermittent fever, &c. Treatment of Stricture of the Urethra. In the treatment of this disease, the first object of the surgeon should be to ascertain the situation and extent of the stricture. Stricture of the Urethra. 203 This may be done by a bougie, catheter, or urethra sound.* A soft wljite bougie of moderate size, well oiled, will exciteTas little irritation as any other instrument, and is well calculated, when softened by the heat of the urethra, to take an exact im- pression, with its point, of the form of the obstruction, and of its precise situation. Over the bougie, however, in many in- stances, the urethra sound possesses a decided advantage, since from its metallic nature, and the small size of its wire rod, it communicates a vibration to the surgeon's finger, and passes easily along the urethra, while the ball at its extremity catches readily upon any irregularity of the canal, and in this way de- tects the slightest obstacle. With this instrument, moreover, the situation of several strictures may at the same time be as- certained—an advantage which the bougie does not combine. Having satisfied himself of the nature of the stricture, its po- sition and extent, the surgeon must next determine upon the means to be employed for its removal. There are three or four methods in common use—dilatation of the stricture by waxen, metallic, or gum elastic bougies,f destruction of it by the lunar or vegetable caustics, and its division by a stilet. Each is adapted to particular cases. When the strictures are numerous and of considerable length, neither the caustic nor stilet can be employed to advantage, and dilatation by the bougie must be mainly depended upon. In using this, the surgeon should make it a rule to proceed as gradually and cautiously as possible, com- mencing with an instrument of moderate size, such as will pass readily through the strictures without giving pain or producing • An instrument invented by Sir Charles Bell, made of silver wire, twelve or fourteen inches long, having at one end a ball, at the other a ring; the former in- tended for the stricture, the latter for the surgeon to hold by while the instru- ment is introduced. j- The finest bougies I have ever seen, were prepared by the late Dr. Balfour of Norfolk, Virginia; a gentleman remarkable for his intellectual endowments, amiable character, and mechanical ingenuity, and whose death will long be de- plored by the inhabitants of the district in which he resided. The wonderful dexterity which he possessed in the manufacture of instruments, of every de- scription, is evinced in the splendid collection of splints and bandages, presented to the museum of our university, in 1830, by his son, Dr. Eleazer Balfour, a most promising young practitioner of Norfolk. Many of the instruments referred to are of exquisite finish and workmanship, such as would puzzle, if not defy, the best regular mechanic in the country to imitate or equal. 204 Stricture of the Urethra. hemorrhage. It should be worn morning and evening, while the patient is in bed, or at regular intervals during the day, taking care not to continue it too long, but, on the contrary, to withdraw it when undue irritation is excited by its presence. Having de- rived full benefit from the use of one instrument, others should be introduced, proportioned in size to the extent of the dilata- tion—being gradually increased. In many instances, the con- stant use of these instruments, for a few weeks, will effect a perfect cure, in other cases, months or years will elapse, before the pa- tient derives the necessary relief. Silver bougies, when well made, are better adapted to the dilatation of a stricture than most others. Many patients, however, experience great benefit from the use of the flexible metallic bougie. For very long and narrow strictures, I have used, with much advantage, for many years past, fine, highly polished, and very flexible whalebone bougies. Caustic has long been employed in the cure of strictures. It was a favourite practice with Mr. Hunter, and has since been highly extolled by his relation Sir Everard Home. I have em- ployed the remedy for many years, sometimes advantageously, at other times, with manifest aggravation of the symptoms. From all I have seen, 1 am disposed to conclude, that it is only adapted to strictures of small extent—such as the thread-like stricture. That much mischief has resulted from its indiscri- minate and injudicious application, I well know; but its strong- est advocates, also, confess, that in their own hands, false pas- sages, hemorrhage, great irritation, severe paroxysms of fever, and other- ill consequences, have often been induced. These remarks will apply to the vegetable as well as lunar caustic, al- though the former has been considered by some writers to be milder in its operation, and to act upon a different principle from the lunar caustic. When a stricture is very small, and situated near the extremity of the urethra next to the glans penis, and there is reason to believe, that one or two applica- tions of the caustic will go through, it may be applied in the following way. The surgeon takes a common soft bougie, oils it, carries it nimbly down to the stricture, keeps it in contact with it a few seconds, and marks with his finger nail the bougie at the external orifice of the urethra before he withdraws it. Another bougie, composed of firmer materials, is next taken, Stricture of the Urethra. 205 a hole, about the eighth of an inch in depth, scooped from its extremity by a sharp penknife, and a portion of lunar caustic inserted into it, and secured by squeezing together the edges of the hole—leaving the central part of the caustic a little ex- posed. A mark corresponding to that on the soft bougie, (which is intended to designate the depth of the stricture from the external orifice,) is then made upon the caustic bougie, and the latter, at once oiled and carried down to the stricture, and kept in contact with it, for one or two minutes, or for a shorter period, should*the patient complain of its severity. In two or three days' time the operation may be repeated, and occasional- ly within the same period until the stricture gives way, or is entirely removed. The stilet, although used by some of the older surgeons in the cure of stricture, was not practised in modern times, until recommended by Dr. Physick. In 1795, he first per- formed the operation, and has ever since continued to employ the same means, and oftentimes with the greatest success. I myself have likewise succeeded* in many instances, in effecting a perfect cure, after bougies, the caustic and other means, have entirely failed. Before the clinical class in the Aims-House Infirmary, some years ago, I perforated, with the stilet, a stric- ture of long standing, near the bulb, which had resisted for se- ven years the efforts of different surgeons, to introduce an in- strument of any description into the bladder. In three minutes after the division of the stricture, a catheter entered, and the patient experienced the greatest possible relief. What renders this plan of treating strictures the more valuable, is the circum- stance of the operation being attended with very little pain, and with no risk, provided the operator possess an accurate know- ledge of the structure of the parts. In ignorant hands, false passages, ulcerations, and effusion of urine may follow. The in- strument used by Dn Physick, is a sort of lancet concealed in a cannula, that may be pushed forward or retracted at pleasure. When it becomes necessary to pierce a stricture situated near the bulb of the urethra, a curved instrument should be used.* Upon several occasions, I have used with success, in strictures seated near the anterior part of the urethra, a common couch- ♦ Drawings of these instruments may be seen in Dorsey's Surgery, vol. 2. Vol. II. 27 206 Stricture of the Urethra. ing needle, rendered blunt at the point, and sharpened at its edges. After the division of the stricture, a bougie or catheter must be worn for some time, to prevent the passage from closing again; From the use of bougies or the caustic, it very often happens that an unnatural route or false passage is created. This is owing, generally, to unskilfulness on the part of the surgeon, or patient himself, or to the use of instruments so small as to enter the lacunae of the urethra, instead of following the natural course of the passage. When once established, a false passage is ex- tremely difficult to remove, and, on this account, great pains should be taken to guard against its formation. To the patient the disease is inconvenient, chiefly by preventing the easy in- troduction of the bougie or catheter, and sometimes, on this ac- count, dangerous, in cases of retention of urine. The best plan, in general, of destroying the unnatural route, is to use a bougie larger than the one by which the disease was created, and to bend its point towards that part of the urethra opposite to the false passage. A large catheter, very much curved, will also pass, in many instances, where no other instrument can be made to follow the natural course of the urethra. Mr. Hunter was in the habit, sometimes, of performing an operation for the re- moval of this disease; fortunately, however, such an expe- dient can rarely, if ever, prove necessary. But in three or four instances, I have succeeded in establishing the natural course of the urethra, where the false passage depended upon the resistance of a stricture, by piercing the stricture with the stilet, and afterwards passing a catheter through it, and suffer- ing it to remain in the bladder for several days. Formerly, a few English surgeons of eminence were in the habit of forcing strictures, by driving bougies and catheters through them, and making an entrance by violence into the bladder. A similar practice for several years past has prevailed in France, where an instrument called sonde conique, is much in vogue. I will not condemn the proceeding, because I do not know it, from experience, to be hurtful; but I confess 1 have a feeling amounting to prejudice against it. Of Arnott's method of curing strictures, by the peculiar instruments named dilators, I have nothing to say—having never tried the plan. Fistula in Perineo. 207 Section II. Fistula in Perinaeo. From strictures of the urethra, from blows and other injuries, fistula in perinaeo is frequently produced. In proportion as a stricture increases, the urethra, at the diseased part, is dimi- nished; while that portion of (he canal immediately behind the obstruction, by the efforts of the bladder and the continual pro- pulsion of the urine against it, is enlarged. The irritation thus kept up gives rise to inflammation and ulceration, and an open- ing is at last made through the urethra, and communicates with the cellular membrane surrounding it. Into this opening the urine finds its way and lodges, and by its acrimony increases the irritation until an abscess is formed; which gradually en- larges, and finally discharges itself externally. The urine then passes out mixed with matter, both from the opening in the perineum and from the external orifice of the urethra. In the course of time, however, it frequently happens that the stric- tured part of the canal, no longer feeling a forcible impulse from the stream of urine, gradually closes, and is finally ob- literated ; after which the whole of the urine is evacuated through the fistula. Sometimes, instead of the ulcerative process first commencing on the internal surface of the urethra, an abscess is formed from irritation in the cellular membrane exterior to the canal, into which the ulceration at last extends, and throws the two cavities !into one. Fistula in perinaeo sometimes pro- ceeds from a rupture of the urethra, (produced by external vio- lence, or by the force of the urine upon the inflamed and tender part of the canal behind the stricture,) and the urine is instant- ly sent abroad into the loose cellular membrane of the perineum and scrotum, where it forms an enormous distention or tumour, and excites most violent inflammation, that terminates in a few 208 Fistula in Perineo. hours in gangrene, and sloughing of the scrotum—leaving, in many instances, the testicles and urethra bare, and endangering the patient's life. There is seldom more than one fistulous open- ing communicating immediately with the urethra, but from it numerous sinuses generally extend in various directions; and in cases of long standing, it is not unusual to find the cellular mem- brane of the scrotum, and of all the other parts through which the urine meanders, greatly condensed and converted into indu- rated tumours, upon the surface o,f which may be found innu- merable small holes, that discharge offensive urine and matter- rendering the patient disagreeable to himself and disgusting to his neighbours. Treatment of Fistula in Perinaeo. It will appear obvious, from what has been stated, that when fistula in perinaeo depends upon stricture, the first indication in the treatment of the disease should be to get rid of the obstruc- tion, and enable the stream of urine to regain its natural route. This, if the canal anterior to the fistula is obliterated, can be ac- complished only by an operation, and the one which I have usually performed, and frequently with success, is as follows. The urine being retained in as large quantity as possible, the patient is placed upon his back on a table covered with a mat- tress or blankets, the thighs bent upon the pelvis, and the legs upon the thighs, separated and supported by an assistant on each side. A female catheter or sound is then carried down to the stricture, and there held firmly by another assistant, while the surgeon introduces a probe into the largest fistulous orifice he can find, and the one nearest to the stricture, and endeavours to feel with it the extremity of the sound, through the walls of the urethra. An incision, proportioned in length to the extent of the disease, is next made in the perineum, along the course of the probe, until the urethra or its remains are laid bare, when Fistula in Perinaeo. 209 the operator will be enabled to cut upon the extremity of the sound, and divide the stricture. The sound may be, afterwards, withdrawn, and a gum elastic catheter introduced at the glans penis, and carried along the urethra into the bladder, where it should be suffered to remain for several days. As soon as the natural route for the urine is thus re-established, the fistulae di- minish, the indurated cellular membrane contracts, the wound begins to fill up, and is finally closed, and, through the medium of granulations, which form around the catheter, a new urethra is created; after which the sinuses all heal, and the patient re- covers. In many instances, the operation is extremely difficult, and very painful, especially in irritable patients, and those who have suffered a long time from the complaint. Cases, indeed, are reported of patients having died under the operator's hands. When.a fistula in perinaeo is complicated with pervious stric- ture, an attempt should be made by bougies, caustic, and other means, to destroy the stricture, or enlarge it, and afterwards to heal the fistulous opening by escharotics; the best of which, for this purpose, is the argentum nitratum. Sometimes a fistula in perinaeo will contract to the size of a hair, and in that state re- main for years, now and then shedding a few drops of urine. For this state of the disease, I have found a blister the best re- medy. Effusions of urine into the cellular texture of the scrotum, from rupture of the urethra, require very decisive measures. Aware of the nature of the disease, the surgeon should lose no time in making very free punctures and incisions into the skin and cellular membrane, from which he will soon find the urine to issue in considerable quantity. When performed in time, the operation may save the parts from sloughing. This, how- ever, is seldom the case. But it is astonishing how much na- ture does for the patient under these circumstances: for even after the testicles have been entirely divested of integument, a new scrotum is almost always formed out of the adjoining parts. The fistula, in general, heals spontaneously. 210 Enlarged Prostate. Section III. Enlarged Prostate. Although the prostate gland is subject to inflammation, ab- scess, scrofulous enlargement, and collections of urinary calculi within its substance, these affections are rare, compared with that commonly known under the name of scirrhus. To this disease old people are almost exclusively liable, and so frequent is it among them, that, according to Sir Everard Home, few subjects beyond the age of eighty are exempt from it. The middle lobe, as well as the two lateral, is often the seat of the disease; but the symptoms differ, in some respects, according as the former or latter happen to be affected. In proportion as the middle lobe enlarges, it pushes before it the internal membrane of the bladder, and by projecting into the cavity of that viscus, immediately behind the inner orifice of the urethra, obstructs the flow of urine ; which, when the tumour, as it often does, at- tains considerable bulk, may be entirely suppressed. The en- larged lobe also, in many instances, becomes ulcerated, and gives rise to severe pain after passing urine, and to spasm about the neck of the bladder. When an enlargement of one, or both, of the lateral lobes of the prostate is conjoined with that of the middle lobe, the symp- toms are still more urgent. A discharge of a viscid, ropy mucus, is another attendant upon enlarged prostate, and a very com- mon symptom of disease of the lateral lobes. The left lateral lobe is more frequently enlarged than the right. When the la- teral lobes attain a considerable size, they project towards the rectum so as to diminish the capacity of that bowel, and may be distinctly felt by the finger per anum. Enlarged Prostate. 211 The causes of enlarged prostate are exceedingly obscure. By many the disease is attributed to syphilis, repeated attacks of gonorrhoea in early life, strictures of the urethra, inordinate indulgence with women, high living, and intemperance, &c. But these inferences are rather gratuitous than founded upon any certain data. Treatment of Enlarged Prostate. The remedies for this disease are palliative only. Opium, internally administered, and in the form of an enema, will prove highly serviceable in subduding spasm about the neck of the blad- der, and thus enabling the patient to pass urine. Frequently, however, every effort of the kind will be unavailing, and the catheter must be employed. One of elastic gum, without the stilet, very flexible at the point, and of large size, will be found to give less pain, and enter with greater facility than a metallic instrument. It should be kept in the bladder for several days in succession, and after the urgent symptoms have somewhat sub- sided, introduced occasionally. In addition to this treatment, the use of mild purgatives, and attention to diet, will be re- quired. 212 Retention and Incontinence of Urine. Section IV. Retention and Incontinence of Urine. From severe gonorrhoea, strictures in the urethra, enlarge- ment of the prostate gland, spasm at the neck of the bladder, stone in the bladder, hemorrhoids, fistula in ano, rupture of the urethra, blows upon the perineum, stimulating diuretics, the application of blisters, injuries of the spine, paralysis of the bladder, stones in the urethra, and some other causes, a reten- tion of urine frequently arises. The disease, when it occurs amongst old people from paraly- sis, is not often followed by serious consequences, unless it should be mistaken for an incontinence of urine; a mistake which is apt, among the inexperienced, to arise from the circumstance of the urine constantly passing off by drops or in a small stream—one of the most decided symptoms of retention. Persons advanced in age are extremely apt to neglect the calls of nature, and suffer the urine to collect in the bladder in large quantity, or when they do make water are not particular enough in discharging the whole of it. From these and other causes, the bladder at last loses its power of expulsion, and the urine accumulates. As a part of it, however, is in general continually passing off by the urethra, that in the bladder seldom exceeds a certain quantity, and in this way the disease may be kept up for weeks together. The retention which takes place in young people, from go- norrhoea, strictures, or any inflammation or excitement about the urethra, neck of the bladder, or neighbouring parts, is very different in its character, and often in its result, from that just spoken of. The urine seldom escapes, even in the smallest quantity, by the urethra, and must of course accumulate, (unless Retention and Incontinence if Urine. J13 the patient be relieved,) until some part of the bladder gives way—either by ulceration or sloughing. It is astonishing, how- ever, to what an extent the bladder will yield in some cases be- fore its parietes are destroyed. Some years ago I was called to a child about two years of age, supposed to labour under ascites, and so strongly did the enlargement and feel of the belly resemble that disease, that I at first took it to be a case of the kind. But, upon inquiring into the history of the com- plaint I ascertained that its duration had not exceeded seven days, and that during this period the patient had passed no urine. This induced me to examine the urethra, in the mouth of which I discovered a calculus that blocked up the passage completely. Upon enlarging the orifice with a lancet, the stone was instant- ly pushed out, and followed, to the surprise of a medical attend- ant and myself, and to the great relief of the patient, in a little time by two quarts of urine.* Many instances are related by writers, of the bladder becoming so distended by urine, as to rise above the umbilicus; and Sir Everard Home relates an in- stance in which the celebrated Mr. Hunter actually tapped the bladder, mistaking the swelling for a dropsy of the belly. But such cases are anomalous; and in most instances, long before the bladder is distended to a great size, it ulcerates, or sloughs at the fundus or neck, and the urine is sent abroad into the pe- ritoneum, or discharged through the rectum, or into the cellu- lar membrane of the scrotum or perineum. In either event, the patient generally dies. During the progress of the disten- tion the patient suffers exceedingly, grinds his teeth in ago- ny, tosses about the bed, or walks his room with his body al- most bent to the floor, is seized with chills, cold sweats and fainting, which are followed by fever, great restlessness, ex- treme thirst, intolerable anguish, swelling of the abdomen, hic- cup, delirium, and death. He seldom survives beyond the sixth or seventh day. Incontinence of urine is the reverse of retention. There are two or three varieties of the disease. Sometimes the urine passes off by the urethra as soon as it is secreted ; at other times the patient can retain it for a certain period, and is then obliged suddenly to evacuate. In a third variety of the complaint, the * A case; nearly similar is reported by Dr. I'arrish. Vol. II. 2S 214 Retention and Incontinence of Urine. discharge generally takes place during sleep. This is commonly confined to young children, while the other varieties are chief- ly met with in adults, and are dependent, for the most part, upon general or local paralysis, general debility, injuries, malfor- mation of the urinary organs, hemorrhoids, stone in the blad- der, &c. Treatment of Retention and Incontinence of Urine. When retention of urine arises from stricture of the urethra, or from any inflammatory affection of the canal, or parts adja- cent, blood-letting, the warm bath, purgatives, and opiate en- emata, should have a full trial. If these fail, a gum elastic bou- gie may be carried down to the obstruction, and kept in contact with it a few seconds, after which, in many instances, the urine will flow. Should this, however, not produce the desired ef- fect, the surgeon will then endeavour to introduce a catheter into the bladder. Than this, there is not, in all surgery, a more im- portant, and, under certain circumstances, more difficult opera- tion—an operation requiring the utmost gentleness, patience, per- severance, and skill. Rudeness and force, indeed, independently of the unnecessary pain and punishment they inflict, seldom con- tribute towards the end in view. It is true that some eminent surgeons, in difficult cases, advise the forcible entry of the ca- theter; but it should be remembered that a great majority of others, not inferior to them in authority, condemn the practice in the most pointed terms. In general, the most favourable position for the easy introduc- tion of the catheter, is the recumbent. But a good rule to ob- serve on such occasions, is, if the surgeon does not succeed, readily, while the patient is in one position, to change it for another. The curvature of the instrument is also a matter of importance; on this account, the operator should be provided with a number, varying in shape and size. Gum elastic cathe- ters, with or without the stilet, are better suited to most cases than metallic instruments. Sometimes, however, I have sue- Retention and Incontinence of Lrine. 215 ceeded, easily, with a silver catheter, when a gum elastic would not enter. In using the latter, there is an advantage now and then obtained, especially when the middle lobe of the prostate is enlarged—in withdrawing the stilet an inch or two, so as to leave the extremity of the instrument more flexible than it other- wise would be. With the same view, Dr. Physick* has long been in the habit of using a gum elastic catheter, with a flexible wax bougie fixed upon its extremity. Stilets made of brass, in- stead of iron wire, are in many respects the most useful. Having oiled the catheter, the surgeon takes hold of the glans penis, on its sides, immediately behind the corona, enters the instrument, with its concavity towards the abdomen, at the urethra, carries it along steadily, and with one continued sweep, (the penis being drawn upwards at the same time upon the instrument, and laid nearly parallel with the abdomen,) un- til it reaches the bulb or triangular ligament of the urethra. Here the passage takes a sudden turn upwards, and it will be necessary to accommodate the point of the catheter to the curve. With this intention, the handle of the instrument is suddenly, but cautiously and without force, depressed. This manoeuvre elevates the point, and causes it to start over the edge of the triangular ligament, and enter the bladder. Should much dif- ficulty be experienced, however, in this stage of the operation, it may be often overcome by placing a finger in the rectum, and, with it, lifting the end of the catheter. Whenever an obstruc- tion is met with in the urethra, which the catheter does not readily pass, instead of attempting to overcome it by force, it will be proper always to withdraw the instrument a little, elevate its point, and then push it on again. In retention of urine from paralysis, the introduction of the catheter is seldom attended with difficulty, and on this account the operation may be repeated two or three times a day, or as of- ten as may become necessary. But when the surgeon finds it in- convenient to attend for that purpose, a flexible catheter may be left in the bladder, for two or three days at a time, and the urine permitted to flow off, at stated periods, in place of dribbling away constantly. After the bladder has recovered its tone, the • For a description" and drawings of this instrument, see Dorsey's Surgery, vol. 2. -10 Retention and lucontine?ice of trine. catheter should he discontinued. Having experienced consi- derable difficulty in introducing the catheter, in some obstinate cases of retention of urine, it occurred to me, in 1811, that the resistance might, perhaps, be overcome by introducing the pipe of a syringe into the orifice of the urethra, and throwing in, gently, a stream of tepid water. Having accordingly tried the plan, successfully, in a few cases, I was induced to recommend the practice for several years, in my lectures. Subsequent ex- perience, however, taught me that very little reliance could be placed upon the method, and I have since abandoned it alto- gether. Jlmusat, of France, has, within the last few years re- sorted to a similar expedient, and, according to his own account, with great success. If, in spite of the efforts of the surgeon to relieve the patient, by the remedies pointed out, and it is found impossible to in- troduce the catheter, it will become necessary to puncture the bladder. The operation may be performed above the pubes, or through the rectum. But it will be proper to premise that neither one nor the other is indispensably necessary once in a hundred times. The operation above the pubes is performed in the following way. The patient being laid upon a table, an incision, about an inch and a half long, is made in the linea alba, immediately above the pubes, through the integuments and fat, and between the pyramidales muscles, until the distended bladder is distinct- ly felt, when a curved trocar, six inches in length, covered by its cannula, is made to pierce the bladder as near the pubes as possible. A vessel being held between the patient's thighs to receive the urine, the stilet is withdrawn and the fluid evacuated. To prevent the cannula from slipping out, tapes are fastened to its wings, and secured to a bandage passed around the body. Its extremity is also plugged up, to prevent the perpetual flow of the urine. The greatest objection to this operation, is the liability of the urine to escape, (after the bladder becomes flac- cid,) into the cavity of the abdomen. Besides this, the constant presence of the silver cannula is apt to excite irritation, espe- cially when it is so long as to rest upon the back part of the bladder. The puncture of the bladder, through the rectum, I should prefer, in every instance, provided the prostate was not so much Relmlion and Incontinence of Urine. 217 enlarged as to require the instrument to be introduced high up the intestine. To perform this operation, (which is still more simple than that above the pubes,) to advantage, the patient should be placed in the position for lithotomy, and the fore-fin- ger of the left hand carried up the rectum, as a guide to the trocar, which is held in the right hand, introduced into the rec- tum, and made to perforate the anterior part of that intestine, at its centre, immediately above the prostate. The stilet being withdrawn, and the urine evacuated, the cannula is plugged, and secured in its situation by tapes. The patient's bowels should afterwards be kept in a soluble state, to prevent the can- nula from being disturbed during an evacuation of the faeces. After the natural route through the urethra is restored, the can- nula may be withdrawn, and the opening in the rectum allowed to heal. Whether the operation of puncturing the bladder be performed above the pubes, or through the rectum, it is very important that it should not be delayed beyond the third or fourth day; for it has been found by experience, that after this period the case has usually terminated fatally. For incontinence of urine, when it occurs in adults, and de- pends upon general or local debility, the internal use of can- tharides, muriated tincture of iron, bark, and opium, conjoined with the cold bath, and blisters to the sacrum, will sometimes effect a cure. That variety of incontinence peculiar to children, gradually subsides, spontaneously, as they advance in age. Pa- rents and children themselves, to guard against this infirmity, have sometimes, most improperly, applied ligatures to the penis over night. From this practice, there are numerous instances on record, of ulceration of the urethra, or of sloughing of the penis, at the part embraced by the ligature. Upon the whole, as regards the diseases of the urethra—par- ticularly stricture—I may state, that more skill, judgment, and experience are required than for almost any other affection in surgery; that, unfortunately, these diseases are, too often, placed in the hands of young, and inexperienced, practitioners, who are more prone to regard cutting, or piercing, instruments as the f only alternative, and bold and decisive measures, as stronger proofs of talent and knowledge, than the slow and cautious pro- ceedings of those, who, taught by the result of unfortunate case , are constantly in dread, and with good reason, of similar 218 Retention and Incontinence of Urine. terminations. I have heard the late Dr. Physick aver that he never approached a diseased urethra, especially in old and irri- table subjects, without trembling and anxiety, and that there were very few whom he would trust with the management of such complaints. My own experience confirms, to the fullest ex- tent, his assertion. On Diseases of the Urethra and Prostate Gland, consult Hunter on the Venere- al—Home on the Treatment of Strictures of the Urethra and Oesophagus, 3 vol. edit. 4— Whateley's Improved Method of Treating Strictures of the Urethra, edit. 2—Letters concerning the Diseases of the Urethra, by Charles Bell—Principles of Surgery, by John Bell, vol. 2, p. 209—Hoiuship's Practical Observations on Dis- eases of the Urinary Organs, 1816—Wilson's Lectures on the Structure and Phy- siology of the Male Urinary and Genital Organs, and their Diseases, 1821—De- sault's Works, by Smith—C. Bell's Surgical Observations, p. 86—C. Bell on the Diseases of the Urethra, &c. by J. Shaw—Bingham on Strictures of the Urethra, 1821—Home on the Treatment of Diseases of the Prostate Gland—Hey's Practi- cal Observations in Surgery, article Retention of Urine, p. 388, edit. 3—Dorsey's Surgery, vol. 2—C. Bell's Operative Surgery, vol. 1—Colles' Surgical Anatomy, p. 159, article Passing the Catheter—Abernethy on the Operation of Puncturing the Bladder, in Surgical Works, vol. 2, p. 189—Cooper's First Lines, vol. 2, p. 215—Practical Observations on Strangulated Hernia, and some of the Diseases of the Urinary Organs, by Joseph Parrish, M. D., Philadelphia, 1836. Urinary Calculus. 219 Section V Urinary Calculus. Most calculous concretions are formed originally in the kid- ney, and thence find their way, along the ureters, to the blad- der, and when too large to pass off with the urine, remain in that viscus and serve as nuclei for other sabulous depositions. But any extraneous body, accidentally lodged in the bladder, may lay the foundation of a stone. A drop of blood, a portion of inspissated mucus, a pin, a piece of bougie or catheter, a mus- ket ball, has often produced the disease. Many years ago, I operated on a boy four years old, and took from his bladder a stone, as large as a pullet's egg, in the centre of which was found the greater part of a needle. Urinary calculi vary exceedingly in form, size, colour, con- sistence, and chemical composition. Some are very rough on the surface, others perfectly smooth; in shape most of them are oval, a few quite round, whilst others are oblong or angular. The difference in magnitude is not less remarkable—being met with from the size of a pea to that of a cocoa-nut. Calculi dif- fer from each other in colour as much as in size and form; the most common variety is generally of a yellowish brown tint; some are nearly as white as chalk, and others, again, red or of a deep chocolate brown. In consistence, also, there is the ut- most variation ; for, at the slightest touch some crumble into dust, whilst others almost resist the stroke of a hammer. Schcele and Wollaston were among the first to investigate the chemical composition of urinary calculi, and their discoveries have led others to pursue the same path. According to the latest and best writers, these substances are found to consist of the following materials: 1st, of the lithic acid, 2d, of the lithate of 220 Urinary Calculus. ammonia; 3d, of the phosphate of magnesia and ammonia; 4th, of the phosphate of lime; 5th, of the oxalate of lime ; 6th, of the triple phosphate of magnesia, ammonia and phosphate of lime; 7th, of the carbonate of lime. ' Of these the lithic acid calculi are by far the most numerous. A very uncommon variety of calculus has been met with, in this country, consisting of sabu- lous matter and hair, and resembling, closely, common plas- tering mortar. Only two instances of the kind have come to my knowledge. The first occurred about five years ago, in the prac- tice of Dr. Physick, and the second, within the same period, in that of my friend, Dr. Lemoyne, an eminent physician, of Wash- ington county, Pennsylvania. In both patients, the formation of this material was progressive, or kept up for months together. Urinary calculi may be contained in the kidney, ureter, blad- der, prostate gland, or urethra; but the bladder is their most common receptacle. Generally they lie loose within the cavity of that viscus, and at its most depending part. Sometimes they are contained in cysts, formed between the coats of the bladder at the termination of the ureters, or between the folds of a con- tracted bladder; at other times they are fixed upon a fungous excrescence, the granulations from which shoot into the inter- stices of a rough stone, and hold it fast. The bladder may con- tain a single stone or a great number. Fifty-five were found in the bladder of the celebrated Buffon after death. Two hun- dred were taken by Desault, from the bladder of a priest. Sir Astley Cooper states that the greatest number he ever extracted, was one hundred and forty-two. Boerhaave and Beauchene, each record an instance of three hundred and upwards taken from different patients. Murat met with six hundred and se- venty-eight. But the largest number ever removed, probably, from the human bladder, was taken by Dr. Physick, seven years since, from Chief Justice Marshall. More than one thousand, varying from the size of a partridge shot to that of a bean, were counted, and many others were lost. They were all of an oval shape, and upon the end of each I examined, as it came out from the wound, there was a black spot of the size of a pin's head. Notwithstanding the frequent introduction of the forceps and scoop, the patient recovered, perfectly, in a shoit lime. When numerous, they are generally smooth upon their Urinary Calculus. 221 surface, and sometimes, in particular places, highly polished from continued friction upon each other. The symptoms of stone must depend, in a great measure, upon the particular situation it happens to occupy. When de- tained in the pelvis or infundibulum of the kidney, the concre- tion sometimes attains a large size, without subjecting the pa- tient to much pain or inconvenience; on the other hand, its pre- sence is occasionally productive of so much irritation as to excite suppuration of that gland. During the passage of a calculus along the ureter, the patient suffers, in most instances, excruciating pain, has frequent desire to make water, and can pass only a few drops at a time, and those very high-coloured and sometimes mixed with blood. So severe is the pain, in some cases, that the patient finds it impossible to leave his bed, and is obliged, in order to obtain temporary relief, to bend himself almost dou- ble. Fever, eructation, nausea, vomiting, and spasmodic retraction of the testicle, are common accompaniments of the disease. As soon as the stone drops into the bladder, the symptoms subside. Sometimes, however, the patient becomes easy for a few hours, even before the stone leaves the ureter, and then has a relapse. This may occur repeatedly. An encysted stone, so long as it continues encysted, seldom gives rise to any severe symptoms; but a stone that lies loose in the bladder, and is liable to move about, must always excite more or less uneasiness, whether it be rough or smooth, large or small. One of the first symptoms of stone in the bladder, is a frequent desire to pass urine, and severe pain upon voiding the last drops of it. About the same period, also, the patient com- plains of an itching at the glans penis, to relieve which he soon gets into the habit of pulling or elongating the prepuce. An- other symptom, is the sudden stoppage of the urine while pass- ing in a full stream. This arises from the stone being carried, by the contraction of the bladder, or by the stream of urine, to the neck of the bladder, where it blocks up the inner orifice of the urethra; in proof of which, if the patient lie down or change his position, the water flows again. After these symptoms have continued for some time, the patient becomes troubled with tenesmus and prolapsus ani, induced by the constant straining and efforts to empty the bladder. When the stone is rough on its surface, there is often a good deal of fetid mucus discharged Vol. II. 29 222 Urinary Calculus. along with the urine, which is now and then mixed with blood. Sometimes the patient is very sensible, when he turns upon his side, or suddenly changes his position, of something rolling in his bladder. The same sensation is experienced whilst on horseback, or in a carriage. Under the sufferings occasioned by the symptoms enumerated, the patient may live for a great number of years. Gradually, however, his health declines, the bladder contracts to a very small size, becomes thickened and diseased, and at last death takes place from long-continued ir- ritation and derangement of most of the bodily functions. When the prostate gland contains a number of stones, it may be possible to feel them through the coats of the rectum, by passing the finger within the gut. Dr. Marcet mentions a case in which Sir Astley Cooper was able, by this expedient, to de- tect a number of calculi moving in a cyst within the prostate, and to hear a distinct clashing as their surfaces were pressed to- gether.* Calculi, when detained in the urethra, generally stop behind the bulb, or at the external orifice of the passage. From being pressed upon by the stream of urine, they are sometimes imbedded in the substance of the penis, and afterwards do not ob- struct the urethra. At other times they find their way out, by ex- citing ulceration of the urethra, and produce a spontaneous cure. Cases of the kind have been reported by Crosse and others. I have known them, in a similar way, to be discharged from the bladder; and one instance of the sort was mentioned to me late- ly by Dr. Jackson, formerly of Northumberland, but now an eminent physician of Philadelphia. The causes of the formation of urinary calculi, although fre- quent attempts have been made to investigate them, have never been unravelled. We know, indeed, little beyond this,—that the disease prevails in certain countries and districts, more than in others, and that in some climates, especially very warm ones, it is seldom met with. Throughout the United States, which embrace a very extensive tract of country, fugitive cases may be every where seen; but, upon the whole, the complaint must be considered by no means common, if we except some portions of the western country, especially Kentucky, Alabama and Tennessee, where it is exceedingly frequent, and usually attri- buted, though, perhaps, erroneously, to the use of lime-stone water. * Marcet on Calculous Disorders, p, 19. Urinary Calculus. 223 Treatment of Urinary Calculus. When a patient is suffering from a fit of the gravel, as it is usually called, or in other words, from the passage of a calculus along the ureter, the most decisive treatment must be at once adopted. If robust and vigorous, several ounces of blood may be taken from the arm, and a brisk purge administered immedi- ately afterwards. These should be followed by immersion of the whole body in a warm bath. If, by these means, the pain is not diminished, ten or fifteen drops of spirit of turpentine may be given, three or four times a day. This remedy has been used by Dr. Physick, for many years, with the greatest success. A combination of turpentine and opium, according to Dr. Marcet, was formerly employed, as a quack medicine, in England, with great benefit in this complaint. By my friend Dr. Samuel Bet- ton, a distinguished practitioner of Germantown, I am informed, that he has frequently employed, with most decided benefit, pills of the inspissated Venice turpentine, to the extent of half a dram in twenty-four hours, and that some of his patients have taken the medicine for weeks before an expected attack, and have thus guarded against it. By the advice of Dr. Physick, I prescribed, some years ago, the tincture of phytolaca (poke- berry) in an obstinate case of lithiasis, and with the most decided relief to the patient. It should be administered in doses of a dessert spoonful two or three times a day. Sometimes I have known the patient much relieved by suddenly throwing up the rectum a stimulating enema. Opiate injections, also, in some cases, prove highly beneficial* as well as opium internally. The existence of a stone in the bladder, can only be deter- mined, positively, by sounding. This preliminary operation should, therefore, always be performed before the surgeon en- ters upon the treatment of the disease. By sounding is meant the introduction of a steel instrument, resembling a catheter, (but solid instead of hollow,) into the bladder. The rules for- merly pointed out for the management of that instrument, in cases of retention of urine, should also be observed in the intro- duction of the sound. Very often the stone cannot be felt, in consequence of its lodging in a depending part of the bladder, below the reach of the instrument. In such cases the finder is 224 Lithotomy. put into the rectum and the lower part of the bladder pressed upwards, and the stone being carried by this manoeuvre along with it, rubs against the instrument. Or, the urine may be permitted to accumulate in large quantity, and the walls of the bladder being then distended, the stone will be raised from its lurking place and touched by the sound. But this expedient sometimes fails: in that event, the practice first pointed out by Dr. Physick should be pursued—by placing the patient " near- ly on his head," so as to render the fundus of the bladder the lowest part, and thus bring the stone in contact with the point of the sound. The surgeon should take care not to mistake a stone in the urethra, or prostate gland, for one in the bladder. He must particularly remember, moreover, never to sound a pa- tient during a fit of the stone, or immediately after his arrival from a journey. Patients have been often injured, likewise, by unnecessary and harsh attempts at sounding. Having ascertained that the bladder contains a stone, its removal should next be deter- mined upon. But, before this is resorted to, the surgeon must en- deavour to mitigate the symptoms as much as possible, or, in other words, to prepare the patient for the operation. Formerly, many attempts were made to destroy a stone, either by the use of inter- nal medicines, or by the injection of fluids into the bladder. The practice, however, has long been abandoned—having been found ineffectual. But in another point of view it has proved highly use- ful—by relieving the symptoms, and thereby rendering the pa- tient's chance of recovery after an operation more certain. The best medicines, for this purpose, in most cases, are the al- kalies, especially in the form of soda water, or the carbonate of soda. Magnesia, also, has often proved very serviceable. To- gether with this treatment, the patient should be obliged, for two or three weeks before the operation, to live on a low diet, and take occasional purgatives. The operation should not, if it can be avoided, be performed during very warm, or very cold weather. A few hours previous to the operation, the rectum should be emptied by an enema, the perineum shaved and a tape tied round the patient's penis to prevent him from making water. The latter is so important, that to ensure its observance, a careful attendant should watch the patient from the time the penis is tied, until the operation. Various modes of performing lithotomy have been practised from time immemorial; but it is merely my intention in this place to describe the lateral opera- Lithotomy. 225 tion as it is performed at the present day by the most eminent surgeons—with the gorget. The instruments are two or three scalpels, a curved probe- pointed bistoury, a straight sharp-pointed bistoury, a staff with a large deep groove, Physick's gorget,* several forceps, smaller than they are usually made, a scoop, tenacula, ligatures, sponges, a curved needle and forceps for the pudic artery, a large pewter injecting syringe with a pipe six inches long, tepid barley water carefully strained, strong bands of woollen or muslin, two inches broad and three or four yards long, and a bowl of warm oil. A narrow dining-table is selected and the leaves turned down. Over the table is placed a thick blanket, several times folded. On this the patient, dressed merely in a shirt and loose night gown, is laid—with a pillow under his head, his pelvis resting on the lower edge of the table, and his legs and thighs sup- ported by an assistant, on each side. The surgeon unties the penis, dips his staff in warm oil, introduces it into the bladder, and having satisfied himself, and the other medical attendants, of the presence of a stone, gives the staff to a third assistant, with an injunction not to let its point slip from the bladder. He then passes each wrist through loops formed at the extre- mities of the bands or fillets, directs the patient to grasp the soles of his feet, and fastens them and the hands together by numerous turns of the bandage. The assistant, holding the staff steadily with one hand, and standing on the side of the patient, is then directed to raise and support the scrotum and testicles with the other hand—taking especial care that the end of the staff is fairly within the bladder. The assistants, appointed to secure the patient's limbs, must each place a knee in their arm- pit, grasp a foot with their hands, and sustain the thighs nearly in a perpendicular position, separating them, at the same time, moderately. The surgeon then seats himself before the patient on a low stool, (having previously arranged his instruments in the order he will require them, on a small table placed within his reach,) takes a scalpel of moderate size, makes an incision in the left side of the perineum, commencing a little below the arch * This instrument differs from the common gorget in having a moveable blade, or one that can be separated from the back, for the purpose of sharpening it to greater advantage. For a particular description of it, see Dorsey's Surgery, vol. 2d. 226 Lithotomy. of the pubes, extending downwards, with a slight obliquity, be- tween the rectum and tuberosity of the ischium, and terminating opposite the lower margin of the anus. This first cut is made, not with the point of the knife, but with its convex edge, through the integuments, fat, and perinaeal fascia. By repeated strokes of the knife, the transversales muscles are next unbridled, and the membranous part of the urethra and prostate gland laid bare. At this stage of the dissection, the operator will some- times find it necessary to stop and take up the transversalis pe- rinaei artery.* The membranous part of the urethra and staff being distinctly felt by the fore-finger of the left hand, the sur- geon next takes the sharp-pointed bistoury, carries it to the bot- tom of the wound, with its back towards the rectum, and opens the membranous part of the urethra, to the extent of half an inch or more, by cutting from behind forwards, or from the prostate towards the bulb. As soon as the urethra is opened, a stream of urine, (provided the patient has retained it,) issues through the wound. Without loss of time the surgeon next lifts the gorget, fixes its beak in the groove of the staff, takes the handle of the staff from the assistant, depresses it, balances for a moment the two instruments on each other, runs the beak of the gorget backwards and forwards, two or three times, to be certain that it is fairly in the gutter of the staff, then with a slow but steady and decided movement carries the instrument on- wards to the bladder through the prostate gland. A sudden gush of urine announces the completion of this stage of the operation. The gorget being withdrawn, the left fore-finger of the operator is immediately introduced, the stone felt, and the staff taken away. Still keeping the finger in the bladder, the surgeon then takes a small pair of forceps, and with the blades shut, carries the instrument through the opening in the prostate, alongside the finger, touches the stone, removes the finger, expands the blades of the forceps, seizes the stone, (gently, lest it break,) parallel, if possible, with its longest diameter, and gradually extracts it. As soon as it is removed, an accurate examination should be instituted, in order to dis- cover whether there be any other stones left behind. If so, the forceps must be again and again introduced, until the whole are extracted. To clear the bladder of any fragments, sand, or * Usually this vessel does not require the ligature. Lithotomy. 227 clotted blood, that may happen to remain, the pipe of the syringe should be introduced, and a quantity of tepid barley water thrown in, repeatedly, until the bladder is completely rinsed out. Any vessel of importance, that may happen to have been cut will probably continue to bleed after the stone has been ex- tracted and should be secured by ligature without delay. If the pudic artery is divided by the knife or gorget, it will pour out blood copiously, and from this cause many patients have lost their lives. The forceps and needle* used by Dr. Physick, for deep-seated arteries, will be found the best instrument for taking it up.f As soon as the hemorrhage has stopped, a gum elastic catheter, of large size, should be carried through the wound into the bladder, the bandage removed from the hands and feet, and the patient laid in bed on his left side—the thighs being lightly bound to each other, by two or three turns of the roller. The gum elastic catheter, projecting from the wound, serves to carry off the urine, which being received in a dish, the patient is kept constantly dry and comfortable. For several days the urine continues to pass by the perineum; at length, however, it is discharged through the penis, and very lit- tle runs through the wound. The catheter should then be re- moved, and, in a short time, the opening in the perineum will heal. In a few rare instances, indeed, the incisions have healed * See vol. 1st, p. 55. f It sometimes happens that after the stone has been removed, and the patient put to bed, secondary hemorrhage takes place, and that the blood finds its way into the bladder, where it excites so much irritation as to cause a contraction of that viscus, and a sudden discharge of urine and coagulated blood through the wound. In fifteen or twenty minutes the same accumulation and expulsion again take place, and may continue until the patient is exhausted, unless the surgeon understands the nature of the accident and the mode of treating it. In all such cases, I have reason to believe, from what I have seen, that the hemorrhage pro- ceeds from the vena: vesicales, or from some of the arteries above the prostate. Under these circumstances, a very ingenious mode of arresting the flow of blood was executed many years ago by the late Dr. Physick, (in the case of a Dr. B.) by introducing a large gum elastic catheter into the bladder through the urethra, and at the same time a long slip of lint between the lips of the prostate, so as to keep them in accurate apposition. The flow of blood being thus stopped, and the urine passing off by the catheter, instead of flowing through the wound, it follows that the hemorrhage will not return, so long as the lint retains its posi- tion, that it is important that it should be left for several days, or until suppura- tion takes place. By adopting this plan I have saved the lives of two patients, who otherwise, I am sure, must have perished. 228 Lithotomy. by the first intention; but in general, three or four weeks elapse before a cure is effected. The operation of lithotomy, as I have described it, must be understood as adapted to the adult, and as calculated for cases unattended with difficulty. The same rules should be observed, in performing the operation on infants and children—the instru- ments and incisions, in such cases, being proportionally smaller. In such subjects, moreover, the surgeon may expect to expe- rience some trouble, from a frequent protrusion of the rectum, during the operation, inasmuch as most children, afflicted with the stone, are subject to prolapsus ani. Upon the whole, how- ever, the operation of lithotomy in children is, compared with that of the adult, attended with few difficulties. To guard against accidents, and to prepare the young surgeon for difficulties, which at some period or other he may expect to encounter, the following mementos should be carefully attended to. 1st. To examine minutely every instrument, before it is used, especially the gorget and staff. If the cutting edge of the former be not extremely sharp, it will not divide the prostate gland, but pushing it forward, will pass between the bladder and rectum, and deceive the surgeon, who, supposing that he has opened the bladder, thrusts the forceps into the wound, makes fruitless efforts to extract the stone, and, perhaps may tear away, as has happened, the prostate and part of the bladder. If the gorget be not accurately fitted to the staff, it may be dis- covered, during the operation, (and at the critical moment of pushing the instrument into the bladder,) that the beak is too large for the groove. Under these circumstances, should the operator persevere in his attempts to thrust the gorget home, great,mischief may ensue. The size of the gorget must always be proportioned to the age and size of the patient. A gorget, for an adult, should never exceed in breadth three-quarters of an inch, and, for most patients, one five-eighths of an inch will answer. Children seldom require an instrument beyond three- eighths of an inch in width. An unusually wide gorget always endangers the pudic artery. The most experienced lithotomists, however, of modern times, have always inculcated, and, as I conceive, justly, a free incision of the prostate and neck of the bladder, rather than tear these parts in attempting to get out a large stone. How then can this be accomplished unless a broad gorget be employed? The answer is very easy. The chief lJ7atr 4 V.i % Svx& . Drawl ty J.Tn-/.vt./m. . Lithotomy. 229 object of the gorget is to make an opening into the bladder; if this opening is sufficiently large to admit the finger of the sur- geon and enable him to touch the stone, this is all he can re- quire. Finding, by the feel, the stone too large to come away through the track made by the gorget, the curved probe-pointed bistoury is at hand, and with this the wound may be instantly enlarged to the requisite extent, and without exposing the pu- dic artery. In running the gorget along the staff, through the prostate and bladder, care should be taken to depress its handle, in order that the blade may be sufficiently elevated to pass in a line corresponding with the axis of the pelvis. This the opera- tor sometimes finds it difficult to accomplish, owing to the blade of the gorget being made as broad near the handle of the instrument as at its point;- and, on this account, not calculated to rest in the lower angle of the incision. To obviate this diffi- culty, I have, for several years past, had the blades of gorgets so constructed, as gradually to taper from the outer corner of the cutting edge to the handle of the instrument. See Plate IV. fg. 1 and 2. 2d. If the surgeon, from timidity, or any other cause, does not make his incisions in the perineum ample, but leaves some of the fibres of the transversales perinaei muscles uncut, he will find, in attempting to extract the stone, great resistance, and a constant tendency in it to slip from the grasp of the forceps, This resistance usually arises from the fibres of the transversalis perinaei alter. In such a case the fore-finger of the left hand should be carried towards the bottom of the wound to depress the rectum, while the remaining obstruction is removed by the knife. A wound of the rectum will not prove so serious an ac- cident as some have represented; but, nevertheless, it should be carefully avoided. 3d. The lithotomy forceps are, in general, made unnecessari- ly large and clumsy; so large, indeed, as often of themselves to fill up the opening through the prostate. The teeth, too, on the inner surface of the blades, are often so large as to act like wedges, and break the stone the moment it is grasped. For a child, a forceps very little larger than the common pocket case instrument, will serve a better purpose than the one usually employed; and the smallest forceps contained in the lithotomy Vol. II. 30 230 Lithotomy. case, provided the handles be somewhat lengthened, will an- swer for an adult.* If a stone should be so large as to require breaking, a strong pair of forceps, with a screw in the handles, will prove more effectual than the complicated instrument of Mr. Henry Earle. Although I have had occasion, however, in three instances, to break large stones, I have never experienced any difficulty in effecting it with the common forceps. Frequently, a stone will break under very moderate pressure of the forceps, and when the surgeon is unwilling for it so to do. In this event, great patience and gentleness must be exercised in ex- tracting the fragments by the scoop, and by injections of barley water. It sometimes happens that one portion of a stone is im- bedded in a cyst in the coats of the bladder, while the other projects into its cavity. This happened in a case, upon which I operated at Alexandria, under the care of two distinguished physicians of that place—Drs. Washington and Sims. Having seized the stone with the forceps, the projecting half broke off, and the remainder with great difficulty, I was obliged to scoop out of the cyst with my finger. The patient had long suffered from the disease, was greatly exhausted before the operation, and died ten or twelve days after it. Some years ago I ope- rated on a young man in the Aims-House Infirmary, and took from his bladder a stone about the size of a walnut, and after- wards introduced my finger to ascertain if there were anypthers left, when, to my great surprise, I discovered that the fundus of the bladder, for a considerable extent, was incrusted with cal- culous matter, which I pealed off in successive layers, some of which were nearly half an inch thick. This patient perfectly recovered. Under circumstances such as I have detailed, the surgeon should never, for a moment lose his self-possession, but proceed cautiously and gently, but firmly, until he has ef- fected his purpose. In the common operation of lithotomy, too, it^, should never be necessary to pull violently with the forceps, but the instrument must be humoured, and its position changed, and twisted gently in a variety of directions. 4th. The after treatment of lithotomy is oftentimes more important than the operation itself; and the surgeon would do • The blades of stone forceps should never touch, but a small spaqe be left be- tween them, to prevent the bladder from being pinched. Lithotomy. 231 well never to operate, unless he could attend the patient through- out the whole course of his confinement. I have now per- formed the operation of lithotomy nearly fifty times, and have lost out of that number, only six patients. My success, I at- tribute, in a great measure, to ample incisions, and to extra- ordinary care during the after treatment. Three out of the six patients died at a distance where I could not attend them, and the other three were greatly exhausted by the disease be- fore the operation was performed. The shock communicated to the system by the severity of the operation, is sometimes sucli as greatly to endanger the patient's life, and, indeed, some have actually died on the table, or a few hours after—reaction having never been established. So long as this state of the system continues, stimulants, particularly ammonia, must be employed. After reaction takes place, then inflammation must be guarded against, and to prevent this, the antiphlogistic sys- tem, to the necessary extent, will be naturally resorted to. The high operation of lithotomy, or that above the pubes, an account of which, it is said, was first given by Franco, in l-r>56, was formerly much practised, particularly by Frere Cosme, Douglass, and Chesselden. The unfortunate termina- tion, however, of numerous cases, caused it to be abandoned al- most entirely. Still it has been revived at different periods, and latterly, by Souberbielle, of Paris, and Carpue, and Sir Everard Home, of London. But, even under the most favour- able circumstances, it is an operation greatly inferior to the la- teral, and, indeed, should only be practised, I conceive, in' cases where the stone is ascertained to be of extraordinary mag- nitude, or where the prostate gland is very much enlarged. The principal objections to the operation arise from the diffi- culty of preventing the escape of the urine into the cavity of the pelvis, and the danger of wounding the peritoneum. If the operation be determined on, I should prefer the mode of exe- cuting it devised by Sir Everard Home, and as described by him in the following case. " An incision was made in the direction of the linea alba, be- tween the pyramidales muscles, beginning at the pubes,and ex- tending four inches in length: it was continued down to the tendon. The linea alba was then pierced close to the pubes, and divided by a probe-pointed bistoury to the extent of three 232 Lithotomy. inches. The pyramidales muscles had a portion of their origin at the symphysis pubis detached to make room. When the fin- ger was passed down under the linea alba, the fundus of the bladder was felt covered with loose, fatty, cellular membrane. A silver catheter, open at the end, was now passed along the urethra into the bladder, and, when the point was felt by the finger in the wound, pressing up the fundus, a stilet, that had been concealed, was forced through the coats of the bladder, and followed by the end of the catheter. The stilet was then withdrawn, and the opening, through the fundus of the bladder enlarged towards the pubes, by a probe-pointed bistoury suffi ciently to admit two fingers, and then the catheter was with- drawn. The fundus of the bladder was held up by one finger, and the stone examined by the fore-finger of the right hand. A pair of forceps, with a net attached, was passed down into the bladder, and the stone directed into it by the finger: the surface being very rough, the stone stuck upon the opening of the forceps, and being retained there by the finger, was ex- tracted. A slip of linen had one end introduced into the blad- der, and the other was left hanging out of the wound, the edges of which were brought together by adhesive plaster. A flexi- ble gum catheter, without the stilet, was passed into the bladder, by the urethra, and kept there by an elastic retainer surround- ing the penis. The patient was put to bed, and laid upon his side, in which position the urine escaped freely through the catheter." Some years ago, I was called to Virginia, to operate for li- thotomy. I found the patient very far advanced in years, and labouring not only under stone, but morbid enlargement of the middle and lateral lobes of the prostate. Knowing the difficul- ties I should have to contend with under these circumstances, I determined, instead of performing the lateral operation, to open the bladder above the pubes. Accordingly, assisted by Drs. Withers and James, two eminent practitioners of the neigh- bourhood in which the patient resided, I performed the opera- tion after the manner of Sir Everard Home above described, and succeeded without difficulty in removing two calculi. The patient's chance of recovery, notwithstanding his age and the enlargement of the prostate, was very favourable ; so much so, that feeling himself, as he imagined, perfectly secure, and tired Lithotomy. 233 of restraint and confinement to bed, he insisted upon the cathe- ter being withdrawn, (contrary to very strict injunctions I had left with him, and in consequence soon after perished from pe- ritoneal inflammation induced by effusion of urine into the ca- vity of the pelvis. This was the first instance, 1 believe, in which the high operation had been performed in America. It has since been done, successfully, by Dr. Carpenter, of Lancas- ter, and also, as I understand, by Dr. Van Volsah, of Lewisburg, Union county, Pennsylvania. Females are subject to calculus as well as males, though the disease in the former is by no means so frequent as in the latter —owing to the female urethra being so short and large as readily to permit the escape of the calculous particles before they be- come so large as to form a stone. The symptoms created by the presence of a stone in the female bladder resemble those which have already been pointed out as characterizing the dis- ease in males; in general, however, women suffer more than men from the disease. There are two modes of extracting the stone from the female bladder—by dilatation of the meatus urinarius, and by incision. The former was often practised by the older surgeons, and within the last twenty or thirty years, has been occasionally re- sorted to. It should be preferred, in general, to the knife, (especially when the stone is small,) inasmuch as it is not so liable to be followed by incontinence of urine. A bit of com- pressed sponge, or wax bougies gradually increased in size, will answer very well to dilate the passage with. When the stone is found to be very large, it will, perhaps, become necessary to divide the urethra, and the best mode of performing the opera- tion, is, I think, the following. The patient is placed in the ordinary position for lithotomy, and her hands secured to the feet by bandages. The surgeon then introduces into the urethra a straight staff, with its groove directed towards the left ischium, and holding it firmly by the handle, passes with the right hand a straight bistoury through the urethra and neck of the bladder, obliquely downwards. The finger being introduced and the stone felt, it may be readily removed with the straight or curved forceps. As incontinence of urine has followed in all the cases in which Sir Astley Cooper has performed or witnessed the 234 Lithotomy. operation, he has expressed his determination, in future, to try the effect of a suture upon the edges of the wound. Carpue's History of the High Operation, &c. 1819—Sanson des Mbyens de Parvenir a la Vessie par le Rectum, 1817—Dictionnaire des Sciences Medicates, tom.28,p. 422—Traiti Historique et Dogmatique de VOperation de la Taille,par J. F. L. Deschamps, Paris, 1796, 4 tomes, 8vo.—John Bell's Principles of Sur- gery, vol. 2, part 1—Desault's Works, by Smith, vol. 3—C. Bell's Operative Surgery, vol. 1, p. 329—Earle's Practical Observations on the Operation for the Stone, 1803—Roux's Journey to London—Allen's Treatise on Lithotomy, 1808— Colles' Treatise on Surgical Anatomy, p. 145 and 169—Cooper's First Lines of ihe Practice of Surgery, vol. 2,jt?.320, edit. 4—Dorsey's Surgery, vol. 2—Dorsey's Inaugural Essay on the Lithontriptic Virtues of the Gastric Liquor, 1802—Mar- cet's Essay on the Chemical History and Medical Treatment of Calculous Disorders —Prout's Inquiry into the Nature and Treatment of Gravel, Calculus, &c.— Magendie on Gravel, &c.— Wilson on the Urinary and Genital Organs, London, 1821, 8vo. A Treatise on the Formation, Constituents, and Extraction of the Urinary Calculus; being the Essay for which the Jacksonian Prize for the Year 1833 was awarded, by the Royal College of Surgeons, in London, by John Green Crosse, Surgeon to the Norfolk and Norwich Hospital, and Lecturer on Clinical Surgery,- Member of the Royal College of Surgeons, and Fellow of the Royal Me- dical and Chirurgical Society of London; Corresponding Member of the Societi Medicate d'Emulation of Paris, formerly Demonstrator of Anatomy in the Uni- versity of Dublin, Member of the American Philosophical Society of Philadelphia, &c. A work replete with every variety of information on the subject it treats; and, as coming from a surgeon of acknowledged ability, industry, zeal, and ex- perience, should be carefully studied by all desirous of obtaining the best pa- *thological and practical information on calculus and its treatment. Lithotrity. 235 Section VI. Lithotrity. Among the obsolete and musty records of ancient times, iso- lated scraps of valuable matter, plausible hints and specula- tions, ingenious instruments and operations are met with as " rari nantes in gurgite vasto." By the industry, however, of such men as Ploucquet, Sprengel, Good, Young, S. Cooper, and a host of German labourers, the golden sand has long been washed and picked from the rubbish which surrounded it, and whether dug from the caverns of Pompeii or Herculaneum, or collected from the deserts of Egypt or Arabia, or scraped from the ruins of Greece, has been preserved pure and unalloyed, and stored up for its rightful owners. But how few and unmerited are the claims of the ancients to those treasures which have been so un- sparingly showered for the last fifty years upon every department of the healing art. And yet no sooner is a discovery made, or a new idea started, or a new operation performed, but the claim to priority is contested by a bold assertion that Hippocrates, Galen, or Celsus, or some other antediluvian, is entitled to the honour of the claim in question. This disposition to detract from well-merited fame, every where so prevalent, and inherent, perhaps, in human nature, was strikingly displayed a few years since in France, in relation to the operation of Lithotrity; for when Civiale and Leroy, poor and obscure, but most meritorious and ingenious individuals, demonstrated that the stone could be de- stroyed in the human bladder, and removed, without the ope- ration of lithotomy, it was immediately proclaimed that there was nothing new about the affair, that they deserved no credit for the operation; for that a monk of Citeaux, and Martin, an English colonel, had both relieved themselves, long before, by 236 Lithotrity. nearly the same means; that Gruitheisen, a Bavarian physician, had made similar experiments, and that even Ammon of Alex- andria, Franco, Ambrose Parey, Hildanus, Sanctorius, Germa- nus, and Haller, were acquainted with lithotrity, that Amusat, and others, were all familiar, before Civiale and Leroy, with the operation. But, in answer to all this, it may be said, (admitting that some obscure hints might have been thrown out, or nugatory experi- ments made by the individuals mentioned, or others,) that no brilliant discovery, or invention, ever was made, perhaps, that had not been previously imagined or thought of by some one, and that the men who, while struggling with poverty and almost overwhelmed with difficulties of every description, have energy enough to bear up and to persevere for years amidst privations and sufferings, and, finally, to bring triumphantly their experi- ments to successful issue, and adapt them to practice, are enti- tled, fairly, to the chief glory of discoverers. To whom but Ful- ton are we really indebted for steam navigation 1 To whom but Civiale and Leroy do we actually owe the operation of lithotrity ? It is natural for us to look, in this age of project and trickery, with distrust towards proposals not sanctioned by long expe- rience, and there were many, accordingly, disposed to under- value the labours of these men. For myself, I candidly own, that for years I had no faith in the operation, as regards the full ad- vantage to be derived from it, and the facility of executing it, and believed, with many others, that it was adapted only to ex- traordinary cases. From the first, however, I never hesitated to speak of it, both in this work and my lectures, as a " most ingenious and beautiful idea," and to say, that the time would probably come, when the operation would be so modified and improved, as to deserve all the praises then so inconsiderately lavished upon it. At the same time, the young surgeon was cautioned how he ventured to undertake the operation, (which from trials, made by some of the most skilful surgeons in this country, was found to be extremely difficult, delicate and dan- gerous,) under the idea, then too prevalent, that any one of ordinary capacity and practice could perform it. That the ad- vice I then gave was just, and such as ought to have been fol- Ipwed, experience has since proved; for although there are now many successful operators in Europe, and a few in this country, Lithotrity. 037 every one of them, I am sure, will acknowledge that lithotrity requires a tact, an attention to minute circumstances, a discrimi- nation rarely possessed, and, above all, instruments which not one cutler in a thousand can manufacture. Upon the whole, then, it may be stated, that lithotrity has become an established operation, that it is adapted to a greater number of cases than was, originally, supposed possible, that in the hands of skilful operators it is generally safe, if not successful, and that when the patients are healthy, middle-aged, or advanced in years, the urethra large and free from disease, the stone small and soft, and when females are the subjects of it, the operation should always be attempted in preference to lithotomy. On the other hand, it must be remarked, that it is seldom adapted to children, or to very irritable and diseased patients, or to cases where the stone is large and extremely hard. Before describing lithotrity, it will be necessary to give an ac- count of the instruments employed in the operation. 1 have al- ready remarked that these are extremely difficult to make. Thoroughly convinced of this, I ordered a set from Paris, of the finest finish and construction, which, through the kindness of M. Civiale, were made under his own eye and direction, and every one examined by him and altered, until it met his approbation. Such of these, only, as are essential in the operation I shall de- scribe in this place. There are many instruments invented by Heurteloup, Leroy and other lithotritists, that possess no advan- tages, I conceive, over Civiale's, and which, therefore, need not be noticed in a work of this description. Civiale's apparatus, or lithon tripteur, consists, 1 st, of a silver can- nula eleven inches long, and from two to four lines in diameter, open at its lower extremity and having at its upper a circular rim,' connected with an oblong shoulder, intended to secure the can- nula in a corresponding handle, or lathe, to be afterwards de- scribed. Attached to this extremity, likewise, is a cylinder of leather enclosed in a circular box, to render the cannula water- tight. 2dly, of a steel cannula, longer than the silver one, made to fit and work on the inside of it, having at its lower end three elastic branches which curve inwards, are rounded at their extremities, are intended to seize the stone, and are so contrived as, when drawn within the outer cannula, to pack closelv to- Vol. II. 31 238 Lithotrity. gelher and form a smooth rounded end, well calculated to glide along the urethra, and enter the bladder. The upper extremity of this cannula is numbered, or graduated, to enable the opera- tor to ascertain the degree of expansion of the lilholabe or claw, and is connected by a screw, to a rim or circular box filled with leather, somewhat similar to the one on the silver cannula, and in- tended for the same purpose—to prevent the escape of fluid during the operation. Sometimes four pincers, or claws, are used in- stead of three; and in certain cases, two only are employed. But Civiale has found three the most convenient, in the generality of cases. 3dly, of the lithotriteur, or perforator,—which is a steel rod, six inches longer than the litholabe, having upon one extre- mity a crown with a number of cutting edges, or teeth, calculated to pulverize, or grind the stone or reduce it to fragments, and upon the other a graduated scale intended to denote the size of the stone within the grasp of the claw. This extremity is rounded, and, for half an inch beyond the scale, is slightly serrated, or ragged, in order that it may be securely held in the jaws of a grooved pulley designed to communicate to the lithotriteur a ro- tatory motion, when passed through the cannula of the litholabe. 4thly, of a brass frame, or lathe, somewhat similar to that used by watchmakers, the curved extremity of which has a square cavity, with lateral grooves on its interior, intended to receive the corresponding oblong shoulder of the silver cannula and to be secured in it by a screw; while the other extremity, or straight square shank of the lathe, is designed as a bar upon which a popet head slides backwards and forwards. Parallel with the bar, and fixed upon the superior extremity of the popet head, is a cylindrical brass tube, which encloses a spiral spring connected with a steel pivot, the cup-like extremity of which receives the rounded end of the lithotriteur, and, by the opera- tion of the spring keeps its dentated crown in perpetual contact with the stone. The lathe, during the operation, is held by the hands of an assistant. 5thly, a steel drill bow, about twenty- five inches long, jointed in the centre, firm but elastic, and well designed to play upon the pulley connected with the lithotriteur, and may be said to complete the apparatus. Three, or four, sets of the external cannula, and litholabe, of different sizes, and a proportionate number of the lithotriteur, (ten or fifteen,) should accompany each case of instruments. Lithotrity. 239 The patient having been sounded, the presence of a stone de- tected, the state of the health inquired into, the condition of the ■bladder, the size, consistence and situation, as far as practicable, of the stone ascertained, and lithotrity determined upon, the first step is to enlarge the urethra, gradually, by the introduction of bougies, sounds, or catheters, commencing with small in- struments, successively increasing their size, and suffering each to remain in the urethra ten or fifteen minutes at a time. This practice having been pursued for eight or ten days, the urethra, besides being dilated, becomes accustomed to instruments, and its natural sensibility thereby diminished. Some operators, how- ever, and among them Leroy and Bancal, deem the preparatory treatment unnecessary; but by Civiale it is considered, generally, indispensable. Immediately before commencing the operation, the bladder is explored by the sound, a second time, and the stone being felt, and appearing not too large to be embraced by the litholabe, the patient is laid on a bed and his hips elevated by bolsters, in order to make the stone gravitate towards the fundus of the bladder. A common catheter is then carried into the bladder, and the pipe of a syringe being adapted to its extremity, pro- jecting from the urethra, tepid water, or strained barley water, is injected until the patient complains of a disposition to urinate. The catheter is then withdrawn and the lithontripteur, (with the branches of the litholabe retracted within the cannula, and all other parts of the instrument accurately adjusted,) well greased, is introduced into the urethra by the right hand—while the penis is depressed by the left, parallel with the thighs, which are slightly flexed. The instrument passes readily until it arrives at the bulb of the urethra; it then meets with resistance, which is only to be overcome by depressing the external portion of the lithontrip- teur, and elevating its point, which starts forward, glides along the membranous portion of the urethra and prostate, and enters the bladder. The stone is then searched for, and, in general, may be felt distinctly. When found, and its exact position deter- mined, the blades of the litholabe are expanded by pushing downwards the rim attached to its upper extremity, taking espe- cial care to keep one blade directed upwards towards the linea alba, and parallel with the graduated scale, which should al- ways be uppermost, and correspond with the screw on the silver 240 Lithotrity. or external cannula, while the other blades lie along each side of the bladder, and in this position can hardly fail to enclose the stone. By attention to this rule, which is extremely import- ant, it is impossible for one of the branches to fall vertically upon the stone, and the surgeon, instead of enclosing it by chance or accident, seizes it to a certainty, by drawing the litholabe up- wards with the right hand, while the left is employed in pushing down the external cannula. To secure the stone firmly in the grasp of the claw, the screw, which traverses the rim of the external cannula, should be turned, and the two tubes rendered immovea- ble or prevented from sliding upon each other. The next step is to attach the frame or lathe to the lithontripteur, to adjust the upper extremity of the perforator to the steel pivot projecting by the spiral spring of the popet head, to apply the catgut to the pulley and rotate it by very slow and gentle movements. If the stone is found not to change its position by the action of the perforator upon it, and the patient does not complain of the mo- tion of the bow, the rapidity of the drilling may be increased and continued until the stone is perforated. When soft this is soon accomplished, but when hard requires some time, and is attended with a good deal of fatigue to the operator. In general, it is best not to attempt too much at the first operation. Having, therefore, succeeded in boring the stone at a single spot, the next step is to remove it from the claw of the instrument. This is done by ex- panding the blades, pushing out the stone by the perforator, then closing them and removing the instrument from the blad- der. In doing this, however, great care must be taken that no fragments are interposed between the blades and drill, as often happens, but may be discovered by the difficulty of withdraw- ing the instrument. A few turns of the crown of the perforator, in such a case, will be sufficient to pulverize and remove them. After the operation the patient should take a warm bath, keep quiet for some hours, and attend to his diet. The urine first discharged is generally found slightly tinged with blood, and along with it pass off more or less sand and fragments of the stone. In three or four days the patient is ready, in most cases, for a second operation. In the«,details just given, I have followed closely the direc- tions of Civiale, and have reason to believe, that, if pursued with minute attention to all the points enumerated, that much Lithotrity. 241 less difficulty will be experienced by operators in this country, who may now resort to the operation, than has been the case hitherto; for I am persuaded that most of the mishaps recorded in former editions of this work, are imputable to want of atten- tion to certain indispensable practical manipulations, the neglect of which must still eventuate in inevitable failure. But to guard, as much as possible, against ill consequences, I shall endeavour still further to inculcate such precepts, from the best authorities, as will be likely to prevent error and to facilitate the efforts of those who may feel disposed to engage in this branch of surgery, and may not have access to those European productions which have issued, latterly, in such numbers from the press. Notwithstanding the facility with which, in many cases, the stone is seized immediately upon expanding the branches of the litholabe in the bladder, yet it sometimes happens, that it pertina- ciously eludes their grasp. This is owing, generally, to the stone resting near the neck of the bladder, so that it comes in contact with the smallest diameter of the branches—that which is next to the extremity of the cannula. This will be understood, easily, when it is recollected that the branches, when opened into the bladder, represent a tringular pyramid, the base of which pre- sents to the sacrum, and the apex to the neck of the bladder. The course to pursue, under such circumstances, is either to withdraw the instrument and raise still higher the hips of the patient, in order to roll the stone towards the fundus of the bladder, or else to draw the instrument with its blades expanded towards the penis, which must have the effect of gaining room by expanding the neck of the bladder, (naturally elastic, and susceptible of dilatation,) and of bringing the claws at the point of their greatest divergence, over the sides of the stone. Still further to facilitate its enclosure, it may be necessary to raise the handle of the instrument, by which the two lateral blades must depress the prostate and embrace the sides of the stone, while the vertical blade descends and rests upon its summit. Having in this way succeeded in seizing the stone, the handle of the instrument should be depressed, by which manoeuvre the stone will be suspended, as it were, in the centre of the bladder, and being sustained in that position while the drilling is going on, there will be no pressure or irritation on the walls of the bladder. 242 Lithotrity. If the stone, as often happens, should be too large to be em- braced by the litholabe, this may be easily known by its re- tiring from the instrument when its claws are expanded to the utmost, and may be proved by examination of the graduated scale. In such a case the lithontripteur is removed, and another of larger dimensions substituted. When the stone does not ex- ceed in bulk a hen's egg, it may be destroyed by the operation of lithotrity, but if larger, the surgeon will act wisely in not at- tempting the operation. The most delicate and difficult part, perhaps, of the operation of lithotrity is the turning of the stone, in order to perforate it in different directions; for after the first operation, and in all sub- sequent ones, this will become an important indication. The assistance of the lithotriteur, upon such occasions, is of the ut- most importance. By moving this in different directions, some- times pushing it forward, sometimes rotating it, and making it bear lightly upon the stone, the latter can be made to shift its position while still in the relaxed embrace of the claw, and as soon as the operator finds that the crown of the lithotriteur bears upon a surface not previously bored, the stone may be again seized and the drilling renewed. Having, in this way, perforated the calculus, in numerous directions, it becomes so holIowred out, and weakened, that it may often be crushed by the pressure of the claw. Soft and friable stones, indeed, as Civiale and others have proved, may be destroyed, sometimes, by the litholabe alone, and without the aid of the perforator. Before attempting lithotrity, it is of the utmost consequence to measure, exactly, by means of a catheter, (having on its side a graduated scale) the exact length of the urethra, which va- ries, as is well known, in different subjects. As soon as the urine begins to flow, the measurement may be taken. Know- ledge, thus obtained, will prevent the operator from attempting to open the blades of the litholabe whilst in the urethra, from which very serious mischief has ensued in several instances. Although the necessity of injecting the bladder, upon all oc- casions, whether for the purpose of exploring its contents, (which is sometimes done with the blades open as well as shut,) or for seizing the stone, has been mentioned, already, as essen- tial, yet it may be well to state, in this place, that without such Lithotrity. 243 preliminary measures, success can hardly be calculated upon. No difference of opinion exists among lithotritists upon this point, and, perhaps, it may be owing to attention in this re- spect, that Civiale has never, as he declared, some years ago, injured the sides of the bladder, although he had, at the time the declaration was made, introduced the lithontripteur upwards of five hundred times. Should the fluid then escape, upon any occasion, previous to operation, there can be no safety unless the bladder is again filled before the introduction of the instru- ments. As regards the number of applications of the lithontripteur, that may be required before the cure is completed, it may be remarked, that this will depend upon the size and texture of the stone, upon the state of the patient's health, upon the condi- tion of the bladder, and a variety of other circumstances. In general, when the stone is soft and small, from one to three operations will be required, and a greater number when it is large and hard. In getting away the fragments, little difficulty is now experienced. They usually pass off along with the urine, from day to day, or are brought away by injections, or by the repeated introduction of the litholabe, or by forceps with two blades, and if too large to pass the urethra, may be easily crushed. Instruments, indeed, have been invented by Jacobson, Heurleloup, Weiss, and others for crushing stones, or for break- ing them with a hammer, and have been found calculated, upon certain occasions, to supersede the lithontripteur. One of this description, admirably contrived for the purpose, either invented or modified by Civiale, was lately sent to me, by that distin- guished operator. An account of these instruments will be given under the head of lithotripsy. Upon the whole, it may be stated that as lithotrity can ne- ver entirely supersede lithotomy, though it will undoubtedly greatly curtail it, the surgeon should strive to make himself so familiar with both operations, and with calculous disorders, as to be able to determine the kind of operation adapted to each parti- cular case, and prepared to perform either, as occasion may re- quire. Upon his judgment in this respect, I venture to predict, will his success, or failure, in a great measure depend. Death has followed both operations, in numerous instances, although per- formed by Civiale himself, less frequently, however, since the va- 244 Lithotrity. rious modifications of the instrument, and experience acquired in using them, than in the infancy of the art. Although Leroy, and some others, have performed lithotrity upon children of three and four years of age, and in a few cases with success, as a ge- neral rule it should not be attempted, on account of the sensibility of such subjects, and the difficulty of introducing instruments suf- ficiently large and strong to destroy the stone. In women, litho- trity is more difficult than might be imagined, owing to the very irritable condition in which the female bladder, when it contains a stone, is generally found, and to the difficulty of keeping it dis- tended, during the operation, with fluids. On Lithotrity, consult de la Lithotritie ou Broiement de la Pierre dans la Vessie, par le Docteur Civiale, 8vo. Paris, 1826—Expose' des divers procedis, employ6s jusqu'a ce jour, pour guerir de la Pierre sans avoir recours a [Operation dela taille,- par J. Leroy. Paris, 1825, 8vo.—Lettres sur la Lithotritie, ou Broiment de la Pierre dans la Vessie, par le Docteur Civiale. Paris, 1827, 8vo.—Lettre sur la Lithotritie, &c, par le Docteur Civiale. Paris, 1828, 8vo.—Lettre sur la Litho- tritie Urttrale suivie d'une revue ge'ne'rale, sur Vetat actuel de la methode Litho- tritique, par le Docteur Civiale, 8vo. Paris, 1831—Lettres sur la Lithotritie ou I'Art de broyer la Pierre, par le Docteur Civiale, 8uo. Paris, 1833—Manuel pra- tique de la Lithotritie, par A. P. Bancal. Paris, 1829, 8vo.—Description of the new Process of perforating and discharging the Stone in the Bladder, &c, by James Atkinson, Esq., 8vo. London, 1831—Lithotrity and Lithotomy compared, being an analytical Examination of the present method of treating Stone in the Bladder, &c, by Thomas King, M. D. London, 1832, 8vo.—Principles of Litho- trity, or a Treatise on the Art of extracting the Stone without Incision, by Ba- ron Heurteloup, 8vo. London, 1831—Case of Lithotrity, successfully performed by L. Deypere, in New York Med. Journal, for Nov. 1830—A. G. Smith on Lithotrity, in North Amer. Med. and Surg. Journal, vol. 12th, p. 256, Lithotripsy. 245 Section VII. Lithotripsy. It is now generally admitted that the operation of lithotrity, 5n the hands of prudent and experienced surgeons, possesses de- cided advantages, in certain cases, over that of lithotomy. But it is also admitted that, to perform lithotrity with any prospect of success, requires great dexterity, extraordinary caution, gen- tleness, perfect familiarity with the use and knowledge of the mechanism of the instruments; and, above all, instruments so well constructed and tempered—so diversified in shape, size, number, and adapted to so many different purposes—as to place the operation within the reach of a very limited number of sur- geons, however competent in other parts of their profession to excel and even distinguish themselves. Perhaps it will not ap- pear strange, then, when asserted, that no man, now in existence, can be called a perfect lithotritist, except Civiale, who, as con- ceded by all that have witnessed his exploits, is as dexterous and successful with his litholabe and other forms of apparatus pe- culiar to himself, as can be imagined. From all this, it may be reasonably inferred, that the cause of failure in so many in- stances, amongst European and American surgeons, is mainly owing to intrinsic difficulties in the operation itself, to want of experience, to deficiency in mechanical ingenuity and tact, to want of proper instruments and skill in manoeuvring them, as. well as the idea so prevalent from the very moment of the dis- covery of lithotrity down to the present time, among physicians and others little accustomed to operations of any description, " that lithotrity is very easy and simple, and may be performed successfully by those who would not dare to venture on litho- tomy.^ Fortunately, in this state of things, an important discovery has Vol. II. 32 *46 Lithotripsy. been "made within the last few years, that there'"is no longer absolute necessity for resorting to lithotrity, but that the same end may be accomplished by other means, not less efficient, within the reach of a greater number of surgeons, less painful Pig. 2, the termination to the patient, attended with lit- of the same instrument, , . , . r , the beaks separated. tie or no risk, (if the surgeon is careful, the case adapted to the operation, and, the patient willing to conform to certain regu- lations,) under favourable circumstances, certain of success. I allude to the operation of lithotripsy, which may be said, perhaps, to have been invent- ed by Baron Heurteloup. This operation is founded upon two principles-— /upon that of crushing and of percussion—the for- mer chiefly adapted to soft and friable stones, the latter to hard and compact. To accomplish these purposes, several instruments have been invented, and various modifications of the same instrument proposed and executed. It is not my intention, however, to describe or comment upon any except the instrument of Heurteloup and that of Jacob- son, both of which have been used sufficiently long in Europe and America, to enable us to ar- rive, with some degree of certainty, at conclusions respecting their merits and defects. Heurteloup's "percuteur," "pince it deux branches,''' or litho- tripteur, as it should be called, is extremely sim- ple in construction, remarkable for strength, and consists chiefly of two portions—a male and female =0 steel rod, about twelve inches long, the former en- closed in the latter, and calculated to move back- wards and forwards at pleasure, about the size of an ordinary adult catheter, straight for eleven in- ches of its length, and, at its lower extremity, turned up and gently rounded in form of a beak, at an an- ^^^^'gleofabout 55 degrees. Near the upper extremi- ty of the male rod, there is a graduated scale, in- Lithotripsy. 247 tended to indicate the size of the stone, and the summit of the rod is terminated by a steel bowl, de- signed to receive pressure of the hand in crushing the calculus, or the blow of a hammer. In the latter case, the instrument is held within the grasp of a vice, which is applied to a square shoulder on the female rod, corresponding in si- Fig. V the termina-tuation with the graduated scale tion of the same, with , . , . , zl . the loop open. on the male rod. Above this shoulder, for two inches and a half in extent, is a male screw, upon which works a small tripod han- dle, calculated to drive forward the male rod upon the female, and, by graduated pressure, to break the stone. The extremities of the beak are ser- rated, (but, at the same time, so rounded off and guarded as to prevent the possibility of pinching the bladder or urethra) and extremely well calculated to seize, retain, and fracture any stone of ordinary dimensions and hardness. The entire length of the instrument, from the summit head to the beak, for a full grown subject, is about 18 inches. For younger subjects and for children, it will vary pro- portionally, in length and diameter. (See Figs. 1 and 2.) Jacobson's instrument is not designed to act upon the principle of percussion, nor is it calcu- lated so to do, but is used, when shut, to detect the presence of a stone, and, when expanded, to close upon and crush it, and would seem, when superfi- cially examined, admirably calculated for the pur- pose. It consists of a silver cannula, eight or nine inches long, a quarter of an inch in diameter, at- tached to the superior extremity of which is a cir- cular steel plate or rim, an inch wide. Through the cannula passes a steel rod, which projects beyond its lower extremity, two or three inches, in form of an ordinary sound, flattened and serrated on its concave surface, and smooth and half round on Fig. 3, Jacobson'i 248 Lithotripsy. its convex. Connected with this extremity by a hinge, resem- bling it in form and size, but only an inch in length, is a piece of chain, which, in like manner, is attached to a second and a third portion, the last of which is riveted to a straight rod, which, like the former, passes through the cannula, for the length of twelve inches, and is intended to retract or expand the links, so as to produce, at will, the form of a common curved catheter or that of a loop. The superior extremity of the straight rod, last men- tioned, for three inches in extent, is a male screw, corresponding with a female one, which passes through the centre of a double convex rim, intended to work the chain backwards or forwards, as may be required. (See Figs. 3 and 4.) With either of the instruments above described and figured, the operation of lithotripsy may be conveniently and success- fully performed. In describing the mode of operating, how- ever, I shall confine myself almost exclusively to the lithotrip- teur of Heurteloup, because I have been more accustomed to the use of it in practice, and because I think it possesses advan- tages over that of Jacobson, which I shall endeavour, afterwards, to point out, and which I think will be appreciated by all who are disposed to give trial to each, and are so situated as to be competent to decide between them. It is a matter of no little consequence, before undertaking li- thotripsy, to determine upon the cases best adapted to it. To want of care in this respect, and perhaps to want of judgment in some cases, I may add, may be attributed, there is reason to be- lieve, the mishaps which have occurred in so many instances, and which have been so sedulously concealed from the public eye, in Europe especially, while the successful cases have been as carefully blazoned forth. I shall not be accused, I trust, of making such remarks invidiously, when I assert that the refer- ence is not to individual cases, or to lithotripsy alone, but will ap- ply particularly to lithotrity. At all events, I shall set the exam- ple, if not already done by others, of stating the successful as well as unsuccessful cases, the only mode by which the profes- sion will be able to form a correct judgment with respect to an operation still in its infancy, and, in many points of view, so in- teresting to science and humanity. When applied to by a patient, supposed from the symptoms to have stone in the bladder, I would advise rest and quiet for three Lithotripsy. 249 or four days, (especially if just from a journey,) the free use of diluents, and a gentle purgative. After this, and at a moment when the patient has less than his accustomed irritation about the region of the bladder and urethra, a simple steel sound, or a sil- ver, or gum elastic catheter may be introduced very cautiously and deliberately, and moved in various directions for the purpose of detecting the stone, and judging in a measure of its size, si- tuation, texture, shape, and for ascertaining whether it be rough or smooth; whether more than one, &c. It often happens that the sound is introduced with the utmost facility, and without much inconvenience to the patient, the bladder carefully explored, and no stone felt. In such cases, the surgeon should not rest satisfied, but, discontinuing his examina- tion after a few seconds, should renew it again in a day or two, and sound at one time when the bladder is full, at another when empty, and endeavour to make his instrument, though in the most cautious and careful way, enter into every nook and corner of the bladder, where it would be possible for the stone to lurk. He should also place his patient, while sounding, in a variety of positions—sometimes on his side, sometimes on his knees, and, upon other occasions, nearly on his head—never failing, in diffi- cult or obscure cases, to introduce a finger into the rectum, for the purpose of elevating the stone, or of removing it from some cyst or hiding place, and of bringing it in contact with the sound. Very small stones, or fragments, may be touched repeatedly by a person unaccustomed to sounding, without his being sensible that there is a particle of foreign body in the bladder; and even an ex- perienced surgeon will frequently find himself at fault in this re- spect. From having experienced more or less difficulty in detect- ing a stone, occasionally, I have, latterly, employed an instrument of peculiar construction for sounding, which I shall notice here- after. If the stone is distinctly felt, is of small size, and has not existed very long; if the patient is an adult, middle-aged, or even ad- vanced in years, has, in other respects, a sound constitution, and the bladder and urethra are not remarkably irritable, lithotripsy may be always resorted to, and with every prospect of success. But, on the contrary, if the stone is large, hard and rough, has existed for many years, the bladder extremely irritable, con- tracted, its walls thickened, the kidneys and ureters diseased, the 1250 Lithotripsy. prostate gland enlarged, the stone imbedded in a cyst, or fastened upon a fungus; if there has been for months or years a discharge of purulent matter, or of large quantities of slime from the bladder, and the patient is advanced in years or enfeebled in constitution, there will be great risk in attempting lithotripsy; and the chance of recovery will be greater, perhaps, from litho- tomy,—though, from the latter operation, also, patients thus situated, will be extremely apt to die. Both of these are, of course, extreme cases; and between the favourable and unfavour- able, there are many intermediate grades, where success must depend, in a great measure, upon the judgment and experience of the surgeon in the treatment of calculous complaints, whether by lithotomy or otherwise. Again, there are cases, as in chil- dren, or very young boys, where, from the very small size of the urethra, or the unmanageable disposition of the patients, very little can be expected from lithotripsy, or any other operation than lithotomy, which last, in such subjects, fortunately, is al- most invariably successful. Upon the whole, it may be stated, that there are many cases, particularly in middle-aged and old people, which may admit of a cure by lithotripsy, if performed before the stone becomes large and the bladder diseased; and, in this point of view, the operation holds out many advantages; for there are hundreds of patients, who, if they could be persuaded that their complaint, in its incipiency, admitted of .relief by a process comparatively easy and free from danger, would willingly submit to it; but who would shrink from lithotomy until compelled by years of suffering to undergo it, and then, unfortunately, with little chance of success. Having ascertained the existence of stone in the bladder by accurate sounding, and determined to submit the patient to litho- tripsy, the next proceeding, on the part of the surgeon, is to pre- pare him for the operation, by a regular system of diet, by deple- tion, if necessary, (and there is nothing in the case to conlrain- dicate the measure,) and by the careful introduction of sounds, catheters, occasionally, in order to accustom the urethra and bladder to the use of instruments, to ascertain the exact position of the stone, its usual location, &c. In using such instruments, however, great care must be taken not to irritate the bladder, and to discontinue them the moment the patient complains; and, upon no occasion to rake the bladder, which cannot be done, even Lithotripsy. 251 in the most insensible patient, without great risk of inflammation of that viscus, and even death. Diet, too, is of so much impor- tance, previous to attempting the operation, as to be, in my esti- mation, almost a sine qua non, and ought to be strictly enjoined, in some cases, for weeks together, previous to any attempt to seize or break the stone. With most patients, I find a dish of black tea and a bit of dry bread for breakfast, and the same for tea, with boiled rice for dinner, together with a quart of barley water, (to which may be added, if required, a small quantity of cream of tartar to keep the bowels soluble) in twenty-four hours, amply sufficient to support any ordinary adult, and admirably adapted to lessen irritability, keep down inflammation and soothe the urinary passages. By steady perseverance in these measures, almost every patient can be brought into a proper state to under- go the operation with fair prospect of success; but extraordinary vigilance is sometimes necessary to guard against irregularities and deviations, and to prevent a patient from deceiving himself as well as the surgeon. In this country, above all others, where food is so abundant that even beggars live luxuriously, and where the idea is so prevalent, among all classes, that strength is ne- cessarily associated with plentiful supplies to the stomach, it is extremely difficult to persuade patients that they can go wrong in gormandizing. Unfortunately, in too many instances, they find out their mistake too late, and the surgeon discovers, to his great mortification, that he has been deceived and trifled with.* As an important preliminary to the operation, a firm thick mattress and several substantial pillows will be required, the for- mer for preserving the patient in the most easy and comfortable posture, and to prevent him from being overheated, which is so apt to be the case when smothered in feathers, the latter for ele- • There is no establishment so much wanted in this and other large cities as a " maison de saute"," where patients, especially those from a distance, could be subjected to a regular system of dietetic discipline. The boarding-houses, even the best of them, are unfit for invalids, and the respectable ladies who often keep them too poor and too badly compensated to give the necessary attention to the sick. And as to nurses, they are often worse than useless, or only prove bene- Icial by consuming the delicacies, tid bits and potations intended by officious ind foolish friends for their sick brethren. When will boarding-house ladies, moreover, divest themselves of the silly and pernicious idea, that by restricting the diet of invalids they will incur the reproach of starving them for mercenary purposes, and thereby hurt the credit of their establishments? 252 Lithotripsy. vating the pelvis to the requisite altitude, by which movement the stone will have a natural tendency to subside towards the fundus of the bladder, the only position in which it can be seized conveniently. Some surgeons, Heurteloup, in particular, recom- mend an armed chair or kind of sofa, for the patient to lie upon during the operation; but, independently of the trouble of car- rying such a machine from house to house, more or less alarm is always created in the mind of the patient by such a formida- ble array in the shape of an apparatus, and as, in reality, there is no necessity for any but the most simple means, such as are within the reach of the surgeon in most families, he should avail himself of them with as little parade as possible. A time having been appointed for the operation, the patient should be enjoined to suffer the urine to collect in his bladder from two to four hours previously, and, upon no account, to permit any of it to escape. But some patients cannot retain their urine beyond an hour, or even so long a time. In that case, a gum elastic or silver catheter may be introduced, and the bladder in- jected with tepid water, by means of a syringe or gum elas- tic bag—taking especial care not to employ force or to distend the viscus too suddenly, or to throw in so large a quantity as to give the patient pain, otherwise spasm of the bladder may follow, and a train of other alarming symptoms. If possible, it is best to dispense with the injection, inasmuch as the introduction of the catheter always renders it more difficult to pass any other in- strument immediately afterwards. As a general rule, too, I would remark that the best period for the operation is in the morning, before the patient quits his bed; for I have almost in- variably observed, particularly in winter, the moment the pa- tient rises and walks about his room, that there is tendency to spasm about the neck of the bladder, and that an instrument cannot then be so readily introduced as it might have been a few moments before. These preliminaries having been settled, an assistant places one or more pillows beneath the patient's pelvis, another under his head and shoulders, and while the thighs are relaxed and brought nearly together, the body lying parallel with the bed and along its edge, the surgeon standing on either side or in front, having well oiled the lithotripteur, introduces the beak of it (the blades closely approximated) into the urethra, and by slow but de- Lithotripsy. 253 cided movement causes the instrument to glide along the passage, to which its own weight partly contributes, as far as the triangu- lar ligament, which it is known to have reached by the slight re- sistance met with, and then by depressing the handle gently be- tween the thighs, the point starts suddenly forwards through the prostate gland and enters the bladder. In general, the introduc- tion is effected immediately, hut in some cases difficulties are ex- perienced, arising, there is reason to believe, from the difference in the conformation of different patients, from some being more irritable than others, so that spasms are induced, or from rude- ness or violence on the part of the operator, or from his being too sudden and rapid in his movements, from an over anxious desire of aiming at feats of dexterity. If any such difficulties should arise, it is better not to persevere by forcible endeavours to overcome them, but to postpone the operation to a future pe- riod. Should a stricture, either spasmodic or permanent, exist in the urethra, the surgeon' must previously get rid of that be- fore he ventures upon lithotripsy. The lithotripteur having been introduced, is not to be carried about roughly from side to side, or fore and aft, for the purpose of raking after and suddenly hunting up the stone, but should be carried very slowly and gen- tly towards the fundus or most dependent part of the bladder, and by the slightest touches with the heel of the instrument, an attempt made in various situations, from right to left, or vice versa, to detect the foreign body. During these manoeuvres, there should not be the slightest whisper in the room, or complaint, if possible to avoid it, on the part of the patient. An experienced hand and an accurate ear will soon detect the stone, and be able to say by the peculiar sensation communicated through the vibrations of the instrument, whether the stone be rough or smooth, large or small, hard or soft, whether there be more than one stone, &c. However, cases now and then present themselves in which it is not so easy to feel the stone at once and deter- mine its character and position. This may be owing to a va- riety of circumstances. The patient may be uncommonly ir- ritable, spasm of the bladder may be induced, by which the urine is forcibly driven from the bladder along the urethra and instrument, or there may be an hour-glass contraction of the blad- der, the stone being in one part and the instrument in the other, or the stone may be encysted, or may lurk under the prostate, Vol. II. 33 254 Lithotripsy., or there may be naturally uncommon width in the lateral diame- ter of the bladder, or the rectum may project on one or both sides of the bladder, compress it and destroy its shape, or hemorrhoids or hardened feces produce a corresponding alteration in its figure. Under these and other trying circumstances, the surgeon should never forget that the longer he gropes about, and the more deter- mined he is not to be foiled, the greater will be his chance of failure. " JVullum numen abest si sit prudential should be his motto, and the sooner he acts upon it, by withdrawing his instrument, the better. But suppose, on the contrary, that none of these difficulties have been encountered ; that the stone has been readily felt, without giving the patient much pain ; that the instrument may be readily manceuvered in the bladder, then the next object in view will be to loosen the blades of the lithotripteur, by turn- ing the tripod or handle of the vice, cautiously opening the claws by pushing back the male rod, and then endeavouring by short, sudden, but gentle lateral movements, with the heel of the instru- ment, on the floor of the bladder, to pass the gutter of the female rod beneath the stone, the situation of which, with respect to this part of the instrument, may be readily ascertained by depressing occasionally the male rod. It is astonishing with what facility, in some cases, the stone, by a slight lateral movement, may be shuf- fled into the jaws of the lithotripteur, so much so that the first at- tempt, sometimes, in the hands of a dexterous surgeon, will suffice for this part of the operation. Having secured the stone within the grasp of the forceps by quickly, but gently, pushing downwards the male rod, the surgeon next turns the tripod with one hand while he steadies the instrument with the other, and gradually strains upon the stone until he feels or hears it crack be- neath the pressure of the serrated claws in which it is em- braced. Soft and friable stones give way quickly under mode- rate pressure, and where no strain is perceived upon the tripod; hard and flinty stones, on the contrary, crack with a sudden jar or snap, and splitting asunder quickly, make a report like the distant smack of a whip, while the tripod is suddenly loosened, but generally resumes its hold upon the remaining portion of the calculus. There are some calculi, however, too hard and solid to be thus broken by graduated pressure ; and if the surgeon, not aware of this, and possessing but little mechanical tact or skill, should apply inordinate force to his screw, the beak of the male Lithotripsy. 255 rod might be broken off, or so sprung as to prevent it from being disengaged readily from the stone. In such a case, then, instead of straining upon his instrument, in the vain hope of smashing the stone, the proper course to pursue is to loosen the tripod, and by gentle taps with a hammer upon the bowl on the summit of the male rod, to fracture the stone or quarry it. But let it not be supposed that such an exploit can be safely performed while the lithotripteur is merely held in the operator's hand. The percussion in that case, would necessarily extend to the walls of the bladder, and might be followed by disastrous effects. Fortu- nately, these are readily guarded against by a vice (lined with lead, adapted to the shoulder of the female rod, and held by the surgeon and assistants,) admirably calculated, in every re- spect, to fulfil the purpose for which it was designed. Ha vine bro- ken the stone, either by graduated pressure or by percussion, the surgeon next closes his instrument and opens it repeatedly, while, at the same time, he moves it quickly from side to side to crush and wash out any small fragments that may project from the edges of the groove, and might wound or lacerate the neck of the bladder and urethra in the act of withdrawing the instrument from that viscus. If he has reason to believe that, by these manoeuvres, the fragments have not been gotten rid of, he may generally accomplish his purpose completely, by slight strokes of the hammer in the manner already directed. After this, the sooner the lithotripteur is removed from the bladder the better, and the shorter the time the surgeon has taken to perform the operation, the greater will be the chance of success. In general, by the time the operation is completed, there is an urgent desire, on the part of the patient, to let off his urine; but it seldom hap- pens that large fragments come away in the first passage of the urine. In general, only a few small pieces are observed, toge- ther with a little sand, and now and then a few drops of blood, produced by the pressure of the shaft or fulcrum of the instrument on the neck of the bladder. It is not desirable, indeed, that the fragments should come away until the soreness of the urethra has passed off, and, fortunately, most patients have the facility of retaining them by lying on their side, and not emptying the bladder completely at each time of evacuating, but always re- taining a small portion of urine. In a day or two, however, they begin to present themselves at the neck of the bladder, where 256 Lithotripsy. they remain a short time, exciting more or less unpleasant feel- ing, and are then suddenly carried forward and bolted out before the patient is aware of it. In this way, one after another, frag- ments may pass in rapid succession, and in a few hours amount to a large collection, the soreness gradually passes away, and after the lapse of five or six days, the patient is prepared to undergo another operation. Such, however, is not the invariable result of an operation for lithotripsy, for although the surgeon may have been abun- dantly successful in breaking up the stone, and may have been ex- tremely rapid and dexterous in his operation, and communicated as little irritation as possible, still the bladder is very prone to re- sent any offence, even the slightest, that may have been offered to it, and will vent its displeasure on the surrounding and even distant parts. Hence a few hours after the operation, or, in some cases, in a day or two, a chill is induced, followed by fever, profuse perspiration, spasms of the bladder, &c, or these symptoms may have been brought about by the lodgement of a fragment in the urethra. The best course to be pursued, I think, in this state of things, is to bleed the patient as soon as the fever has come on, to administer an opiate injection occa- sionally, to restrict the diet within the closest bounds, and not to permit the patient to get out of bed—a rule, indeed, which the lithotriptist would do well to observe after each operation, whe- ther any bad symptoms show themselves or not. If a fragment has lodged about the neck of the bladder, and seems disposed neither to retire nor advance, the best plan is to push it back into the bladder by a large catheter or sound; if it has advanced within a few inches or a short distance of the external orifice of the ure- thra, then it may be got away generally by a bent probe, by a pair of urethra forceps, or, still better, by the curette of Leroy— a most ingenious little instrument, admirably adapted to this and many other purposes.* When the irritation has entirely passed away, which general- * " Elle est formed d'une canule plate, a l'extr£mite de laquelle est fixee par une charniere une petite plaque creusee comme un cure-oreille. Son articula- tion avec la canule a lieu de telle sorte que, depassant un peu en arriere, elle forme un talon sur lequel est fix£e une tige qui par court toute la longueur de la canule, et se termine par quelques pas de vis; suivant que cette tige est pous- see ou tiree, la curette se coude ou se redresse." De La Lithotripsie par Le- roy D'Etiolle—Paris, 1836, p 300. Lithotripsy. 257 )y happens in four or five days, or, at farthest, a week, the sur- geon renews his attempts to seize and destroy the stone, in the manner already described; but, as each operation generally be- comes more difficult in proportion as the stone is diminished in size, owing to the greater difficulty of feeling a small foreign body than a large one, it will be proper to detail certain expe- dients which may be resorted to advantageously in most instances. The course to pursue, then, under such circumstances, is to in- troduce the lithotripteur, and having reached the fundus of the bladder, to withdraw the male rod for half an inch and upwards, and fish about from side to side, or in various directions, with the groove of the female rod, and, by so doing, the operator will be very likely to collect one or more fragments, the presence of which can be readily ascertained by closing occasionally the jaws of the .instrument, crushing the fragments, and then again expand- ing and making further search, until all the pieces that happen to fall within the gutter of the lithotripteur are completely bro- ken up or pulverized, and may afterwards be thrown off by the action of the bladder. It is a leading principle indeed, now, with all lithotriptists, to reduce the fragments by successive attempts, to the smallest compass, so as to facilitate their pass- ing off quickly, and with the least possible risk of irritating, or tearing the urethra; and fortunately the bladder, in most in- stances, seems to understand the surgeon's views, and is abun- dantly disposed to second them. But, in other cases, old and de- bilitated patients, especially, there is sometimes so little power in the bladder, that it does not contract sufficiently to expel the fo- reign bodies which may have been broken up into numerous pieces, and, by accumulating, may still keep up irritation, or in time, by the conglomeration and matting together of particles, lay the foundation of another stone. This was one of the strongest objections, some years since, both to lithotrity and lithotripsy, so much so that it was customary at that period to recommend lithotomy in patients thus situated, ra- ther than either of the other operations. By the ingenuity of Heurteloup, however, this difficulty has been in a measure ob- viated, by means of the " evacuating sound," an instrument of pe- culiar construction, and exceedingly well calculated to collect and bring away, without annoyance to the bladder and ure- thra, fragments of considerable size, as well as the sand, or de- "5° Lithotripsy. bris which accumulates in such quantities in the hollows and certain rendezvous met with in most bladders. But, for- tunately, there is another circumstance, independently of the advantage to be derived from the instrument referred to, which may serve to console patients in whom the power of the blad- der to expel the urine with its accustomed force is diminished or destroyed—that there is reason to believe, in certain cases, that soft and friable stones are susceptible of solution in the urine, and are removed in the shape of sand or mud, mixed with slime and other matters. Heurteloup speaks of cases of the kind, and one of this description, I am very sure, has occurred in my own practice. I do not pretend, in this communication, to give more than a sketch or outline of lithotripsy, illustrated by a few cases; and if what I have said shall answer the purpose of drawing the atten- tion of the American surgeon to the operation, of clearing up the doubts of some and confirming the sentiments of others, my la- bour will not be in vain. It has been said, and is even now often reiterated, that I have decried the operation. This is a great mistake. I have never condemned lithotripsy; but have always doubted of the perfect success of «lithotrity," so far as the great mass of operators is concerned. In this text book, years ago, and in lectures, I have spoken of the original idea of destroying, by in- struments, stone in the bladder, as a most ingenious and beautiful one have said that the time would come, when such instruments would be so modified and improved, as to deserve the highest com- mendation, and that the operation would become an established one, though it would never supersede in toto, lithotomy. Have not my predictions been verified? Have not the most disastrous consequences followed lithotrity, even in the hands of Civiale himself, the prince of lithotritists, whose magic powers are still unequalled and can never be surpassed in his particular line, and in the management of his own tools? Is not lithotrity now spoken of in Europe, constantly and without reserve, as the "old method," the "ancient operation?" That more or less of the same difficulty, though never, I trust, to the same extent, will attend lithotripsy, I have no doubt; that patients will be subjected to the operation who are unfit for it; that mistakes will be committed by the inexperienced and adventurous; that the most wary and prudent operators will be baffled, and foiled, Lithotripsy. 250 and deceived in their expectations, partly from perverse and ob- stinate patients, partly from neglect of those about them, and part- ly from the complicated nature of cases which no human wisdom could foresee, I am prepared to believe and admit.' But "Quia non omnes convalescunt idcirco nulla igitur est medicina," is a maxim of sound sense and truth, which should never be lost sight of—which will apply, now and then, to every operation in surge- ry, and to every medical case, from the most complicated to the most simple. Before proceeding to detail the cases of lithotripsy in which I have been engaged, and from which most of the foregoing re- marks have been derived, I propose to make a few comments upon the instrument of Jacobson, and to compare it with that of Heurteloup; in so doing, however, I beg leave to declare that it is not my intention to unfurl the banner of opposition on the one hand, or to be led captive on the other, but " to render unto Caesar the things which are Caesar's." One advantage, at least, an American possesses over Europeans, amidst their controver- sies concerning inventions, improvements, discoveries—that he can be impartial. Of Heurteloup, personally, I know nothing; of Jacobson, nothing; of French and English lithotriptists and anti- lithotriptists, their politics, parties and squabbles and academical debates, I know and care, if possible, still less. With their in- struments I am well acquainted, and equally well disposed to give them all the credit, in my poor judgment, they deserve. Jacobson's instrument is an ingenious and beautiful one; ex- tremely simple; remarkably strong; not too bulky; of the best form, seemingly, for easy introduction; readily withdrawn if any part of it should give way; better adapted, as regards facility, than any other instrument to catch and enclose a small stone, and when seized, of great power to break it; and, upon the whole, well calculated, apparently, for success. But, withal, it is a dan- * In a letter lately received from my friend, John Green Crosse, Esq., a dis- tinguished surgeon of Norwich, in England, it is remarked, " the use of litho- tripsy, as a substitute for lithotomy, is rather fading here. We hear less and less of the practice; it is, however, a most valuable resource in certain cases, and in dexterous hands; though by no means possessing the recommendations which some have represented, of being suitable to provincial surgeons of small expe- rience. These can, I think, better lithotomize than Hthotrize, and numerous fatal instances from the latter method, under their hands, have come to my know- ledge in this district." 260 Lithotripsy. gerous weapon; for the natural tendency of the closing of the loop, or zigzag chain, which binds upon the stone, in the act of demolishing it, is to drag the folds about the neck of the bladder and prostate into the embrace of the steel rods, where they emerge from the mouth of the cannula, and to pinch them to excess. Nor is this all—the irregular loop, full of small angularities; the numerous joints, and rivets, and dovetails; the prominent knots, and depressions, about each hinge; the inaccuracy and uncer- tainty, and lateral irregularity of the closing of the different joints; the long line of loop, running from stem to stern along the per- pendicular edges which frown from the serrated flat lining the interior of the chain; so well calculated to rake and harrow the plain surface of the bladder; so unadapted to descend into the nooks and hollows; to pass beneath the overhanging bank of the prostate; to enter into a cyst, or between the folds of a contract- ed bladder—together with the impossibility of enclosing a large stone; of the difficulty of picking up very small fragments after the stone has been quarried and of applying the principle of percussion to the instrument, and thereby its inaptitude to very hard stones; of the certainty of numerous small fragments, being drawn into the cannula between it and the chain, so as to render the remo- val of the instrument from the bladder difficult and painful; to say nothing of the difficulty of fixing the stone securely, and of pre- venting it from shifting from side to side of the instrument, in the act of closing the chain; which want of steadiness, in part, arises from the great length of chain which gives it a serpentine motion when dragged upon, and, in part, from the chain not hugging the stone closely over its entire surface, but standing off, (particular- ly if the stone is flat, as most stones are) at every part of the loop corresponding to a joint in the chain; and, lastly, the com- plaint of most patients when the loop is expanded in the bladder, and an attempt made to scoop the stone within the bow of the instrument—a complaint so characteristic, that when 1 passed it upon one occasion the patient cried out, without knowing the conformation of the instrument, that " I had put a basket into his bladder." These objections are the result of my own ob- servation; I have not hunted up European publications to cull them from; I have seen, indeed, but one publication on this particular subject, and from that I will venture to make an ex- tract, as it seems to confirm the view I have taken:—"La Lithotripsy. 261 decouverte de cette instrument, etait precieuse lorsque celui de M. Heurteloup n'existait pas, car on pouvait commencer avec l'instrument a trois branches et continuer avec le brise pierre de M. Jacobson: mais a present il est devenu absolument inutile: l'instrument de M. Heurteloup le remplace toujours: et j'ai prouve, dans le chapitre precedent, que le perceuteur peut s'appliquer, avec le moins de dangers, et le plus de facilite possible, dans tous le cas ou la lithotritie est practicable; c'est pourquoi il est evi- dent que l'instrument de M. Heurteloup est preferable a tous les autres, et que M. Velpeau a eu tort de choisir l'instrument de Jacobson comme le meilleur. La preuve la plus manifeste de la verite de mes paroles est que cet instrument n'est employe par aucun lithotriptiste connu."*—Not to be unjust, however, to Ja- cobson's instrument, (whatever my own impressions of it, or those of others, may be) it is but fair to state, that it has been em- ployed successfully in this country in several cases by Ur. Jacob Randolph of this city, and Dr. Nathan R. Smith of Baltimore; and the inference, therefore, is plain that it must be an instrument of some merit,—and this I am not disposed to deny, whilst, at the same time, I am inclined strenuously to contend that the lithotripteur of Heurteloup is a better one—and, for the fol- lowing reasons: 1st. That in addition to its working upon the principle of graduated pressure, it combines the important power of concussion; 2nd. That it does not give the patient so much pain, either during the introduction or whilst ma- noeuvred in the bladder; 3d. That it can grasp a larger stone; 4th. That its beak can descend behind the prostate and enter every corner or pocket of the bladder; 5th. That it is extreme- ly well adapted to seek out and pick up fragments; 6th. That it is so constructed as to render it almost impossible to pinch the bladder, were the surgeon even disposed so to do; 7th. That although not so strong, perhaps, as Jacobson's chain, that it would be next to impossible, when well tempered, to break it; 8th. That the only inconvenience I have ever experienced from it, is the liability of the groove, in the female rod, to become clogged with sand and small fragments, so as to give the patient pain in withdrawing the instrument—that this, however, is easily obvi- ated, after a little practice, by opening the forceps, and by slight • Sur La Lithotripsie et la Taille par M. P. Doubovitzki: Paris, 1835. Vol. II. 31 262 Lithotripsy. lateral movements, washing out the fragments, and afterwards crushing the remainder by a few taps of the hammer. One re- mark, however, may be made in conclusion, and should not be lost sight of, as regards the employment of instruments in gene- ral—that almost every surgeon, when once accustomed to a par- ticular instrument, even although that instrument may be an awkward and ungainly one, will perform better with it than another surgeon equally skilled but unaccustomed to it. From numerous sources entitled to credit, I learn that the modifications of Heurteloup's and other instruments are almost endless, and that there is scarcely a lithotritist but has some instrument peculiar to himself. Hence, probably, the great variety of opinions on the subject, and the endless and bitter controversies which have been for some time past, and still are, waging among them. Time, the great instructer in all things, will be able " tant as componere lites." Many of the foregoing remarks will be illus- trated by the following cases. Case I. Dr. F-------, of North Carolina, consulted me on his case in June, 1835, which, in several respects, was a distressing one. He had submitted to lithotomy some months before I saw him; and although the operation had been performed skilfully, the wound never healed, but remained fistulous, and in a little time the stone made its appearance again, and seemed to be enlarging with ra- pidity. He had been making attempts, I found, to crush it, by means of Jacobson's instrument, but had never succeeded (owing to the severe pain and spasms which followed each trial) in sei- zing it, or in detaching fragments. I proposed the employment of Heurteloup's lithotripteur, and explained to him jts mechanism, with which he was so much pleased as to consent to its introduc- tion a day or two after. So extremely sensitive, however, was the bladder, and so great his apprehension, that he would not suf- fer the instrument to be introduced except in the slowest and most deliberate manner, consuming five or six minutes, frequent- ly stopping its progress with his own hands, and, in fact, almost performing the operation himself. Having at last reached the bladder and felt the stone, I expanded the forceps to an inch and Lithotripsy. 263 upwards in width, seized the stone and broke off a large piece of it. All this was effected so quickly, according to his ideas of time, as greatly to delight him, and determined him to submit to further efforts to obtain relief. Accordingly, a few days after- wards, another trial took place; and although the operation was performed partly by me and partly by himself, it proved equally successful as the first attempt, and encouraged him to proceed with other trials, at one of which Dr. Hays and other gentlemen were present. After each operation, however, there was always more or less chill and fever; and as the patient's constitution had been greatly impaired by long suffering previous to my having seen him, I was almost afraid, after each trial, to touch him again. In proportion, however, as the fragments were gotten away (though sometimes by sticking in the urethra they gave him great uneasiness,) his constitution continued to improve so rapidly as to enable us to renew attempts with greater frequency, but always with more or less success. Towards the end of July, however, I was obliged to leave town, and to take my instruments with me, which put a stop to further proceedings for several weeks. During my absence, the patient had procured an imita- tion of Heurteloup's lithotripteur, and assisted by some of his friends, particularly by Dr. Rose, had succeeded in removing other fragments. From that period, during the whole of the last win- ter, he was engaged in operating on himself, with occasional as- sistance from myself and Dr. Rose, and was enabled, by great industry and perseverance, to make in the spring a collection of fragments and sand amounting to 3 5 12 grs. in weight. By this time his health was so much improved as to enable him to return to Carolina. Such is the tendency, however, in his particular case, to generate calculous matter, that it is very questionable whether he will not be liable, always, to its formation, unless by change of diet, water, and climate, he can effect such a change in his constitution as to get rid of the diathesis.* Case II. At the request of Doctor Tyndale, a respectable practi- tioner, whom I had the pleasure of meeting during a visit of a few days at the White Sulphur Springs, in Virginia, in the summer of 1835, I saw, in consultation with him, W. T., • This patient, as predicted, has had a return of his disease. 264 Lithotripsy. Esq., of Pittsylvania. Believing, from the symptoms, that the patient had stone in the bladder, I was induced to sound him, and discovered a calculus of considerable size, under which he had laboured, in all probability, for several years. From this and other causes, his health had been long impaired and his con- stitution irritable. In some respects, however, his case appeared to be adapted to lithotripsy, but totally unfit for lithotomy. Having my instruments with me, and wishing to ascertain whether the stone was hard or soft, I prevailed on Mr. T., to submit to the introduction of the lithotripteur of Heurteloup; and although the bladder had not been fully distended with water, or the patient prepared by diet for the operation, I succeeded in detaching small portions of the stone, which were brought away in the gutter of the instrument, and which proved to be soft and mor- tar-like, but full of sharp, needle-like points. A slight chill and fever followed this attempt; from which, however, after a few days, no inconvenience resulted. I then took leave of the patient, and advised him to repair to Philadelphia the ensuing autumn and undergo the operation of lithotripsy, enjoining upon him at the same time the necessity of regular preparation, by appro- priate diet, for several weeks previous to leaving home. Shortly after my departure from the Springs, Mr. T., from eating boiled corn and other unwholesome articles of food, had a violent at- tack of cholera morbus, and with great difficulty recovered from it. From that period his constitution became enfeebled, and he suffered more than ever from the disease in his bladder, pass- ing occasionally lumps of sabulous matter, like mortar in consist- ence, but full of so many sharp crystallized points as to create great pain and soreness in passing them. During the whole winter he remained at home, unable to set out for Philadelphia; but towards the spring, finding his health somewhat improved, made the attempt, and arrived, after encountering bad roads and very unfavourable weather, on the 27th of April, 1836, exhibit- ing great marks of fatigue and long suffering, and very much changed in appearance since the period I had first seen him. Finding that Mr. T., had been making no preparation in the way of regimen to facilitate the operation of lithotripsy, and to guard against irritation and inflammation, I placed him at once in lodgings, as near to my own residence as possible, in order that I might watch him closely and be with him at a moment's warn- Lithotripsy. 205 ing in case of difficulty, impressing at the same time upon his landlord the necessity of the strictest attention to diet, &c. Having consumed neatly a month in subjecting him to dietetic discipline, and dilating the urethra by gum elastic catheters, I commenced regularly, May 24th, with the operation of lithotripsy, introduced Heurteloup's instrument, touched the stone, but could not seize it, owing to the small quantity of urine contained in the bladder, but which, notwithstanding, the patient informed me, had been collecting for several hours. From this operation no inconve- nience followed, and the patient was ready on the 26th for an- other trial. The lithotripteur being introduced, the stone could not be felt, owing to the small quantity of urine contained in the bladder. To obviate this difficulty I withdrew the instrument, injected the bladder with tepid water, again introduced the //- thotripteur, seized a portion of the stone, which readily crumbled beneath the pressure exerted upon it, and brought away small mortar-like fragments. Other pieces of similar appearance were discharged along with the urine in the course of the day. To facilitate the seizure of the stone upon this occasion, I found it necessary to introduce a finger into the rectum, and raise the stone from the fundus of the bladder, or the bed, or cyst, into which it had been accustomed, as I had reason to believe, to lurk. Four hours after the operation the patient complained of having a slight chill; this continued for an hour, and was fol- lowed by a little fever. These symptoms I thought might be attributed in part to the weather being uncommonly cold, raw and damp, from the continued prevalence for some time of easterly winds. Towards night the constitutional symptoms passed away, and the only complaint the patient made was of unusual soreness along the urethra, which I accounted for by the passage of the mortar-like substance, armed with its crystal- lized points. Upon visiting the patient next day, (27th,) I found him com- plaining of desire to evacuate urine every twenty minutes, and of a discharge of ropy mucus of yellowish tint. These symptoms continued throughout the day, more or less, and were unabated on the next day (28th,) which induced me to order the hip bath and 30 drops of black drop, and a weak opiate injection per anum. Under the influence of these, Mr. T. slept soundly until 3 o'clock, P. M. During the afternoon, however, more or less of drowsi- 266 Lithotripsy. ness continued, and the desire to make water had nearly ceased, and so remained throughout the night, but, in the morning (29th,) returned with its former urgency. To combat this as soon as possible, the opium was again resorted to, both in form of injec- tion and black drop, internally. In the afternoon, also, an aloe- tic pill was administered, and a blister applied to the sacrum. Under the influence of these the patient passed a good night, al- most undisturbed by spasms. On the next morning, (30th,) the desire to pass urine, accompanied by spasms, returned and con- tinued all day, at intervals of fifteen or twenty minutes. At five o'clock, P. M., a suppository, consisting of three grains of ci- cuta, and two of opium, was administered. At eight o'clock, P. M., the pulse, for the first time, became full and bounding, owing to too much nourishment (consisting chiefly of raw oys- ters) having been taken, and to the room being filled with the gas of anthracite coal, which is as deleterious in its operation as that of charcoal. To remove these symptoms, the patient was bled to ten ounces. Notwithstanding the bleeding, the pa- tient passed a restless night, and on the next morning (31st) the spasms returned with more violence than ever. In the course of the forenoon, a laxative enema was ad ministered two or three times, and produced copious evacuations. At 3 o'clock. P. M., it became necessary, on account of frequency of alvine discharges, to administer an opiate enema. This checked the diarrhoea and spasms for the night, but in the morning (June 1st) the spasms returned again, and continued with more or less violence through- out the day. Various remedies, besides the opiates and other means detailed, were tried ineffectually, and, although the symp- toms varied from time to time, the spasms and pain in passing urine were the prominent ones, and came on at last with such violence, and at such short intervals, as to prostrate the patient beyond the possibility of recovery. Two days afterwards {June 3d) he died. Permission could not be obtained to examine the bladder and its relations, a circumstance much to be re- gretted, especially as lithotripsy is still in its infancy and requires all the light that can be shed upon it. But, although denied the opportunity of examining the condition of the bladder, and of as- certaining positively the cause of death, there are several circum- stances connected with the case exceedingly well calculated to unravel a part of the mystery. From the history of it I have Lithotripsy. 267 detailed, it Will be seen that extraordinary pains were taken to prepare the patient for the operation, by restricting his diet in every possible way—by confining him to his room, and by the use of instruments calculated to enlarge the urethra and accus- tom it afterwards to those to be employed for the destruction of the stone. Unfortunately, however, the interesting sufferer was not aware of his own danger, and with the best possible inten- tions, in deceiving me in what he supposed to be little matters of no moment, he deceived himself, and led to results which I am very confident would not otherwise have followed. Instead, then, of attending strictly to the regimen I had prescribed, (as I have since ascertained from the best authority,) instead of living entirely on barley water, black tea, dry bread, and rice, and avoiding altogether animal food during the entire month of preparation preceding the operation, his meals were taken with the family with which he lived, and every article on the ta- ble he happened to fancy freely indulged in. This course, to- gether with undue exercise, either in his room or abroad in the streets, was calculated, as I am sure every experienced sur- geon will admit, to produce the worst effects, especially in a pa- tient advanced in years, of irritable constitution—one who had long suffered from violent attacks of other diseases—whose blad- der had been thickened and contracted by the lodgement, for years, of a large stone—-whose kidneys, in all probability, were also diseased, besides other organs, more or less important in the animal economy. I trust it will not be supposed that I mention these facts by way of exculpation or for the purpose of casting a veil over any errors I may have committed. Those who know me, I think, will acquit me of such intentions. Nor would I have it supposed that I am casting unjust and unnecessary cen- sure upon the respectable patient for whom I felt the highest personal regard and respect, and in whose case I took the most sincere and lively interest. My only motive in detailing such circumstances, is the public good, and for the benefit of those who may be now engaged in treating similar cases, or who may do so hereafter; for there is nothing more likely, than that patients similarly situated with Mr. T., (who from having always been accustomed to plentiful and luxurious living—to all the comforts and delicacies of life,) will not voluntarily refrain from such en- joyments, especially if they can persuade themselves that the 268 Lithotripsy. indulgence in them cannot interfere, materially, with their com- plaints^and the mode of treating them. Case III. At the request of my friend, Dr. Joseph G. Nancrede, I saw, in consultation with him, in April, 1836, Mr. Charles O'H., 63 years of age, who, for the last few years, had led a sedentary life, and complained, latterly, of symptoms of stone in the blad- der. Upon sounding the patient, a stone of large size was dis- tinctly felt, both by Dr. Nancrede and myself, and the case pro- nounced, in every respect, suitable for lithotripsy. The patient having consented to the operation, was accordingly prepared for it, by being placed on a diet of rice, barley water, and black tea; very little time, however, was required for this purpose, in- asmuch as he had abstained for some time previously, from ani- mal food, by advice of Dr. Nancrede. On the 1st of May, I commenced the operation in presence of Dr. Nancrede and Dr. J. Y. Hollingsworth of Maryland, by in- troducing a large silver catheter, and injecting the bladder with tepid water, until the patient complained of uneasiness from a sense of distention. The catheter was then withdrawn, and the lithotripteur of Heurteloup introduced, but the stone not felt un- til the patient turned a little on his side; I then perceived it to roll over the instrument heavily, which convinced me, at once, that it was large. Upon placing the patient on his back, and elevating his hips with pillows, the heel of the lithotripteur came in contact with the stone, which was readily seized, (though not until I had expanded the blades of the instrument beyond an inch and a quarter,) and by a few turns of the tripod, broken it into several large fragments, the cracking of which, as they were rent asunder, could be distinctly heard. During these manoeuvres the patient remained perfectly still, experienced not the slightest uneasiness, except that arising from over distention of the blad- der,) and was conversing, cheerfully, during the whole operation, which did not exceed in duration five minutes. Upon withdraw- ing the lithotripteur, and directing the patient to stand up and evacuate his urine, numerous small fragments were discharged, besides those contained in the blades of the instrument. The Lithotripsy. 269 catheter being again introduced, and the bladder injected, other fragments were brought away. Neither pain, chill, nor fever followed the operation; the fragments, in small quantity, con- tinued to pass away, but not with as much rapidity as if the mus- cular power of the bladder had been greater. On the 16th of May, I repeated the operation, in presence of Drs. Nancrede, and Horner, seized, without difficulty, fragment after fragment, and fractured them, without giving the patient any pain whatever, except upon withdrawing the instrument, which, from being a little clogged with pieces of the stone, pro- duced slight irritation at the external orifice of the urethra. No constitutional disturbance followed, and the patient, as here- tofore, passed again small fragments. May 19th, in presence of Drs. Nancrede, Hays, Caldwell, and Bush, of Kentucky—Cabell, of Virginia, and several medical stu- dents, I renewed my attempts upon the fragments of Mr. O'H's. stone, with the success I had hitherto met, and without the ope- ration having been followed by a single unpleasant symptom. Fewer fragments, however, than usual, passed away, immediate- ly after the operation, and for several succeeding days, owing to continued inactivity of the Hbladder, or want of muscular power. 21th, in presence of Dr. William Crump, a distinguished phy- sician of Powhattan County, Virginia, Drs. M'Crea, Stewardson, Pennebaker, Smith, Mr. W. Tunstall, of Virginia, and many me- dical students, I performed upon Mr. O'H. the operation he had, upon former. occasions, undergone. Previous to commencing it, however, it was necessary to remove a fragment from the urethra, which lodged about an inch behind the glans and was easily removed by a bent probe. Several of the fragments in the bladder, notwithstanding the former operations, measured, by the graduated scale, half an inch, and even three quarters. These were distinctly heard to crack, by several of the gentle- men present, under the pressure of the tripod. This, like the former operations, was followed by no unpleasant occurrence. 29th. (Drs. Nancrede, W. P. Johnson, and J. Wallace being present,) I performed lithotripsy for the fifth time on Mr. O'H., and without injecting the bladder seized upon fragment after fragment, and instantly reduced them to pieces so small, that scarcely a particle could be caught larger than a quarter of an Vol. II. 3o 270 Lithotripsy. inch, though in the commencement of the operation, two or three fragments, exceeding half an inch in size, were met with. As usual, the patient bore the operation without a murmur. Several fragments and a good deal of debris came off in the blades of the forceps. But several days elapsed, after this operation, before any pieces of consequence were discharged with the urine. Early in the morning, however, on the 1st of June, I was sent for to remove a fragment that blocked up the urethra near the neck of the bladder, which I thought best to push back with a ca- theter. June 12th. Accompanied by Drs. E. Peace and W. B. John- son I again visited Mr. O'H., introduced a large silver catheter and drew off a small portion of urine, which the patient could not expel by his own efforts, injected the bladder with tepid water, and introduced the lithotripteur of Heurteloup, with a view of crushing any fragments that might remain, but, much to my surprise, found that none could be detected; not satisfied, however, with this examination, I determined to explore the bladder with the common sound; but still with the same result. This was accounted for by examination of the bottle containing the discharged pieces, which had accumulated since the last ope- ration, (May, 29th,) so considerably, as to add largely, to the por- tions previously expelled, and which, taken collectively, from first to last would have been sufficient to form a stone of the size of a walnut, and one much larger might have been formed, if the patient had taken pains to collect all the pieces—but owing to inaccuracy in this respect, a great deal of sand and numerous fragments, there is reason to believe, must have been lost. As usual, no inconvenience resulted from this examination ; but, four days afterwards, (June 16th,) I was sent for, early in the morn- ing to visit the patient, who felt alarmed at the idea of a frag- ment being lodged in the urethra; such, however, upon passing the instrument, I could not discover, and, therefore, concluded that irritation had been created by the patient having changed his diet too suddenly, after having been told that he was nearly rid of his calculus. Upon this occasion, indeed, I found him over a large bowl of coffee, and surrounded by piles of bread and butter. By directing him to resume his tea and barley water, all uneasiness about the bladder and urethra disappeared in a few hours. On the 20th of June, I paid him another visit, Lithotripsy. 271 and found him complaining of slight tenderness in one testicle and a pricking sensation in the urethra. Suspecting the lodge- ment of a fragment, I introduced a pair of small forceps and ex- tracted a piece about a quarter of an inch in length. In the presence of my friend, Dr. Norcom, an eminent physi- cian of North Carolina, Dr. Chase, Dr. Nancrede, and Mr. Schi- vely, I repeated the operation to-day, (June 29,) on C. O'H., by injecting the bladder, introducing the lithotripteur, and searching for the stone; but, after moving the instrument in every direc- tion, within the bladder, I could not touch a fragment. The li- thotripteur was withdrawn, and the patient rose and passed his urine. It then occurred to me, that by sounding the patient with the bladder empty, I might be able to feel the stone and crush it. Upon so doing, accordingly, a fragment about half an inch thick, was distinctly felt, and almost immediately seized and de- molished. Another was also caught, and as readily destroyed. In the groove of the instrument, as usual, portions of mortar-like matter were found. Fully convinced from the accurate exami- nations made at different periods that the fragment destroyed to- day was the only one the bladder contained, I felt very confi- dent that the patient would soon be entirely rid of his complaint. For the last eighteen months he has been perfectly well. Case IV. H. M., of Virginia, thirty-four years of age, arrived at Phila- delphia on the 29th of April, 1836, and consulted me on his case, which, in some points of view, was a singular one. According to the patient's statement, a persimmon seed had been introduced into his urethra, and found its way into the bladder, where, in all probability, it had served as a nucleus for a stone; for, in a short time after, symptoms resembling those of stone, were manifested. Upon sounding the patient, I discovered a calculus of small size, and (judging from the feel communicated to the sound) of soft consistence. Anxious to undergo lithotripsy, or lithotomy if I preferred it, he was placed, at once, upon appropriate diet, di- rected to drink plentifully of diluents, and while pursuing this course, had the urethra dilated with bougies, catheters, &c. Af- ter persevering in this system for three weeks, the patient be- 272 Lithotripsy. came exceedingly desirous of submitting to the operation itself, and, as he possessed considerable mechanical skill and ingenuity, and had examined with great curiosity the instruments for litho- tripsy, expressed a decided preference for that of Jacobson. To gratify him, therefore, it was employed, and, with the utmost caution and gentleness, attempts made to seize the stone; but, so great was the irritation, and so severe the spasmodic action of the bladder, induced by its presence, that it appeared to me it would have been forcibly expelled from that viscus. I was obliged, therefore, to withdraw the instrument, after the lapse of a few seconds. This attempt was followed by severe chill and fever, which confined the patient for several days. On the 26th of May, I commenced, regularly, with Mr. M., and, at his request, again employed the instrument of Jacobson, notwithstanding the suffering it had previously occasioned him. Accordingly, it was introduced, but created so much pain and inconvenience that he peremptorily demanded its removal. Upon withdrawing the instrument, the urine which had been re- tained three or four hours, escaped, and rendered it necessary, before proceeding further, to inject the bladder with tepid water. After this, the lithotripteur of Heurteloup was introduced, and the stone almost immediately seized and crushed under the pressure of the tripod or screw—creating a sound similar to that of chalk, when broken between the fingers. In the groove of the instru- ment, numerous small fragments were found, and, in course of the day, several large pieces discharged along with the urine, some of which were encrusted with a dark brown or black skin, similar to the husk of a persimmon. The stone, as I had pre- dicted, was of rather soft consistence, aad apparently composed of the ammoniaco-magnesian phosphate. Before the completion of the operation, the patient suffered a good deal from pain and spasm of the bladder, but these soon ceased, and were not fol- lowed, as in the former attempts, by chill and fever.; Two days (May 28th) after the operation, however, the patient complained of great pain in the urethra, but was suddenly relieved by the discharge ef a large fragment, in the centre of which was a hol- low or depression, corresponding in shape and size with a per- simmon seed. On the 29th, another fragment was discharged, but, as no other made its appearance from that period until the 6th of June, I in- Lithotripsy. 272 troduced, on that day, in the presence of Dr. Saltmarsh, the in- strument of Heurteloup, and used it as a sound, but could not de- tect any portion of stone. However the next day, (June 7th,) a fragment, half an inch long, and hollowed out in the centre, passed off with the urine. At the same time, a portion of black skin resembling the rind of a persimmon was thrown off. On the 9th of June, the lithotripteur was introduced, but without de^ tecting a fragment. The same operation was repeated four days after (June 13th) in presence of Drs. Johnson and Peace, but with no better success. Having experienced no inconvenience from the two last examinations, another was made (June 17th) in presence of Dr. Saltmarsh, and a fragment about the size of a bean felt at the fundus of the bladder, which was readily caught and crushed. Irt the course of the day, three oblong fragments, a quarter of an inch thick, passed away with the urine. With the view of ascertaining whether other fragments still remained in the bladder, the lithotripteur was again introduced, (June 20th, Dr. Saltmarsh being present,) but nothing could be felt. Soon after this examination, the patient changed a pair of cloth pantaloons for thin ones, and walked about the streets for some time, and, when he returned to his lodgings, was seized with chill, followed by high fever, which rendered it necessary to bleed him and re- strict his diet more than ever Since that period he has been confined to his room with sore throat, cold, and more or less fever, which, for the present, prevent the operations from being con- tinued. That any fragment of stone remains in the bladder, seems to me extremely doubtful; it is more than probable, how- ever, that the persimmon seed is still there, inasmuch as no por- tion of the substance of the seed has been yet discovered, and, as he complains, after passing urine, of something presenting itself at the neck of the bladder. Whether the lithotripteur will be able to destroy the texture of such a substance, (which closely resembles softened horn,) I am at a loss to say. In truth, untiL I saw the pieces of black skin discharged along with the frag- ments, I did not believe that such a foreign body had found its way to the bladder, and had placed the patient's account of the mode of its getting there to the effect of imagination. On the 28th of June, the patient having recovered, in a great measure, from the effect of his cold, another examination was made with the lithotripteur, but smaller in the shaft and shorter 274 Lithotripsy. in the beak than the one commonly employed. This did not en- ter with facility, but met with considerable obstruction at the neck of the bladder; it finally started forward, very suddenly, and was completely introduced. Some hours after, the patient dis- charged, along with the urine, more or less venous blood, the re- sult, no doubt, of the pressure of the short beaked instrument upon the prostate and neck of the bladder. To-day (June 29th) the urine is colourless and the patient free from soreness in the urethra, and, as the weather is becoming warm and oppressive, and he complains*of being weakened and reduced, I have ad- vised him to postpone further operations for the present, and re- tire for a few weeks to the country. In the following autumn he returned to town and submitted to two or three more opera- tions, and was soon perfectly cured, (by the removal of the per- simmon seed,) and has so remained ever since. Case. V. P. P., Esq., about 48 years of age, of literary and sedentary habits, troubled more or less with dyspepsia, came to Philadel- phia in 1835, by advice of my friend, Dr. Thomas, a distinguished physician of Westchester, to consult me about symptoms resem- bling those of stone in the bladder. His engagements, however, at that period, were such as to prevent him from being sounded, and from remaining in town. About the middle of May, 1836, he returned to Philadelphia, and upon sounding him I discovered a stone, and concluded from its ringing distinctly when struck by the sound, that it was a hard one. Believing the case adapted to lithotripsy, I advised the operation, placed him in suitable lodgings, and commenced a system of diet, which, indeed, he himself had been observing, in a measure, for some time before, having anticipated the necessity of such a course. After using, also, gum elastic and other instruments to familiarize the urethra with such guests, I commenced the regular operation (May 21,) by introducing Jacobson's instrument, which, however, gave ex- cessive pain, brought away blood, created severe chill and fever, and rendered the patient so ill as to induce me to advise him to return to the country after the symptoms had abated, and re- main until he recovered sufficiently to undergo a trial with another instrument. Accordingly, he left town on the 26th of Lithotripsy. 21 o May, and returned on the 4th of June, improved in appearance and health. On the 8th of June, I introduced the lithotripteur of Heurte- loup; and after searching for the stone a few seconds, discovered, seized, and fractured it, as it lav in the fundus of the bladder on its right side. During the turning of the screw, the fragments could be heard cracking distinctly, the report being very sharp and sudden, like that of a distant whip. Upon removing the instrument, numerous small fragments were found in its claw and gutter, of a yellowish or gamboge tint, intermixed with harder portions of dark brown fragments; which from appearance, I should suppose were made up of oxalate of lime and lithic acid. During the operation the patient scarcely complained of pain, and remarked that the uneasiness arose more from sense of distention, from having retained his urine two or three hours previous to the ope- ration, than from the instrument. Neither chill nor fever follow- ed this operation ; and the next day sand and several small frag- ments were discharged with the urine. On the 14th of June, the patient felt well enough for another trial, which was accordingly made, and with the same happy re- sult—the stone having been seized instantly and crushed with an audible noise. Numerous fragments came away in the groove of the lithotripteur, and the next day three larger than a pea were discharged along with the urine—the whole collection, from the two operations, being sufficient, if put together, to form a stone the size of a large almond. During the operation, the patient did not complain of pain or spasm of the bladder; more or less of which last he had usually experienced while the instruments remained in that organ. On the 17th, I visited Mr. P. again, (accompanied by Drs.. Peace, Chase, and Johnston) with the view of searching for frag- ments ; but the patient not having allowed the urine to collect in sufficient quantities to seize them with safety, I declined the operation, but merely used the lithotripteur as a sound, to deter- mine the size and situation of the pieces. On the 22nd of June, in presence of Dr. Saltmarsh, I made another examination, but without being able to detect a fragment, and repeated the effort on the 25th and 29th, but with no better success. That there is still a fragment in the bladder, however, is rendered probable by the circumstance of the patient feeling 276 Lithotripsy. an obstruction, occasionally, about the neck of the bladder after walking or remaining for some time in the erect position, an ob- struction sufficient to impede the flow of urine for a moment, or un- til removed by a change of position. But the patient's engagements are such as to prevent him from staying longer in town at present; and as he is desirous of recovering, also, from the effects of his restricted system of living, he returns to his farm, and, after har- vest, intends to have the bladder still further explored. He came back, accordingly, after the lapse of a few weeks, and by one or two more trials with the lithotripteur, was restored to perfect health, and so continues to the present time. The above account of lithotripsy was published, two or three years ago, in the American Journal of Medical Sciences, and has been transferred to these pages with few alterations. Since that period I have not had occasion to vary much the opinions I then formed on the subject. The instruments, however, which I at first employed I have altered, more or less, to suit my conve- nience, especially the beak of the lithotripteur—by enlarging, considerably, the opening, or slit, near its heel, to permit the free passage of fragments. Of these alterations, I shall give an ac- count at some future period, and, probably, in another publica- tion ; and record, at the same time, the result of other lithotriptic operations, in which I have been for some time engaged. On Lithotripsy, consult case of Lithotripsy successfully performed by L. Dey- pere, in New-York Med. Journal, for Nov. 1830—The Operation of Lithotripty, by Jacob Randolph, M. D., in Amer. Journal of Med. Sciences, No. 29, Nov. 1834, and in subsequent numbers of same Journal.—Parallele des divers moyens de traiter les Calculeux, &c. &c.,par le Docteur Civiale, Paris, 1836—De La Lithotripsie par Le Roy—D'Etiolle, Memoire No. 1, Paris, 1836—Smith's Cases of Litho- tripsy, in Amer. Journal of Med. Sciences, No. xli. Nov. 1837—Lithotripsie, Me- moires sur La Lithotripsie par percussion, et sur ^instrument appeli percuteur courbe a marteau, qui permet de mettre en usage ce noveau systeme de pukeriza- dion des peirres vesicates, &c. &., par le Baron Heurteloup, Paris, 1833. Diseases of the Eye. 277 CHAPTER X. DISEASES OF THE EYE. The eye, from its delicate and complex structure, and the number and diversity of its diseases, was formerly much ne- glected, especially in Europe, by the regular members of the profession, and attended to almost exclusively by ignorant and itinerant oculists. Within the last twenty years, however, the value of this important branch of surgery has been duly estimated, in proof of which it need only be mentioned that Ware, Saun- ders, Gibson of Manchester, Adams, Wardrop, Travers, Vetch, in Britain, and Scarpa, Beer, Schmidt, and others on the conti- nent, have contributed largely by their writings and operations to elevate this department to a most respectable rank. Many of these gentlemen, indeed, forsaking the general practice of their profession, have devoted their whole attention to ophthal- mic surgery, and with a result truly honourable to themselves, and glorious to their country. The most common affection, perhaps, of the eye. is ophthal- mia. Of this, therefore, it will be proper first to treat. Oph- thalmia is employed by most modern writers as a generic phrase —denoting ocular inflammation. For the sake of precision and accurate discrimination, other terms have been invented, some of them simple and expressive enough, others formidable in the extreme, or altogether monstrous.* To elucidate the varieties • Nothing short of affectation or pedantry will enable us to tolerate, in many instances, the phraseology of Beer and Schmidt—such as opthalmo-blennorrhoea, t>lepharo-opthalmo-blennorrhcc3, dacryoadenitis, blepharophalmitis idiopathic*, Vol II. 36 278 Diseases of the Eye. of the disease, I shall not follow the exact arrangement of any individual author, but endeavour to simplify as much as possi- ble, and oppose every distinction which is not perfectly clear and obvious. anchyloblepharon, symblepharon, and a hundred more, either of which surpasses in complexity the old anatomical mouthful, baseochondroceratoglossus, 8cc. Conjunctival Ophthalmia. 279 Section I. Conjunctival Ophthalmia. Conjunctival inflammation, to denote which some writers employ the word ophthalmitis, is the most common form of ophthalmia, and is characterized by the following symptoms—a sense of uneasiness, or itching, an impatience of light, diffused redness of the conjunctiva, pain, heat, and swelling of the globe of the eye, an epiphora or increased secretion of tears, a pun- gent pain, proceeding apparently from the lodgement of a particle of sand or some other extraneous body, but in reality from one or more bundles of enlarged vessels. To these symptoms are superadded, if the inflammation continues to advance, deep-seat- ed, pulsatile and violent pain in the eye-ball, which extends to the forehead, accompanied by fever and other general indispo- sition. Very often, moreover, the conjunctiva becomes thick- ened, and projects in a fungous form beyond the margin of the cornea. At other times blood is extravasated between the con- junctiva and sclerotic coat. In the still further advanced stages of the disease, suppuration is liable to ensue, followed by de- struction of the cornea, evacuation of the humours and abolition of sight. It is seldom, however, that a simple conjunctival oph- thalmia terminates so unfavourably; on the contrary, the symp- toms gradually decline, and the eye is restored to its natural state, though sometimes the disease assumes a chronic form, and is then very difficult to manage. The causes of conjunctival ophthalmia are, for the most part, exposure to extremes of cold and heat, sleeping in the open air without cover, too intense and vivid a light to the eye, whether direct or reflected, blows, wounds, irritation from the 280 Conjunctival Ophthalmia. lodgement of extraneous bodies upon the globe, or between the eyelids, disorder of the digestive organs, &c. Catarrhal ophthalmia is a variety of conjunctival inflamma- tion exceedingly common on the continent of Europe, and sometimes met with in this country. It is frequently epidemic, and occasionally accompanies influenza. It is marked, in the early stage, by a peculiar dryness of the eye and eyelids, and by a pungent pain near the caruncula lacrymalis. In a few days these symptoms diminish, and are followed by a copious flow of tears, and a mucous discharge, which is generally so acrid as to excoriate the eyelids and adjacent parts of the cheek. The patient is scarcely ever free from fever. In severe cases of the disease the whole conjunctiva is covered with small pustules, containing purulent matter or a yellowish serous fluid. Purulent ophthalmy differs from the catarrhal in many re- spects. It is a very formidable and destructive disease, and some- times destroys one or both eyes in the course of a few hours. Adults, as well as children, are liable to it, but especially the latter. It usually commences four or five days after birth, by a slight redness and tumefaction of the conjunctiva lining the eye- lids. This is speedily followed by the secretion of a thin ad- hesive matter, which glues the lids together. In a few hours the discharge becomes very copious, thicker in consistence, ac- quires a yellowish or greenish cast, and is so acrid as to exco- riate the cheeks. From the lids the inflammation extends to the conjunctiva covering the ball of the eye, and the whole membrane is converted into a thick fungous mass; which, when the eyes are opened, projects beyond the lids, and obscures the cornea. If the disease should continue to spread, the cornea is next involved, and either ulcerates or sloughs, the humours are discharged, and the eye lost. A great deal of constitutional irrita- tion attends the early stage of the disease, but this subsides in three or four days, and the ophthalmia then assumes a chronic form. To assign any satisfactory explanation of the origin of puru- lent ophthalmia is very difficult. Some writers suppose it to be closely allied to the gonorrhoeal ophthalmia, others that it proceeds from leucorrhea; the matter of which, in both instances, is applied, it is imagined, to the eyes of the child during its Conjunctival Ophthalmia. 281 passage through the vagina. Mr. Saunders is inclined to be- lieve that the inflammation is of the erysipelatous kind. Gonorrheal ophthalmia, another variety of conjunctival in- flammation, bears a striking similitude to purulent ophthalmy, that form of it especially which is so prevalent in Egypt and other eastern countries, and from which the British and French troops, a few years back, suffered so severely. The symptoms, however, are, in every respect, more vehement, and such as to terminate almost invariably in the loss of one or both eyes. That it follows, in many instances, the direct application of the gonorrhceal virus, I have the strongest proofs; having had, at different times, patients under my care in whom the disease was produced by the practice, so common among the vulgar, of washing inflamed eyes with urine. There is reason to believe, also, that the disease is sometimes induced by sympathy or a metastasis, in consequence of suppressed gonorrhoea. Scrofulous ophthalmy, a disease very common amongst scro- fulous children, may be distinguished from other affections of the conjunctiva by a peculiar morbid irritability of the eye, or intolerance of light, unaccompanied with pain, which obliges the patient to keep the lids constantly in a half closed state, and confine himself altogether to a dark room. In addition to this, numerous distinct vessels may be seen running towards the cor- nea, some of which pass to the centre of that tunic, and termi- nate in a small pustule or ulcerated spot. This disease may continue for months together, without much alteration, and is very apt to be followed by corneal specks. Treatment of Conjunctival Ophthalmia. In the early stage or acute form of simple inflammation of the conjunctiva, the disease may be removed, in a short time, by general 'and local blood-letting, mild purgatives, nauseating doses of antimony, low diet, blisters behind the ears, or on the 282 Conjunctival Ophthalmia. back of the neck, lotions of tepid water, a solution of opium, or of the acetate of lead. If, in spite of this treatment, the inflam- mation should not terminate, but runs into the chronic stage, cold astringent washes and stimulating ointments may then be- come necessary, such as the vinous tincture of opium, the ci- trine ointment, the ointment of the red oxide of mercury, &c. For catarrhal ophthalmia the best remedies are moderate depletion, at first, and afterwards highly stimulating collyria and ointments. Purulent ophthalmia, in the commencement, should be treated upon common antiphlogistic principles, and by moderately astringent washes, introduced into the eye by means of a syringe. The best lotion for this purpose is the undiluted li- quor of the acetate of lead. In advanced stages of the disease, an infusion of two drams of the leaves of tobacco in eight ounces of water, was found highly serviceable by Mr. Vetch, in re- straining the discharge, relieving pain and removing watchful- ness. The aqua camphorata of Bates' Dispensatory has been praised as extremely efficacious in the chronic form of purulent ophthalmy. I have often tried it, however, without benefit, and sometimes with manifest aggravation of the symptoms. Gonoirhceal ophthalmia, unfortunately, admits of no relief; at least, in several instances of the kind which have fallen under my care, and in others which have occurred in the practice of Dr. Physick, no benefit whatever has resulted from any mode of treatment that could be devised. Mr. Vetch, however, with great confidence states, that the disease may be certainly cured by those remedies adapted to the treatment of Egyptian oph- thalmia. Scrofulous ophthalmy seldom requires antiphlogistic mea- sures ; on the contrary, a tonic plan of treatment will generally be indicated. In the commencement of the disease, however, it may be necessary to purge the patient, regulate strictly his diet, order warm clothing, moderate exercise in the open air, &c. To alleviate the intolerance of light, which is so much complained of by all patients in this disease, a blister at the back of the neck, kept open by savin cerate, will be found the best remedy. Sometimes the internal use of mercury will be required. The best collyria are those composed of weak solu- tions of the argentum nitratum, of sulphate of zinc, alum, &c. Sclerotic Ophthalmia. 283 Section II. Sclerotic Ophthalmia. An inflammation of the sclerotic coat, described by many Writers under the name of rheumatic ophthalmia, is often met with. That it is closely allied to rheumatism is exceedingly probable, both from the circumstance of its being a frequent con- comitant of that disease, and from the nature of the texture which it occupies. The pain in the commencement of the dis- ease, is generally seated in the temple, and extends thence to the eyebrow, cheek and eye of the affected side. It is constant- ly present, but commonly most severe during the evening and late at night. The eyeball itself, when examined, does not pre- sent the common appearances of conjunctival inflammation. There is no purulent discharge, nor does the patient complain of intolerance of light. The vessels, moreover, instead of fol- lowing a tortuous course, run in parallel lines upon the sclero- tic coat, and terminate at the margin of the cornea. These ves- sels are small and very numerous, and from being distributed over the whole albuginea, give it a uniform red colour; the red- ness, however, is not of the bright scarlet or vermilion hue, hut of a dingy, brick-dust tinge. More or less fever, and de- rangement of the digestive organs, generally accompany the disease; and in bad cases, the inflammation may run so high as to involve the cornea and destroy the eye. 284 Sclerotic Ophthalmia. Treatment of Sclerotic Ophthalmia. The chief indications in the treatment of this disease, are to restore, by means of emetics and purgatives, the functions of the stomach and biliary organs, or, if the inflammation has been in- duced by exposure, to excite the skin by antimonials. After- wards bark may, perhaps, be employed with advantage. The best local applications are a blister behind the ears, and the free use of the vinous tincture of opium as a collyrium. General, as well as local blood-letting, will, in certain cases of this disease, prove serviceable, but in others injurious. Hence the variety of opinions entertained on the subject by different surgeons; some contending that the depleting system should never be pursued, others, that it is indispensable. When ac- companied by a full pulse, and met with in plethoric patients, general blood-letting, leeches to the temple, or forehead, or around the eye, will almost always relieve the pain and other urgent symptoms; but when the complaint occurs in thin, and debilitated subjects, has been of long standing, or connected with general rheumatism, little or no benefit may be expected from venesection. Opiate frictions to the temples are extolled by Beer and other oculists, and belladonna to the eyelids and superciliary ridges. Applications to the ball of the eye, with exception of wine of opium, so useful in other forms of ophthal- mia, are seldom of much service in this variety of the complaint. Iritic Ophthalmia. 285 Section III. Iritic Ophthalmia. The term iritis was employed by Mr. Saunders to denote a variety of ophthalmic inflammation which previous to his time had been very little attended to. From the peculiarity and dis- tinctness of the symptoms, there can be no question as to the propriety of considering the disease purely an inflammation of the iris, and totally independent of every other species of oph- thalmia. These symptoms are severe lancinating pain extend- ing from the eyebrow to the orbit; and shooting thence through the globe of the eye towards the optic nerve, extreme impatience of light, and an extraordinary morbid sensibility of the eye. Unlike most other varieties of ophthalmia, iritis is unaccom- panied by redness of the conjunctiva, but the sclerotic coat is covered with numerous red vessels, which are particularly con- spicuous on that portion of it connected with the margin of the cornea. On the iris, also, at least on its anterior surface, red vessels may be distinctly seen; but the most remarkable change that this membrane undergoes, is the loss of its brilliancy, and a change from its natural colour to that of a reddish or greenish hue. At the same time the pupil becomes contracted and ir- regular, and its edge is turned backwards toward the crystalline lens. Instead of terminating in suppuration, the inflammation generally stops at the adhesive stage, and lymph is deposited upon the outer surface of the iris in one or more spots, and is sometimes secreted so copiously as to fill the anterior chamber. From this cause, incurable obliteration of the pupil often en- sues. The causes of iritic ophthalmia are various. Sometimes the disease is induced by exposure of the eye to intense or vivid light; sometimes it proceeds from wounds of the iris made by Vol. II. 37 286 Iritic Ophthalmia. the cornea knife or couching needle; at other times it appears to arise from some constitutional affection, such as gout. In the greater number of instances, however, it is the result of syphilis. or of the abuse of mercury. Treatment of Iritic Ophthalmia. The antiphlogistic system, carried to its full extent, will barely prove sufficient, in many instances, to arrest the progress of this severe disease. Hence the propriety of resorting to it as speedily as possible after the inflammation has set in. To guard against obliteration of the pupil, by breaking up the bands of coagulable lymph which extend across it, the extracts of bella- donna or stramonium will be found immensely serviceable. They should be applied to the outer surface of the eyelids, or over the eyebrows two or three times a day, and kept on for half an hour at a time. Care should be taken, however, not to employ them during the height of the inflammation. For the re- moval of syphilitic iritis, the moderate use of mercury, followed up by sarsaparilla, will generally prove an efficient remedy. For other varieties of iritis, also, mercury will often be found indis- pensable, and is chiefly useful in preventing the absorption of lymph, and even in preventing its deposition. Cantharides and oil of turpentine, as local applications to the forehead and temples, are likewise useful. Quinine in chronic Iritis is sometimes em- ployed advantageously. Psorophihalm ia. 287 Section IV. Psorophthalmia. Some of the German writers understand by psorophthalmia, a variety of inflammation of the eyelids, induced by psora or itch. In the usual acceptation of the term, however, nothing more is implied than simple inflammation or ulceration of the lids, whe- ther induced by small-pox, measles, scrofula, erysipelas, sties, or any other cause. Children, particularly those of scrofulous constitution, are very subject to this disease; adults, however, are not exempt from it. The inflammation first appears on the edges of the lids, and extends thence along the conjunctiva towards the globe of the eye. The pain is sometimes very severe, and the red- ness considerable, but the most distressing symptom is the in- tolerable itching, to relieve which the patient is obliged con- stantly to rub the affected part; and in this way only aggravates the disease. Sometimes the inflammation runs so high as to terminate in suppuration. This is followed by troublesome ul- ceration of the tarsi, and frequently by great deformity. The Meibomian glands are always more or less affected in this com- plaint, and pour out an adhesive fluid, that glues the lids together during sleep. To open these, in the morning, some force is usually employed, and this keeps up constant irritation, and fre- quently renders the disease chronic, causing the formation of small crusts or scabs along the tarsi and the cilia to drop out. In bad and long-standing cases of the disease, the puncta lacryma- lia are sometimes permanently obliterated, and an incurable epi- phora is produced. 288 Psorophthalmia. Treatment of Psorophthalmia. In the early stage of this disease, purgative medicines and a moderate diet will contribute very much towards a speedy cure. Weak solutions of the acetate of lead, of the sulphate of zinc, or sulphate of copper, will also be found useful as collyria. To prevent the lids from adhering, a very important indication in the treatment, a little fresh cream or butter should be placed between them every night before the patient retires to rest. After the inflammation has, in a measure, subsided, and is verging towards the chronic stage, the unguentum hydrargyri nitrati, applied to the edges of the lids, two or three times a day, will prove singularly useful in relieving the itching, and in healing the ulceration. With the same view, an infusion or decoction of the pith of the sassafras is sometimes used, and in many instances with decided advantage. Not unfrequently the disease resists, for a long time, every remedy, and, indeed, continues for years together. Under these circumstances, blis- ters behind the ears and neck, and a course of mercury may prove useful. Pterygium. 289 Skction V. Pterygium. The pterygium, or eye wing, is a thin membranous expan- sion seated upon the conjunctiva. It commonly occupies the inner angle of the eye, in the shape of a triangle, the apex of which looks towards the cornea. The disease is very common, but in most instances productive of so little inconvenience, that many persons are subject to it for years together, without be- ing aware of its presence. In the early stages, it resembles a globule of fat, and appears to possess little vascularity ; a slight cold, however, or an inflammation of the conjunctiva, renders its vessels very distinct. Although the disease may remain sta- tionary, or nearly so, for many years, it is always liable to in- crease, and in this case may extend over the surface of the cor- nea. But it is somewhat remarkable, that it seldom, if ever, passes beyond the semidiameter of the cornea. Sometimes a pterygium originates at each angle of the eye, and approaching the cornea in opposite directions, covers the whole of ils surface. The disease is then called a pannus. There are two varieties of pterygium—the membranous and fleshy. Treatment of Pteiygium. So long as this membranous excrescence continues small, and does not encroach upon the cornea, it will seldom be necessary 290 Pterygium. to resort to an operation for its removal. When, however, it has attained considerable bulk, and is a frequent source of irrita- tion, it should be dissected off either by a small scalpel or curved scissors. The scissors will generally be found the most con- venient. To perform the operation advantageously, an assistant should stand behind the patient and support his head firmly upon his breast, and with one or two fingers elevate the upper eyelid, whilst another assistant depresses the lower lid, and keeps it fixed. The surgeon then taking a pair of small forceps should elevate the pterygium from the conjunctiva, and by a few strokes of the scissors separate the whole of it from the globe. A smart and sometimes violent inflammation follows the operation, and this must be subdued by the usual remedies. Encanthis. 291 Section VI. Encanthis. The encanthis, an enlargement of the lacrymal caruncle and semilunar fold, is a very uncommon, but sometimes most malig- nant disease: It proceeds, in some instances, from obstinate and protracted ophthalmia; at other times the gland assumes a can- cerous action, and terminates, like most diseases of this descrip- tion—unfavourably. In every disease of the kind, whether be- nign or inveterate, the caruncula lacrymalis presents a granu- lated and livid aspect. In proportion, however, as the tumour increases, its surface becomes less rugged, and is covered with varicose vessels. From the caruncle the disease extends some- times to the cornea, and along the inner surface of each eyelid. When the tumour attains a large size, the puncta lacrymalia are commonly compressed or obliterated, and a troublesome epi- phora ensues. Treatment of Encanthis. Excision of the caruncula and of the valvula semilunaris is the only remedy for this disease; but the operation frequently fails either from the whole of the tumour not being taken away or from the malignant character of the complaint. In perform- ing the operation, the surgeon will find it most convenient to se- cure and control the tumour, by introducing a small hook into its substance, and then dissecting it out with a narrow scalpel. Care must be taken to avoid the puncta lacrymalia. If the tu- mour lias taken on the cancerous action, is very large, and has involved the surrounding parts, it may become necessary to ex- tirpate the globe of the eve. 292 Opacity of the Cornea. Section VII. Opacity of the Cornea. There are three varieties of corneal speck, noticed by most writers under the names of nebula, albugo, and leucoma. By nebula is commonly understood a " superficial opacity of the cornea, preceded and accompanied by chronic ophthalmia, through which the iris and pupil are seen, and which does not, therefore, entirely take away from the patient the power of see- ing, but only causes the surrounding objects to be seen as if covered with a veil or cloud."* The whole cornea is sometimes covered by a nebula; in other instances, several distinct specks appear in spots upon its surface, each of which is generally sup- plied with one or more vessels from the conjunctiva, or other coats of the eye. These vessels, indeed, serve to nourish or keep up the disease. The albugo differs in several respects from the common nebula. It is more deeply seated, and occupies the lamellae or substance of the cornea; it is also of a white or pearl colour, is frequently unaccompanied by ophthalmia or by red vessels, and is always the result of an abundant effusion of lymph. Leucoma is a dense callous speck of the cornea of a pure white or chalk colour, and polished aspect. It is usually the re- sult of a cicatrix from a wound or ulcer. Sometimes it follows small-pox or measles. * Scarpa. Opacity of the Cornea. 293 Treatment of Opacity of the Cornea. A simple nebula or cloudiness of the cornea, may often be dispersed by slightly astringent collyria, such as are calculated to subdue the ophthalmia that usually accompanies the disease. But, in many instances, a division of the vessels supplying the speck is rendered necessary. If the trunks are large, they should be elevated by forceps, and a piece taken out of each by the curved scissors. The treatment of an albugo of long standing will always be found very difficult, and nothing short of highly stimulating ap- plications will effect a cure. One of the best for this purpose is the unguentum hydrargyri nitrati, applied by means of a camel hair pencil to the surface of the speck once or twice a day. A weak solution of argentum nitratum, will, in most cases, prove very serviceable. The same may be said of sul- phate of copper, and of corrosive sublimate. Red precipitate ointment, also, is a very useful remedy. Finely powdered loaf sugar, calomel, and other similar articles, are frequently blown into the eye, and produce most salutary effects. A drop of molasses, between the lids night and morning, has frequently dispersed both nebula and albugo. In several obstinate cases of the disease which have resisted all the usual remedies, I have known a speedy absorption of the speck accomplished by the re- peated ablution of the eye and eyelids with diluted vinegar. In addition to the local treatment, the internal use of calomel and other preparations of mercury should be resorted to. The leu- coma is seldom, if ever, removed. Vol. II. 38 294 Ulcer of the Cornea. Section VIII. Ulcer of the Cornea. The cornea, as well as the fine lamina of conjunctiva cover- ing its surface, is liable to assume the ulcerative action. In either case, a very troublesome, and, perhaps, destructive disease may be induced. This ulcer is commonly the result of the different varieties of ophthalmia, or it may proceed from the introduction of acrid or caustic substances into the eye. Sometimes the whole cornea is covered by the ulceration; at other times, a small dimple-like cavity, not larger than the head of a pin, occu- pies some particular part of the cornea, and instead of spreading towards its margin, penetrates the layers until it lays open the anterior chamber of the eye. An ash-coloured slough, resem- bling wet pasteboard, generally covers the surface of the corneal ulcer. The edges of the ulcer, also, are high and serrated. Treatment of Ulcer of the Cornea. To relieve the excessive pain that usually attends this dis- ease, and to promote healthy granulation, there is no application so effectual as the argentum nitratum. The sore should be lightly touched with the caustic, until an eschar forms on its surface, and when this drops off, which it generally does in Ulcer of the Cornea. 295 twelve or eighteen hours, the application should be renewed— taking care to wash away, with milk and water, any superfluous caustic that may happen to lodge about the eye or eyelids. When the ulcer assumes a healthy aspect, the caustic may be discontinued, and mild collyria or ointments substituted. " In all cases," says M'Kenzie, " we endeavour, of course, to check the ulcerative process, by those measures which are fitted for subduing the inflammation in which the ulcer took its origin. So long as there is an appearance of activity in the inflammatory disease, and much pain of the eye, local blood-letting must be employed. The bowels must be kept freely open, and opium administered in such a combination as shall be likely to operate on the skin. In strumous cases, sulphate of quinine operates very advantageously. In chronic superficial ulcer, calomel given so as to affect the mouth is sometimes necessary. In al- most all cases of ulcerated cornea, counter-irritation will be found useful. As the inflamed state of the eye abates, the pa- tient finds the pain greatly relieved, and we observe the ulcer clearing and beginning to contract." 296 Staphyloma. Section IX. Staphyloma. In the sense affixed to it by most modern writers, the term staphyloma implies a thickening and opacity of the layers of the cornea, together with a greater or less projection of the anterior surface of that tunic. Children, in whom the cornea is propor- tionably thicker than in adults, are most subject to the disease. One eye or both may be affected at the same time or in succes- sion. Small-pox, purulent ophthalmia, wounds of the eye by the couching needle or extracting knife, blows, and other in- juries, are among the most frequent causes of staphyloma. In the advanced stages of the disease, the tumour of the cornea is sometimes partially absorbed, and both the anterior and pos- terior chambers of the eye appear to be filled with a serous fluid. Two forms of the disease are met with—one in which more or less transparency of the cornea is preserved, and, along with it, a slight degree of vision, the other, in which the whole cornea is perfectly opaque. The former is denominated partial, the latter total staphyloma. Again; staphyloma has been di- vided into conical and spherical. Treatment of Staphyloma. There is no remedy, unfortunately, for this disease; at least the transparency of the cornea cannot be restored, and the patient, Staphyloma. 297 therefore, must for ever remain blind. But the surgeon, gene- rally, has it in his power to alleviate the severe pain and in- flammation (caused by dust and other extraneous bodies lodging upon the portion of the cornea projecting beyond the eyelids) by an operation. The object of this is to evacuate the humours, and permit the eye to collapse. To accomplish this purpose most effectually, and prevent a return of the disease, a section of the most prominent part of the cornea, by the knife used for extracting the cataract, should be made. The humours having escaped, the flap of the cornea may be removed with curved scissors. A circular opening will thus be made large enough for the contents of the eyeball gradually to drain away, whereas, if the surgeon were merely to puncture the cornea with a needle, as formerly practised, the opening would soon close, and the dis- ease return. However, it has been recommended, and practised, by many modern oculists, not to evacuate the contents of the eye, if it can be avoided, but suffer the humours to remain, and endeavour to produce cicatrization of the cornea, in order that the rotundi- ty of the eye may be preserved, and the deformity arising from the collapse of the organ obviated. With this view, all pres- sure upon the eye after the section of the corneal tumour must be avoided, the lids immediately closed by court plaster, and not opened for several days. In conical staphyloma it is more difficult to prevent the humours from draining off than in the spherical variety. 298 Hypopion. Section X. Hypopion. In consequence of violent deep-seated ophthalmia, it some- times happens, that purulent matter is formed within the poste- rior or anterior chamber of the aqueous humour—constituting the disease known under the name of hypopion. Besides ex- treme redness of the conjunctiva, a yellowish crescent-shaped spot may also be observed at the bottom of the anterior chamber, which gradually increases in size until the whole of the cavity is filled. During the height of the inflammation, the pain, in- tolerance of light, &c, are intensely severe, and the matter co- pious ; but as these symptoms decline, the pus is proportionably absorbed, and sometimes disappears in a few days without ma- terial injury to the eye. In other instances, it remains for weeks together, after the inflammation has entirely subsided, in the an- terior chamber, mixed with the aqueous humour, which it ren- ders turbid. It is seldom, however, that the disease terminates so favourably. On the contrary, in bad cases of the kind, ulce- ration and sloughing of the cornea are apt to ensue, followed by discharge of the humours and destruction of the whole eye. When the matter is lodged between the lamellae of the cornea, the disease takes the name of onyx from its resemblance to the white spot at the root of the nails. Treatment of Hypopion. The proper mode of managing this disease is not to puncture the cornea and evacuate the matter, as some advise, but to sub- Hypopion. 299 due the accompanying inflammation, after which it will be found, commonly, that the matter is slowly absorbed, and will, in time, entirely disappear. When, however, the collection of pus is so large and the inflammation so violent, as to leave no hope of saving the eye, it may become expedient to open the cornea and discharge the matter, in order to relieve the patient from unnecessary pain and irritation. Nevertheless, cases have been reported by Wardrop, Mon- teith, and others, where, in the early stages of onyx and hypo- pion, the aqueous humour has been evacuated, and the purulent matter discharged, with speedy relief to the patient, and preser- vation of the eye. From statements made by Monteith, in par- ticular, it also appears, that what, in many instances, seems to be pus, is, in reality, lymph, as is proved by its consistence, and other properties, and that its removal checks the disposition to suppuration. Scarpa, long ago, maintained, that the fluid poured out into the anterior chamber, in cases of hypopion, was, gene- rally, lymph, secreted by the choroid coat. 300 Hydrophthalmia. Section XI. Hydrophthalmia. Dropsy of the eye, a disease rarely met with, may originate either in the anterior or posterior chamber of the eye. It is, for the most part, dependent upon some constitutional affection, and is frequently connected with general dropsy. The most striking symptom of the disease is a gradual enlargement of the globe of the eye, without much pain or injury to vision. When the globe, however, begins to protrude from the socket, and the coats of the eye are rendered tense by the accumulation of se- rum within their cavities, a considerable degree of pain is ex- perienced, which extends in some instances to the head. At the same time the vision becomes impaired, the aqueous hu- mour acquires a turbid appearance, and the iris appears more deeply seated than usual, and trembles upon the slightest mo- tion of the patient's head. Finally, if not evacuated by an ope- ration, the humours accumulate in such quantity as to excite violent irritation and suppuration, and the eye is irrecoverably lost. Collections of serum between the sclerotic and choroid coats, and between the choroid and retina, are, occasionally, met with—the former termed sub-sclerotic, the latter sub-cho- roid dropsy. Conversion of the retina into a cord, and absorp- tion of the vitreous humour, may be the result, from pressure, of sub-choroid dropsy, which is much more common than the sub- sclerotic. Treatment of Hydrophthalmia. When hydrophthalmia depends upon general dropsy, and is attended to in the commencement of the disease, some benefit Hydrophthalmia. 301 may be derived, perhaps, from internal remedies—such as digita- lis, squill, volatile tincture of guiacum, calomel, cicuta, &c. But after vision has been materially injured, or destroyed and the eye projects beyond the lids, the operation of paracentesis is the only mode of treatment calculated to afford relief. This must be considered, however, as merely palliative. It may be performed with a common lancet or couching needle, and the operation oc- casionally repeated, or whenever the accumulation of water is such as to require its evacuation. When the disease proceeds from local causes, such as blows upon the eye or superciliary ridge, and the fluid is confined to the anterior chamber, friction with mercurial ointment around the eyelids, and blisters to the temples will now and then stop the progress of the complaint, and effect a cure. To relieve the violent pain accompanying sub-choroid dropsy, puncture of the eye with a grooved needle at the place where couching is usual- ly performed, should be resorted to. Ware and other oculists report interesting cases, where great benefit followed this mode of treatment. Vol. II. 39 302 Obliterated Pupil. Section XII. Obliterated Pupil. From common ophthalmia or from iritic inflammation, whether induced by operations for cataract or by other causes, closure or obliteration of the pupil frequently takes place. The iris, un- der such circumstances, becomes wrinkled or puckered, and the pupil is either entirely effaced or contracted to a very small compass. If complicated with cataract, the opaque lens or its capsule may generally be seen behind the pupil of a whitish or bluish aspect; but if the lens and capsule remain transparent, the pupil, although contracted, still retains its natural black co- lour; and vision, perhaps, to a certain extent, is still preserved. Treatment of Obliterated Pupil. This disease can be relieved, or cured, only by an operation. Since the time of Chesselden, who was the first to resort to such an expedient, various methods have been practised. Chesselden's operation, in his own hands, proved eminently successful; with others it often failed, and was at last abandoned altogether. Recently, however, it has been revived by Sir William Adams, and as modified by him is better calculated, I conceive, for most cases of closed pupil, than any other operation. " The patient being seated as in the operation for cataract, and the eye ren- Obliterated Pupil. 303 dered steady by a gentle pressure with the concave speculum, placed under the upper eyelid, the artificial pupil knife should be introduced through the coats of the eye about a line behind the iris, with its cutting edge turned backwards instead of down- wards. The point is next brought forward through the iris somewhat more than a line from its temporal ciliary attachment, and cautiously carried through the anterior chamber until it has nearly reached the inner edge of that membrane, when it should be almost withdrawn out of the eye, making a gentle pressure with the curved part of the cutting edge of the instrument against the iris in the line of its transverse diameter. If in the first attempt the division of the fibres of the iris is not sufficient- ly extensive, the point of the knife is to be again carried for- ward, and similarly withdrawn, until the incision is of proper length, when the radiated fibres will immediately contract, and an opening of a large size will be formed. After the operation is thus completed, the eye should be covered over with a plaster of simple ointment, spread on lint, and the patient put to bed with his head raised high."' If the obliterated pupil should be combined with an opaque lens or capsule, the surgeon should make it a point at the time he divides the iris, to cut up or la- cerate these textures, and thrust them forward through the pu- pil, which they will assist in keeping open. Wenzel, Gibson, of Manchester, and many other oculists, pre- fer in cases of closed pupil, a section of the cornea and the re- moval of a portion of the iris with scissors. Under particular circumstances, I should select this operation in preference to that of Chesselden. Several years ago, Dr. Physick invented a small instrument, resembling a saddler's punch, for cutting out a piece of the iris; but he never, as he informed me, had used it. It will, some- times, become necessary to make an artificial pupil (even al- though the natural one remain of its usual size) on account of corneal opacity. Beer, Schmidt, Reissinger, Maunoir, Flagani, Assalini, Scarpa, have all particular modes of operating for obliterated pupil; they possess no advantages, it appears to me, over those in common use. * Adams' Practical Observations, &c. p. 137. 304 Procidentia Iridis. Section XIII. Procidentia Iridis. A prolapsus, or projection of the iris through an ulcer or wound of the cornea, is by no means unfrequent. The pain attending the disease is extremely severe, and the intolerance of light so excessive that the patient cannot bear the exposure of the eye for a moment. The pupil, in this disease, always assumes an unnatural shape; its particular form, however, will depend very much upon the situation of the opening in the cornea. General- ly, it is of an oval figure. Sometimes there are two or three projections of the iris, each of which passes through a distinct opening of the cornea. After the protrusion has continued for some time, an adhesion is apt to ensue between the cornea and iris, and the part of the iris that projects beyond the cornea be- comes dry and hard, and sometimes sloughs' away. Treatment of Procidentia Iridis. When this disease follows a wound of the cornea, the iris may always be replaced at the time the edges of the wound are adjusted; but when it proceeds from an ulcerated opening, the surgeon will find it impossible to retain the iris in its natural situation so long as the ulcer exists. The great object, there- fore, in the treatment should be to heal the ulcer, and this will be most speedily accomplished by repeated touches of the ar- gentum nitratum. The caustic will serve the additional pur- pose of subduing the morbid sensibility of the iris, and of re- moving the superfluous portion of it projecting beyond the cornea. Cataract. 305 Section XIV. Cataract. The ancients entertained very erroneous notions respecting the nature and seat of cataract. They supposed it to be formed by an adventitious membrane in the posterior chamber of the aqueous humour. Dissection, and operations on the living sub- ject, afterwards proved that the disease was confined to the crystalline lens or its capsule, which becoming opaque prevented the rays of light from passing to the retina. Cataracts differ from each other as much in consistence as co- lour. Sometimes the lens is rendered perfectly fluid, and re- sembles milk, and on this account has been called the milky cata- ract. Sometimes it is found of the consistence of jelly or cheese, and hence the terms gelatinous and caseous cataracts. Not unfrequently the lens is perfectly hard, or ossified, so much so, that the sharpest instrument will make no impression upon it. When the anterior or posterior capsule is rendered opaque, and the lens remains transparent, or is absorbed, the disease is called capsular cataract. When a cataract exists at birth, the appel- lation congenital is applied to it. Most cataracts are of a bluish or pearl colour; some are gray or green; others white as snow. In a few rare instances the lens has been found of a brownish tint or perfectly black. The formation of cataract has never been satisfactorily ex- plained. By some the disease has been attributed to inflammation of the lens and its capsule, by others to hereditary transmission. That it may proceed from blows upon the eye and from wounds of that organ is very certain. In all cases of the kind there is reason to believe that the anterior capsule of the lens is either ruptured or cut, so that the lens itself is brought into immediate contact with the aqueous humour, which possesses the well 306 Cataract. known property of dissolving its texture as well as that of its capsule. It is remarkable, however, that an injury or destruc- tion of one eye, as I have several times witnessed, will frequent- ly give rise, at a subsequent period, to a cataract in the other. Old persons are most subject to cataract, though the disease may occur at any period of life; indeed, new-born infants are not exempt from it, and it has sometimes happened that all the chil- dren of a numerous family have been born with cataracts in both eyes. Persons whose eyes are much exposed to vivid and reflected lights are said to be peculiarly liable to cataract. The existence of cataract may be determined, generally, by the following symptoms. In the commencement, the patient is often sensible of a diminution of sight long before any opacity can be observed behind the pupil. Objects, moreover, especial- ly white ones, appear to him as if enveloped in mist or smoke, and when the eye is suddenly exposed to a strong light, vision is nearly destroyed. In a dull light, on the contrary, vision is more distinct, because the pupil being expanded, the rays of light, besides their increased quantity, pass through the thin margin of the lens. When the lens is completely opaque, its colour will commonly indicate the nature of the disease. The black cataract, however, is very liable to be mistaken for amau- rorosis. Cataracts are said to have been formed very suddenly, or in the course of a night, without any obvious cause ; but I am inclined to believe this to be erroneous, and that the disease has ex- isted, at least in one eye, for some time, without the patient being aware of its presence, and that the discovery of it has been pure- ly accidental. Treatment of Cataract. Although repeated attempts have been made, both by internal remedies and by local applications, to remove cataract, there is no well attested instance, I believe, on record, of a cure having ft.iif ■> I :i €M Krujr^J hj-J.j, Cataract. 307 been effected, except by an operation. There are two or three different operations now in use, each of which it will be proper to describe. Couching or depression of the cataract, an operation prac- tised, there is reason to believe, long before the time of Celsus, is usually performed by the modern surgeon either with a curved or straight needle. The former is preferred by Scarpa —the latter by Hey. (See Plate V. figs. 1 and 2.) The patient being seated on a low stool, with an assistant behind to support his shoulders and head, the operator, sitting or standing before him, passes the speculum of Peltier (Plate V. fig. 3,) beneath the upper eyelid, and directs the assistant to hold it steadily, while with one or two of the fingers of his own hand he de- presses the lower lid. He then takes the needle, (and if Scarpa's be used, which I prefer to any other,) holds it in his fingers like a pen, and laying the handle of the instrument nearly pa- rallel with the patient's temple, directs its point backwards, and its convex surface forwards, and penetrates the coats of the eye, at its external angle, about two lines posterior to the iris. The needle is next pushed towards the superior margin of the crys- talline lens, and thence in the direction of the pupil, until its point is distinctly seen. It only remains to lacerate freely, but cau- tiously, with the point of the needle, the anterior capsule of the lens; which being done, the lens itself should be pressed down- wards and backwards by the needle, and lodged in the vitreous humour. Instead of withdrawing the needle immediately after from the eye, as is too often done, it should be suffered to re- main a few seconds, lest the lens reascend, in which case the surgeon should again depress it, and then carefully remove his instrument and close the eyelids. Extraction of the cataract is performed by a knife instead of a needle, and the opening made in the cornea in place of the sclerotic coat. There are two knives in general use—the one invented by Wenzel and improved by Ware, straight and blunt on the back, convex on the edge, five-eighths of an inch in width, and in other respects shaped like a wedge, or gradually tapering from the handle to the point—the other invented by Beer, and differing from that of Wenzel chiefly in having a triangular shape. (See Plate V. figs. 5 and 6.) With either, the operation may be equally well performed. 308 Cataract. The necessary arrangements being made, the patient is placed on a low chair or stool, and his head committed to an intelligent assistant (one accustomed to the office and in the habit of perform- ing the operation,) who with his fingers, instead of a speculum, elevates the superior eyelid, and supports it against the super- ciliary arch. The surgeon himself taking charge of the lower lid, which he depresses with one or more fingers, and waiting until the patient rolls the eye towards the inner canthus, and holds it steady, enters the knife above the equator of the cornea and about a quarter of a line anterior to its junction with the sclerotica, with the edge downwards, passes it slowly and steadi- ly along through the anterior chamber until its point emerges at the inner edge of the cornea. This completes what has been called the punctuation of the cornea, and to finish the section it is still necessary to push on the blade of the instrument until it cuts itself out. As soon as this is accomplished, the aqueous humour is discharged, the knife is withdrawn, and the lids are closed for a few moments. The next step of the operation, and the most im- portant one, is to separate the lids, gently raise the flap of the cornea with the curette, (Plate VII. fig. 7,) pass a gold or sil- ver wire through the pupil, and cautiously lacerate the anterior capsule of the lens precisely in its centre. If this part of the opera- tion be well managed, and care taken to avoid any thing like pres- sure upon the globe of the eye, the lens, after its capsule is broken, will gradually approach the surface and be discharged through the opening made in the cornea, without bringing with it any portion of the vitreous humour. As soon as the lens is removed, the flap of the cornea should be adjusted, the lids closed, and a bandage applied lightly over both eyes. It sometimes happens, owing, principally, to the cornea knife being dull and ill-con- structed, that the aqueous humour flows before the section of the cornea is completed, and that the iris falls under the edge of the knife, and is liable to be wounded. To guard against this, Baron Wenzel suggested an expedient which has proved ex- tremely important—friction of the cornea with the end of the finger during the passage of the knife. If this plan be adopted, the iris will immediately retire from the edge of the knife, and so remain as long as the friction is continued. The absorbent practice, as it is denominated by Sir William /%//<• 7 V.2 111 k Cataract. 309 Adams, may be said, perhaps, to have originated with Mr. Pott; at least, that eminent surgeon was fully aware of the sol- vent power of the aqueous humour, and frequently took advan- tage of the circumstance, by pushing fragments of the lens which happened to be detached, during the operation of couch- ing, into the anterior chamber. Gleize, also, as well as Scarpa, Hey, and others, followed the same practice. But it is chiefly owing to Saunders, Conradi, and Adams, that this mode of re- moving the cataract has been brought to its present degree of perfection. There are two operations in use, each founded upon the ab- sorbent principle—the anterior and posterior. The first, or the operation of Conradi, as it is usually called, is chiefly adapt- ed to the soft or fluid cataract, and may be performed in the following way. The pupil being dilated by the application of the extract of belladonna or stramonium to the eyebrow, an hour or two before the operation, the patient is seated, and the eye secured as in the operation of couching or extraction. With a straight spear-pointed needle, an inch in length, rounded in the shank, and tapering from the shoulder towards the point, (Plate VII. fig. 1,) the surgeon penetrates the cornea, at its lower and outer part, about a line anterior to its union with the sclerotic coat, carries the needle along the plane of the iris and through the pupil as far as the centre of the crystalline lens, the capsule of which is first lightly scratched over its whole surface, then freely torn, after which the lens itself may be broken up and some of its fragments brought by the needle into the anterior chamber. It is highly important, in per- forming this operation, to guard against wounding the iris; the surgeon, therefore, should not attempt to accomplish too much at a single operation, but calculate, in most instances, upon a second or third being necessary. In general, several weeks elapse before the remains of the capsule and lens entirely disap- pear. The posterior operation is distinguished from the anterior by the circumstance of the opening being made in the sclerotic coat instead of the cornea. Mr. Saunders was in the habit of performing this as well as the anterior operation; but for many valuable improvements in the mode of executing it, and for the invention of ingenious instruments adapted to the purpose, we Vol. II. 40 310 Cataract. are particularly indebted to Sir William Adams. The needle (Plate VII. fig. 2,) chiefly employed by that surgeon for " solid cataract in children and adults," is spear-pointed, eight-tenths of an inch long, the thirtieth part of an inch wide, and slightly con- vex throughout the blade. The eye being fixed by a concave specu- lum, (Plate VII. fig. 3,) the needle is passed through the sclerotic coat about a line behind the iris, perpendicular to its edges, until it reaches the anterior chamber and the nasal margin of the pupil. Its edge is then turned backwards, and at a single stroke made to divide the capsule and its lens. After this, repeated cuts are made in different directions, so as to divide the cataract into numerous pieces, most of which should be pushed afterwards by the flat surface of the needle into the anterior chamber, for solution. Formerly, Sir William Adams, in cases of very hard and so- lid cataract, was in the habit of introducing a knife similar to that recommended by him for artificial pupil, but smaller, and of slicing off pieces of the lens: finding, however, the operation very difficult and sometimes impossible, and having known, in several instances, violent inflammation and even destruction of the eye to follow the lodgement of an entire lens, or of large portions of it in the anterior chamber, he has latterly performed the ordinary operation with his spear-pointed needle, with which he pushes the whole of the lens into the anterior cham- ber, and thence immediately afterwards extracts it through the cornea by making a section of that tunic with a knife of pecu- liar shape, (Plate VII. fig. 4,) enlarging the incision, should he find it necessary, with a blunt-pointed curved knife, (Plate VII. fig. 5.) Besides couching, extraction and the absorbent practice, other operations have been proposed for the removal of cataract. For the most part, however, they are entitled to so little atten- tion, as to render a description of them unnecessary. But a question naturally arises respecti»g the merits of the operations in common use, and how far one should be preferred to another; though there is little probability of such a question being ever satisfactorily determined; for, on both sides, it has been custo- mary to extol the merits of one, and exaggerate the inconve- niences of the other. Perhaps, it may be fairly stated, in rela- tion to the operation of extraction, that under favourable cir- Cataract. 311 cumstances—where the subject is young, healthy, the eye prominent, the vitreous humour sound, &c—this operation, when dexterously performed, possesses advantages over every other, inasmuch, as the cataract is at once removed, and a speedy cure follows. But, on the other hand, it must be recollected that the operation is always extremely difficult, and that, if it once fail, it cannot be repeated. As respects the operation of couching, it appears to me that the chief objection to it arises from the difficulty of keeping the lens below the axis of vision; in addi- tion to this, from its lodgement, in many instances, upon the re- tina, great pain and incurable amaurosis have not unfrequently ensued. Under most circumstances, therefore, I am inclined to prefer the " absorbent practice," principally, because the opera- tions are easily executed, give little pain, and, if necessary, may be repeated again and again without injury to the eye, and are the most likely to prove successful. It should be remembered that previous to the performance of any operation for cataract, the patient must be prepared by diet, purging, &.c.; that the stramonium or belladonna be invariably used ; that means be taken to subdue inflammation after the ope- ration, and that the eye be not prematurely exposed to too strong a light. As a general rule, too, no operation should be under- taken so long as the patient enjoys the perfect sight of one eye. 312 Congenital Cataract. Section XV. Congenital Cataract. This disease is more common than is generally imagined; in- deed, many examples are recorded of all the children of a nu- merous family being born with cataracts in each eye. In the District of Columbia, there is a family of six children, all of whom are blind from congenital cataract. Sometimes only one eye is affected. There is a peculiarity attending this disease which is seldom observed in common cataract—an extraordinary mobility or in- cessant rolling motion of the eye which increases with the age of the patient, and is seldom, if an operation be long delayed, entirely gotten rid of. It is somewhat remarkable, also, that, unlike ordinary cataract, the lens of the congenital variety, in most instances, is gradually absorbed, and the two capsules ap- proach each other, and are at last identified, forming a tough elastic membrane. This fact was first particularly noticed by Saunders. Treatment of Congenital Cataract. Formerly, surgeons entertained the opinion that congenital ca- taract did not admit of relief until the patient attained the age of eight or ten years. Gibson of Manchester, and Saunders of Lon- Congenital Cataract. 313 don, were among the first to correct this erroneous doctrine. Independently of the importance of an early operation, as respects education of the child, it is equally necessary to correct the mobility of the eye, and to guard against decay of the retina, which, for want of its natural exercise, is apt to fade and die. For the removal of congenital cataract, I prefer, with the ex- ception of the mode of securing the patient, the anterior ope- ration as performed by Saunders, and described in the preceding section. Instead of four or five assistants to hold the child, some of whom must necessarily be in the way of the operator, I am inclined to recommend, from experience, the plan of Mr. Gibson, of Manchester, which is simply to enclose the body, arms, and legs of the patient in a bag open at each end, and furnished with tapes or strings to secure the limbs. Thus si- tuated, the child may be laid on a large pillow placed on a ta- ble, and firmly held by one or two assistants. The operation may be performed, if necessary, on infants a month or six weeks old. Before concluding the subject of cataract, it may be proper to state that the anterior capsule of the lens sometimes adheres to the iris, and occasions an immobility of the pupil. Under these circumstances, I should still prefer the posterior operation, and the use of the curve-pointed needle of Sir William Adams, (Plate VII. fig. 6,) taking especial care to be as gentle as possi- ble in separating the adhesion, lest the iris be so injured as after- wards to cause obliterated pupil. It now and then happens, that after operations for cataract, (and operations, too, that have suc- ceeded for a time,) secondary cataract is produced. This arises from capsular opacity. The posterior operation will, for this variety of the disease, also be found the most suitable. 314 Amaurosis. Section XVI. Amaurosis. Amaurosis, gutta serena, or an insensible state of the retina, a disease of frequent occurrence, and always extremely difficult to cure, may be distinguished, generally, from other affections of the eye by the following symptoms. The pupil is of a green- ish black colour, greatly expanded beyond its natural size, ir- regular in its shape, and its edges undulating. When exposed to the strongest light, no perceptible contraction can be observed. Sometimes, however, instead of being dilated, it is unnaturally contracted. In other instances the iris retains its sensibility so far as to be obedient to the stimulus of light, and contracts and dilates as usual, and yet the retina is completely insensible. In addition to these symptoms, the general aspect of the eye is peculiar, its natural lustre and intelligence are diminished or lost, and in bad cases of the disease, the patient is unable to di- rect his eyes steadily at any object, but turns them towards it obliquely. Most patients, in the incipiency of the disease, are exceedingly annoyed by fantastic figures, called by most wri- ters muscae volitantes, which are constantly flitting before their eyes, especially when white and shining objects are looked at. Severe pain about the superciliary ridge and orbit is a frequent concomitant of the disease. The causes of amaurosis are either local or constitutional. Among the former may be enumerated blows upon the head, wounds of the supra-orbitary nerve, exposure of the eye to vi- vid lights, long continued fatigue of the eye from examination of minute objects, the use of powerfully magnifying glasses, confinement in dark cells or dungeons, pressure upon the optic nerve from tumours, hydrocephalus, &c. The constitutional causes are derangement of the digestive organs, violent mental Amaurosis. 315 emotions, suppression of accustomed or periodical discharges, immoderate venery, manstupration, excessive indulgence in opium and other narcotics, frequent attacks of syphilis, repeated mercurial courses, and a great variety of similar sources of ex- citement. There is a singular variety of amaurosis, called nyctalopia, or night blindness, in which patients see objects with perfect distinctness during the day, but lose their sight as soon as it becomes dark, remain blind throughout the night, and upon the approach of morning again recover their vision, which con- tinues perfect until the return of evening This disease some- times arises without any evident cause; generally, however, it is endemic, and prevails to a greater extent in the East and West Indies than in other countries. Sometimes it appears to be hereditary; at least there are instances of whole families for several generations being subject to it. In Maryland there are now two distinct families in which the disease has existed from time immemorial. Persons having black eyes are said to be more subject to the complaint than others. When examined the eyes do not commonly exhibit any visible defect, except that the pupil is unusually large, and less moveable than natural. Treatment of Amaurosis. This must depend in a great measure upon the cause of the disease. When it arises from any organic defect, and from most of the local causes above enumerated, there will be very little probability of affording permanent relief. If it proceed from gastric derangement, or from passions of the mind, emetics and purgatives will prove the most useful remedies, and after full be- nefit has been derived from these, tonics may be resorted to. For nyctalopia, repeated purgatives and a succession of blisters to the temples, are highly recommended by Mr. Bamfield,* the most experienced writer on this subject. • Medico-Cliirurg. Transactions, vol. 5, 316 Hordeolum. Section XVII. Hordeolum. The hordeolum, or stye, is a red, inflamed, and painful tu- mour involving one or more of the Meibomian glands. It is similar, in many respects, to the common furuncle or bile, met with in other parts of the body, and is usually seated upon the lower eyelid near its inner angle. The disease is very common, and arises, for the most part, from some disordered action of the stomach. Like the furuncle, it seldom terminates in suppura- tion. Treatment of Hordeolum. Purgative medicines and attention to diet will often, without the aid of local applications, remove hordeolum. When the tu- mour, however, continues stationary for some time, and is pain- ful, an attempt should be made, by warm emollient applications, to excite suppuration in the cellular membrane surrounding it. By these means we sometimes succeed in detaching the core or slough that occupies the centre of the tumour, after which the opening left will soon heal. When the inflammation has sub- sided.^and the tumour becomes indolent, the application of lunar caustic or of nitric acid will frequently effect a cure. lumours of the Eyelids. 317 Section XVIII. Encysted Tumours of the Eyelids. Steatomatous and melicerous tumours, from the size of a pea, to that of a large bean, are frequently met with beneath the conjunctiva, or imbedded in the substance of the eyelid. They are, generally, soft, devoid of pain, and roll under the finger. The upper eyelid is the most common seat of the disease. When the tumour attains a very large size, it is liable to interfere with vision, or it may produce eversion and other diseases of the eye- lids. Treatment of Encysted Tumours of the Eyelids. Extirpation is the only remedy, and this, when the tumour has acquired a moderate size, is easily accomplished, especially when it is seated on the inside of the lid immediately beneath the conjunctiva. The surgeon everts the lid with his finger, secures the tumour by a fine hook, then makes an incision with a diminutive scalpel over its surface parallel with the eyelid. As soon as the external covering is fairly divided, the tumour is easily loosened from its bed, and by a few strokes of the knife or scissors entirely removed. When it is deeply seated within the substance of the orbicular muscle, or lies exterior to it, the operator will find it most convenient to extract the tu- mour by cutting through the lid on its outer side—taking care to separate the muscular fibres longitudinally. Vol. II. 41 318 Entropeon. Section XIX. Entropeon. By the term entropeon is understood an inversion of the tar- sus, or its cilia. Trichiasis is also used to denote the same dis- ease. The upper eyelid is commonly the seat of entropeon, which, in proportion to its duration and the extent of the inver- sion, is productive of more or less irritation by encroaching upon the ball of the eye. In general, the entropeon proceeds from protracted ophthalmia, or psorophthalmia, and from other causes capable of producing a morbid inclination of the tarsus, or a wrong direction of the cilia. Treatment of Entropeon. An evulsion of the eyelashes by a pair of fine forceps or tweezers, when the entropeon depends upon their unnatural po- sition, is the only remedy calculated to remove the complaint, and this does not succeed always. For inversion of the tarsus itself, several different operations have been practised. In sim- ple cases, especially where the disease appears to be owing to inordinate relaxation of the skin of the eyelid, the removal of an oval portion of this superfluous skin by the forceps and curved scissors will generally effect a cure, provided the surgeon take care to cut as closely as possibly to the tarsus, and afterwards draw the edges of the wound together by a fine suture. The Entropeon. 319 cicatrix that ensues will afterwards prevent the tarsus from fall- ing inwards upon the globe of the eye. But this operation does not commonly answer for cases of long standing. Mr. Cramp- ton, an ingenious Irish surgeon, has proposed to dissect off the thickened conjunctiva, which he conceives to be the most com- mon cause of entropeon. On the other hand, Mr. Saunders and Dr. Dorsey advise the entire or partial removal of the tarsus. I have, however, tried these different operations, and have found them painful and difficult, and not always successful. I am in- clined to think more favourably of an operation lately proposed by Dr. Jaeger of Vienna, though I have had no opportunity of fully testing its merits. The surgeon, instead of removing the whole tarsus, merely dissects off its anterior edge, and along with it the cilia, thereby removing a considerable source of irritation, at the same time preserving that portion of the cartilage which serves to guide the tears towards the puncta lacrymalia. 320 Ectropeon. Section XX. Ectropeon. The ectropeon is the reverse of the entropeon,—the eyelid being turned outwards instead of inwards. Sometimes both the upper and lower eyelids are simultaneously affected, but in most instances the lower lid is the seat of the disease. Like the en- tropeon, it may proceed from repeated and long continued at- tacks of ophthalmia, and in such cases the conjunctiva lining the lid is generally thickened or in a fungous state. Occasional- ly, the ectropeon arises from burns or wounds in the neighbour- hood of the eyelids, the cicatrices of which, by contracting and distorting the tarsus, evert the lid and expose its inner surface. In all cases of the kind, the deformity arising from the red and exposed surface of the conjunctiva is considerable, and the irri- tation to the globe of the eye such as not unfrequently to pro- duce opacity or ulceration of the cornea. Treatment of Ectropeon. Excision of the fungous conjunctiva, and the application of va- rious caustics, have been advised by most writers. The only operation, however, likely to afford permanent relief is that practised by Sir William Adams. It is performed in the fol- lowing way. A portion of the lid, in the shape of the letter V, is removed from the outer angle of the eye by a pair of straight sharp scissors. The thickened conjunctiva is next carefully Ectropeon. 321 dissected off, when there will be no obstacle left in most cases to the replacement of the lid. To retain it in its situation and to promote adhesion, a fine interrupted suture should be passed through the edges of the wound, and supported by a compress. The size of the portion to be removed must depend upon the extent of the eversion, &c. It needs hardly be mentioned that the base of the triangular incision should look towards the edge of the tarsus. When the ectropeon depends upon a cicatrix, from loss of substance near the lid, or from a burn, it may be- come necessary to make incisions parallel with the lid through the contracted integuments, and afterwards interpose lint to prevent their reunion. But the operation seldom succeeds per- fectly—owing, perhaps, to ignorance, want of attention, miscal- culation as to the quantity of substance to be removed, or to the incisions being made in the wrong direction, and other causes. In some cases the removal of the cicatrices themselves will effect a cure. 322 Fistula Lacrymalis. Section XXI. Fistula Lacrymalis. Epiphora or stillicidium lacrymarum, and fistula lacrymalis, have been used by some writers indiscriminately to denote the same disease; by others they have been looked upon as essen- tially distinct; they may, however, I conceive, be ranked with propriety as varieties or stages of the same complaint; but it by no means follows that every epiphora must necessarily terminate in fistula lacrymalis, although fistula lacrymalis may be said to be preceded invariably by epiphora. Epiphora may arise from several different causes—from an undue secretion of tears—from closure of the puncta lacrymalia or obliteration of the canaliculi lacrymales—from inflammation of the lacrymal sac, and from stricture of the nasal duct. These in their turn may be the result of other agents, especially of the different varieties of ophthalmia, &c. When the puncta lacrymalia are closed, the tears constantly flow over the lids, and spreading upon the cornea, produce a morbid refraction of light, which obliges the patient constantly to wipe them away. On the contrary, when the nasal duct is obstructed, the tears accumulate in the sac, and form a tumour immediately below the tendon of the orbicular muscle; and upon pressing this tumour, the tears regurgitate through the puncta mixed with flocculent matter. So long as the disease continues in this state, the terms epiphora, and stillicidium lacrymarum, are strictly applicable to it. Should the sac, however, inflame and ulcerate, and an opening be established between it and the in- teguments, then a fistula lacrymalis is produced. In such cases the inflammation generally extends to the globe of the eye, and in some instances to the side of the face and head. If neg- lected, the disease may continue for months or years, or indeed Fistula Lacrymalis. 323 during the patient's life, sometimes better, sometimes worse, and in the end may be followed by caries of the unguis, and injury of the asthmoid and spongy bones. Treatment of Fistula Lacrymalis. A simple epiphora, dependent upon obstruction of the nasal duct, or, as sometimes happens, upon a morbid secretion from the Meibomian glands, may be generally removed by the re- peated introduction of Anel's probes into the puncta and duct, and by the application of the unguentum hydrargyri nitrati, and other astringent ointments, and washes to the lids and edges of the tarsus. After the obstruction has been overcome by the probes, the passages should be syringed out two or three times a day, taking care to introduce the curved pipe of the syringe into the lower punctum,, and, at the same time, with the" point of a finger to stop the upper punctum, and thereby prevent the regurgitation of the fluid. Tepid water, at first, and afterwards a weak solution of the sulphate of zinc or acetate of lead, will be found the most suitable wash. When the epiphora depends upon obliteration of the puncta or canaliculi lacrymales, the dis- ease may be considered incurable. Fistula lacrymalis can be removed only by overcoming the obstruction in the nasal duct, or by establishing a new route for the tears through a perforation of the unguis. The first mode should, if practicable, be always resorted to. The surgeon in- troducing into the fistulous orifice a common pocket case probe, carries it, at first, horizontally, until it is fairly introduced into the cavity of the lacrymal sac; the handle of the instrument is then raised, and made to rest nearly in a perpendicular direc- tion against the superciliary ridge, while the point is directed downwards in the course of the duct, and pressed firmly but steadily against the stricture. As soon as this is overcome, the probe passes easily into the nose, and a few drops of blood and 324 Fistula Lacrymalis. matter issue from the nostril of the affected side. The probe is then withdrawn, and a silver style, (an instrument resembling in shape and size the probe, but only an inch and a quarter in length, and having a head obliquely placed upon its top) intro- duced in its place. This is permitted to remain in the passage, and serves the purpose of conducting the tears by a sort of ca- pillary attraction into the nostril. In the mean time, the fistu- lous orifice gradually contracts around the neck of the instru- ment, the head of which afterwards prevents it from falling into the nose. Occasionally, the style should be withdrawn, and the passage syringed out. Some patients find it necessary to wear the style several months, others are cured by it in a few weeks. Where the fistulous orifice is so small that the probe will not en- ter, it should be enlarged by a spear-pointed lancet. Sometimes it is necessary to make an opening into the sac, where the fistula is not properly situated, or does not exist. Under these circum- stances, the surgeon should always take as his guide, the small tendon of the orbicularis, and immediately beneath this make his incision. If, as sometimes happens, the nasal duct be permanently closed by stricture, or by an exostosis from the surrounding bony canal, it will become necessary to perforate the os unguis. This can be most conveniently done by the perforator of Cruik- shank, (an instrument resembling, in some respects, the shoe- maker's punch,) which is carried through both sides of the la- crymal sac, and made to bear upon the inferior part of the un- guis. To prevent the instrument from passing too far inwards, a narrow piece of horn should be carried up the nostril, and upon this, the perforator will rest and perform its office with great facility. After the opening has been made through the sac and bone, a silver or leaden style, somewhat shorter than that used for the natural duct, should be introduced and worn as long as may be found necessary. When the operation is pro- perly performed, the opening will always be made between the superior and inferior spongy bones. There are other operations practised for the cure of fistula la- crymalis, but they seldom prove so effectual as those I have described. Fistulu Lacrymalis. 325 On Diseases of the Eye, consult—Scarpa's Practical Observations on the Prin- cipal Diseases of the Eyes, translated from the Italian, with Notes, by James Briggs, 2d edit.—Ware's Chirurgical Observations relative to the Eye, in 2 vols. 8vo.— Wdrdrop's Essays on the Morbid Anatomy of the Human Eye, in 2 vols. 8vo. Edinburgh, 1808 and 1818—Vetch's Practical Treatise on the Diseases of the Eye, 1820—Trovers' Synopsis of the Diseases of the Eye, and their Treatment, 1820—A Treatise on some Practical Points relating to the Diseases of the Eye, by the late John Cunningham Saunders, 8vo. 1811—Practical Observations on Ectropeon, or Eversion of the Eyelids, with the Description of a neio Operation for the Cure of that Disease,- on the Modes of Forming an Artificial Pupil, and on Cataract, by William Adams, 8vo. 1812—An Essay on the Entropeon, by Philip Crampton, M. D. London, 1806—WcnzeVs Ireatise on Cataract, by Ware, 1791—Pott's Remarks on Cataract, in third vol. of his Chirurgical Works —Hey's Practical Observations in Surgery—A Practical Inquiry into the Causes of the frequent Failure of the Operations of Depression, and of the Extraction of the Cataract as usually performed, with the Description of a Series of New and Improved Operations, &c, by Sir Willian Adams, 8vo. 1817—Practical Observa- tions on the Formation of an Artificial Pupil, and Remarks on the Extraction of Soft Cataracts, by Benjamin Gibson, 8vo. 1811—A Treatise on the Diseases of the Eye, including the Doctrines and Practice of the most eminent modern Surgeons, and particularly those of Professor Beer, by George Frick, M. D. 8vo. 1823—A Practical Treatise an the Diseases of the Eye, by William Mackenzie, 8vo. Lon- don, 1830—A Treatise on the Venereal Diseases of the Eye, by William Lawrence. London, 1830—Lectures on the Operative Surgery of the Eye, by J. G. Guthrie. London, 1827, 8vo.—A Manual of the Diseases of the Eye, by S. Littell, M. D., Philadelphia, 1837, 8vo.—an excellent little work, and well deserving the atten- tion of the American student. Vol II. 42 32G Diseases of the Ear. CHAPTER XI. DISEASES OF THE EAR. From the complex structure and diminutive form of the au- ditory organs, the older surgeons always despaired of arriving at any certain knowledge of the nature and treatment of their dis- eases. Hence, all the information we possess on the subject, may be considered, comparatively, of modern origin. Still we are much in the dark, and may, perhaps, for ever continue so, respecting many affections, especially those of the internal ear. For these very reasons, however, the student, instead of neglect- ing, as is too common, the anatomy of the ear, under the impres- sion that he can never acquire an accurate knowledge of it, should strive to make himself minutely acquainted with its most intricate structure, as the only means of understanding its dis- eases, which after all are not in reality so complicated and ob- scure, as is commonly imagined. Much assistance, also, may be obtained from a simple and accurate classification of these dis- eases—such as I shall endeavour to present in the ensuing sec- tions. Diseases of the External Ear. 327 Section I. Diseases of the External Ear, and Meatus Auditorius. The external ear may be separated from the head by a sabre cut, or by a cannon ball, or it may be bitten off. It is sometimes frost-bitten, and sloughs away; at other times, it is destroyed by ulceration. Formerly, it was supposed that such accidents or diseases would necessarily be followed by loss of hearing; but ex- perience proves the reverse; indeed, cases are recorded of pa- tients born without external ears, who, nevertheless, enjoyed to a certain extent the sense of hearing. Of the individual parts of the ear, the lobe is the most subject to disease. In several instances, I have known sarcomatous tumours to spring from it —in shape resembling the vegetable called prickly pear—which have sometimes attained a large size. In all these cases, the disease was met with in negroes, and seemed to originate from brass ear-rings worn by the patients. Encysted or steatomatous tumours of the lobe are very common. They generally occupy the centre, and seldom increase beyond the size of a pea. The meatus audilorius is liable to accidents and diseases. Ex- traneous bodies, such as peas, stones, glass beads, pieces of slate pencil, cherry stones, bits of wood or metal, are frequently put into the ear by children; and by lodging at the bottom of the meatus, or upon the membrana tympani, excite irritation or sup- puration. Sometimes insects find their way into this passage, and produce great alarm to the patient, as well as pain. Worms, also may be generated within the meatus, in consequence of the eggs from which they are produced, having been deposited by flies during the patient's sleep. At other times, worms creep into the ear, as in the following instance. Several years ago, a 328 Diseases of the External Ear. poor woman, the wife of a skin dresser, brought her child to me, stating that a few days before, the child had been playing with its companions on a pile of sheep's wool that lay in the yard; and that in a few minutes after, he complained of uneasiness in the ear, which was soon followed by violent ear-ache, and sub- sequently by suppuration. To relieve the pain and check the discharge, the mother poured sweet oil into the ear, and in a few moments, to her great surprise and horror, observed a worm make its appearance near the surface, but upon attempting to seize it, it immediately retired beyond her sight and reach. Scarcely giving credit to the woman's statement, I repeated the experiment with the oil, and in a few seconds the woTm ap- peared, its approach being preceded by several bubbles of air passing through the oil. I tried instantly to secure it with a pair of slender forceps, but with great dexterity it eluded the grasp* and made its escape. Several times the attempt was repeated, and at last, with success. When placed on the table, the animal was found three-quarters of an inch long, about as thick as a com- mon piece of twine, black about the head, and white on the rest of its body. It was extremely active, and appeared very tena- cious of life. The woman immediately recognised it as a spe- cies of worm very commonly met with amongst new-shorn wool, and had no doubt that it had found its way into the boy's ear at the time he was playing on the pile. Cases, in some respects, similar to this are recorded by Acrell, Valsalva, Morgagni, and others. The cerumen, or wax of the ear, often accumulates in undue quantity, and forms an inspissated mass, which may interrupt or destroy the hearing. Suppuration of the lining membrane of the meatus auditorius, is a very common affection, especially amongst infants and young children, in whom it arises from cold, want of cleanliness, &c. When the discharge is profuse and long continued, it becomes, particularly during warm weather, very offensive, and if not checked, may eventually destroy the membrana tympani and small bones of the ear. Polypi of the meatus, are occasionally met with. They spring from the bottom of the passage, or from the sides of the membrane. In either case, they generally increase until they Diseases of the External Ear. 329 fill up the whole cavity, and project beyond the orifice, so as to render the patient partially or entirely deaf. An herpetic eruption is another complaint to which this pas- sage is subject. It is rather frequent than otherwise, and oc- curs chiefly in scrofulous patients. The discharge from the sore is extremely offensive, and sometimes so profuse, thick and viscid, as to block up the passage. Occasionally, the erup- tion extends beyond the meatus, and affects the external ear. Children are sometimes, though very rarely, born with the meatus auditorius imperfect. This may proceed from a thin membrane covering the orifice of the passage, or seated some distance within it, or from the whole tube being filled up by a tumour, or by a coalescence of its sides. Treatment of Diseases of the External Ear, tyc. For sarcomatous tumours of the lobe of the ear, there is no other remedy than excision, and this commonly succeeds. En- cysted, or steatomatous, tumours if they attain a sufficient size to produce deformity, or to become troublesome, may be dis- sected out in the same manner that they are removed from other parts of the body. Extraneous bodies introduced into the meatus auditorius, if attended to before they excite inflammation and swelling, may generally be removed by a pair of very slender forceps. Beads, cherry stones, and shot, however, are always difficult to seize, on account of their round form and smooth surface. Upon one occasion, after having ineffectually tried to extract a pea from the ear of a child by the forceps, I succeeded in splitting it with a couching needle, and then removed the pieces without dif- ficulty, by throwing in a stream of water from a syringe. A bent probe will sometimes answer a better purpose in the re- moval of an extraneous body than any other instrument. But the best instrument, ever invented, is, for this purpose, the curette 330 Diseases of the External Ear. articul^e of Leroy.* Insects that find their way into the meatus, or are generated in the passage, are easily gotten rid of by pour- ing olive or any other mild oil into the ear. The oil obstructs the pores of their respiratory apparatus and obliges them to come to the surface. They may also be destroyed by the smoke or infusion of tobacco, or by other stimulating articles. Hardened wax is easily removed by the repeated use of the syringe and ear-pick. Warm water, or soap and water, are the best solvents for this wax. Suppuration of the lining membrane of the meatus audi- torius may be relieved or removed, in most instances, by an- tiphlogistic remedies, and by moderately astringent injections, provided the disease is attended to in its commencement. The passage should be protected during cold weather by a dossil of wool introduced into its orifice. In scrofulous children it is not uncommon to meet with of- fensive discharges from the ear, which have continued for years. In all such cases I have derived great benefit, and sometimes effected perfect cures, by fumigating the passage with aethiops mineral. A small portion of the powder may be strewed on a heated iron and held close to the ear, or the fumes may be con- veyed more accurately to the part by collecting them in a tin vessel resembling an ear trumpet. The operation should be repeated two or three times a-day. Polypi of the ear, if not too deeply situated, may be ex- tracted by slender forceps; but the operation is a delicate one and requires considerable skill. The ligature recommended by some surgeons, cannot be employed with advantage. The appli- cation of lunar caustic is sometimes rendered necessary to de- stroy the remnants of the disease. For the removal of herpetic eruptions, mercurial preparations are the most serviceable, especially the internal use of calomel, and a weak solution of corrosive sublimate, as an injection. The imperforate meatus auditorius has sometimes been re- stored by dividing the membrane which blocks up the passage, and afterwards wearing a tent to keep it from closing. When the sides of the tube are firmly united, and all remains of the original meatus obliterated, an operation will seldom prove successful. * See article Lithotripsy. Diseases of the Tympanum, fyc. 331 Section II. Diseases of the Tympanum and Eustachian Tube. Otalgia or ear-ache, a very common, and sometimes most se- vere affection, is generally the result of acute inflammation of the membrane lining the cavity of the tympanum. The pain is excessive, and extends, in many instances, from the ear to other parts of the head, accompanied by fever and delirium. If these symptoms continue for any length of time, suppuration is al- most sure to ensue, and matter collects not only in the cavity of the tympanum, but in the mastoid cells and Eustachian tube. This matter is generally ichorous and sometimes sanious. When copiously secreted, it destroys by pressure the membrana tym- pani, and is discharged at the meatus externus, not unfrequent- ly along with one or more of the small bones that occupy the tympanum. From this cause, and from obliteration of the Eus- tachian tube by inflammation, permanent deafness is extremely apt to follow. Caries, too, of the tympanum and mastoid cells, complicated with fungus, is a frequent consequence of this dis- tressing disease. The Eustachian tube is frequently closed, independently of any affection of the tympanum, from the sloughing or ulcera- tion which sometimes follows cynanche maligna, scarlet fever, cynanche tonsillaris, syphilis, the immoderate use of mercury, &c. In all such cases, partial deafness ensues, owing to the air within the tympanum being confined, or absorbed, or to the cavity being filled by mucus. The membrana tympani, in either event, is incapable of the resquite degree of vibration, and the patient's hearing is thereby rendered very indistinct, or entirely destroyed. It is not always easy to discriminate between this variety of deafness and that proceeding from other causes. 332 Diseases of the Tympanum. Much information may be gained, however, from accurate in- quiries into the history of the complaint, and by directing the pa- tient to close the nostrils and mouth, and blow forcibly with his breath, which, if the Eustachian tube be closed, will not enter the cavity of the tympanum and communicate an impulse to its membrane or drum, as generally happens when the guttural ex- tremity of the tube is pervious. Moreover, patients deaf from closure of the Eustachian tube, are seldom disturbed by those unpleasant sounds in the ear which so commonly accompany nervous deafness. Treatment of Diseases of the Tympanum, SfC A most absurd and highly pernicious practice is frequently pursued in the treatment of inflammation of the membrane lining the tympanum—that of pouring stimulating or acrid fluids into the meatus externus, with a view of relieving the intense pain accompanying the disease. Instead of this, general and topical blood-letting, purging, blistering, &c, in the commencement of the disease, are the proper remedies. If by these means sup- puration be not prevented, and the matter is rapidly accumu- lating, the surgeon, without delay, should make a small opening with a sharp-pointed probe or couching needle in the membrana tympani, and evacuate the matter; otherwise, the whole of this membrane may be destroyed by ulceration, the ossicula dis- charged, and the hearing irrecoverably lost. After the in- flammation has subsided, astringent injections may be employed to correct and suppress the discharge. If fungous or polypous excrescences sprout from the tympanum and fill up the meatus, they should be removed by the forceps and lunar caustic. For the relief of deafness arising from obliteration of the Eus- tachian tube, an ingenious expedient was suggested, long ago, by Chesselden, and afterwards practised by Sir Astler Cooper— the perforation of the membrana tympani. This operation, as Diseases of the Typanum. 333 was correctly imagined, served the purpose of admitting the ex- ternal air to the tympanum, and thereby, for a lime, restored the patient's hearing. It was soon found, however, in most instances, that the benefit was temporary—owing to the inflammation excited by the puncture, producing an induration of the mem- brane, and a consequent loss of vibratory power. The opening in the membrana tympani, in other cases, moreover, was found to close speedily after the operation. For these and some other reasons, the operation is now seldom practised. Should it ever become necessary to resort to it, a small sharp-pointed probe will answer all the purposes of the regular and more complicated in- struments—care being taken to select such cases of deafness only, as are dependent upon closure of the tube, and, in performing the operation, to avoid perforating that part of the membrane to which the handle of the malleus is attached. Some of the English and French surgeons have contrived in- struments for cleansing the Eustachian tube, when clogged with mucus or extraneous bodies. The difficulty, however, of intro- ducing the pipe of a syringe or probe into the guttural extremity of this passage, has deterred most persons from attempting the operation. Vol. II. 43 334 Diseases of the Internal Ear. Section III. Diseases of the Internal Ear. That variety of deafness, usually called nervous, is exceeding- ly common, and arises, for the most part, from some organic de- fect, or change in the structure of the auditory nerve. The membrane, also, upon which the nerve is expanded, and the fluid which it contains, may undergo such alterations as render them unfit to perform their proper functions, and from these causes there is reason to believe that nervous deafness frequently proceeds. So far as inferences can be drawn, from the appear- ances presented upon dissection, the following circumstances may be enumerated as likely to interfere materially with the sense of hearing; 1st. An unusual hardness of the auditory nerve; 2dly, a diminution of the nerve; 3dly, a thickening of the mem- brane of the labyrinth; 4thly, the formation of a steatomatous or caseous substance within the cavity of the vestibule; 5thly, cal- careous matter in the vestibule; 6thly, malformation of the ves- tibule, semicircular canals, and cochlea. If, from these or other causes, nervous deafness should arise, it will be indicated, in most instances, by tinnitus aurium, or ringing in the ears, by unplea- sant and peculiar sounds resembling the dashing of waves, the murmuring of bees, the roaring of a cataract or water-fall, the hissing of a tea-pot, the rustling of leaves, the singing of a conch or shell, the vibration of the stethoscope, and many other strange, and, to the patient, unaccountable noises. These symptoms are most urgent during the winter, at night, and in cloudy weather, and whenever the patient has taken cold. Most patients, in- deed, troubled with nervous deafness, are peculiarly susceptible of cold; from this, and from other causes, there is a diminution of the ceruminous secretion, and, consequently, a peculiar dry- ness or huskiness of the meatus auditorius. Despondency is a frequent concomitant of nervous deafness. Children, totally deaf, at birth, from some permanent organic defect of the internal ear, necessarily remain dumb. Diseases of the Internal Ear. 335 Treatment of Diseases of the Internal Ear. For confirmed nervous deafness, unfortunately, there is no re- medy, though much may be done towards arresting the progress of the disease whilst in the commencement. The chief indica- tion, generally, is to reduce the patient by blood-letting, purging, and low diet; after which a blister behind the ear, or a succes- sion of blisters, will often prove highly beneficial. In addition to this treatment, the patient should be directed to guard, carefully, against cold or exposure, by protecting the feet, wearing in other respects suitable clothing, avoiding a current of air, &c. The free use of common salt applied to the skin, or rubbed among the hair of the head, will be found to contribute very much to this end, and was frequently prescribed by Dr. Physick in cases of ner- vous deafness accompanied by great susceptibility of cold. Ner- vous deafness from syphilis is by no means uncommon, and may generally be removed radically by a course of mercury. In many incurable cases of deafness, the patients derive great assis- tance from the use of ear trumpets, one of which, lately invented in France, in the shape of a flexible tube, eighteen or twenty inches long, has been found extremely useful, and far superior to any other instrument of the kind I have met with. See The Anatomy of the Human Ear, illustrated by a Series of Engravings, of ihe natural Size,- with a Treatise on the Diseases of that Organ, the Causes of Deafness, and their proper Treatment, by the late John Cunningham Saunders, 8vo. 1817—A Treatise on the Physiology and Diseases of the Ear,- containing a Comparative View of its Structure and Functions, and of its various Diseases, &c, by John Harrison Curtis, 8vo. 1817—An Essay on the Human Ear, ils Anatomical Structure and incidental Complaints, &c, by W. Wright, 8vo. 1817 —Observations on the Ejects which take place from the Destruction of the Mem- brana Tympani of the Ear, by Sir Astley Cooper, 4to. 1800—Further Observa- tions on the Effects which lake place from the Destruction of the Membrana Tym- pani, with an Account of an Operation for the Removal of a particular Species of Deafness, by Astley Cooper, 4/o. 1801—Richerand's Nosographie Chirurgicale, ou Nouveaux Elemens de Palhologie, tom. 2, p. 135 —Dictionnaire des Sciences Medicates, tom. 38, p. 24, article Oreille—Rosenthal, Essai d'une Palhologie de fOrgane de I'Ouie, in Journ. Complement, du Diet, des Sciences Med. tom. 6— Memoire sur la Theorie des Maladies de I'Oreille, et sur les moyens que la Chirur- gie peut employer pour leur curalion, par M. Leschevin,- in Memoires sur les Sujets proposes pour le Prix de L'Academie Roy ale de Chirurgie, tom. 9, p. Ill, Edit, duodec. 33G Diseases of the Arteries. CHAPTER XII. DISEASES OF THE ARTERIES. The arteries, like most other textures, are supplied with blood- vessels, nerves, exhalents and absorbents, and are made up of coats or coverings, differing from each other in structure, con- sistence and tenacity. Hence, they are subject to many dis- eases to which other soft parts are liable; whilst, at the same time, they possess powers of resisting disease peculiar to them- selves. To understand their diseases, an accurate knowledge of their structure and conformation is very necessary—though the study is commonly much neglected by students. There are three coats to an artery—an external, middle, and internal coat. The external coat is composed of condensed cel- lular membrane, is remarkably elastic and tough, of a pure white colour, smooth on its inner surface, and rough on its outer, where it is in contact with a cellular sheath or an additional investment. The middle coat is uncommonly thick, and ap- pears to consist of muscular fibres arranged in a circular direc- tion. There is a every reason to believe, however, that these fibres are not muscular, for they are compact and solid, but they rea- dily break; whereas, muscular fibres are soft, and bear exten- sion, and are with difficulty broken. In several other respects, also, these fibres differ from the muscular and approach to the fibrous texture. The third, or internal coat, is remarkable for its extreme delicacy, and is so exceedingly thin as to appear nearly transparent. It is of a very white colour, and its inter- nal surface has an unctuous feel. Externally it is connected Diseases of the Arteries. 337 slightly to the middle coat, though not by intermediate cellular membrane. Notwithstanding the tenuity of this coat, it is pos- sessed of considerable strength longitudinally, but tears readily when force is applied in the circular direction. The vasa vasoi-um, with which all arteries are supplied, are com- monly derived from the adjoining trunks or branches. They first penetrate the cellular coat, upon which they are abundant- ly distributed, then send numerous ramifications to the surface throughout the substance of the middle coat, and finally termi- nate, there is no reason to believe, upon the inner surface of the third coat. According to Bichat,* however, these vessels do not reach the internal coat; but, as this coat is evidently vascu- lar, as may be distinctly seen after careful maceration, the sup- ply of blood is probably derived from the vasa vasorum, and perhaps also from some other source. Arteries are subject to inflammation, suppuration, ulceration and sphacelus. They are also liable to have their texture subvert- ed by the formation of calcareous concretions, by uniform enlarge- ment or dilatation of their differcn coats, or by rupture of the internal and middle coats, in which latter case the disease pro- perly termed aneurism is produced. The internal coat is more subject to inflammation than either the middle or external coat. This is evinced by the effusion of lymph, which is often poured out in large quantity upon the inner surface of an artery in consequence of inflammation of contiguous parts, from the application of ligatures, from wounds, from the pressure of tumours, and from many other similar causes. Sometimes the inflammation thus excited travels along the vessels as far as the heart, and proves fatal. Chronic in- flammation of the arteries is frequently met with, and is very apt to follow or precede calcareous depositions. An appear- ance similar to that produced by inflammation is often present- ed upon the internal surface of arteries—a vivid redness or scarlet tinge. This is not, however, always the result of in- flammatory action, for it is seldom accompanied by an effusion of lymph. Arteries, likewise, that have been exposed for a few days to the air in the dissecting room, invariably assume the same colour. • General Anatomy, translated by Hay ward, vol. i. p. 317. 338 Diseases of the Arteries. Although arteries resist for a long time the ulcerative action, they are liable eventually to be destroyed. So long, however, as they continue sound, the risk of ulceration is diminished ; hence the process rarely takes place except in arteries that have been tied by ligatures of an improper form or size, or have been com- pressed by blood, which has injected the cellular membrane around the vessel and destroyed its vasa vasorum, and thereby deprived it of its nourishment. Ossified arteries, also, as they are called, sometimes ulcerate and give rise either to hemorrhage or to aneurism. Extensive ill-conditioned ulcers, by penetrating deeply and laying waste the soft parts, may occasion fatal he- morrhage by opening large arteries. It is unusual for arteries to mortify and slough, and when the process does take place, it is seldom followed by hemorrhage; for during the progress of the mortification among the surround- ing parts, the vessels become filled with coagula to a considera- ble extent, which seal their extremities for a time and prevent hemorrhage: these coagula are afterwards absorbed, and the mouths of the vessels permanently closed, through the medium of adhesive inflammation. But the most common disease of arterial trunks and branches is the deposition of calcareous matter. So common, indeed, is this condition of the arteries in the advanced periods of life, that the vessels of few old subjects are exempt from it. It is not pe- culiar, however, to old age, but has been occasionally met with even in the arteries of infants. The outer surface of the internal coat is the most frequent seat of the calcareous deposite. From this surface it extends gradually through the coat and projects into the area of the vessel, being for a time still covered with a fine pellicle or membrane. At last this membrane gives way, and the concretion is then brought in contact with the blood. It is seldom that we find an artery completely incrusted with this earthy matter, so as to form an entire rigid cylinder; the depositions, on the contrary, are scattered in irregular patches, varying in shape, number, and size, over the surface, and through- out the substance of the internal coat. Sometimes they are in- , termixed with a curdy, pultaceous, or steatomatous matter. It is this condition of an artery which generally lays the founda- tion of aneurism, as will hereafter be explained: from this cause, also, it often happens, that arteries are unable to bear the opera- Diseases af the Arteries. 839 tion of the ligature, which, when applied, either produces rup- ture of the vessel or excites ulceration. There are several other diseases, moreover, that seem to result from this earthy degene- ration of the arterial tubes. A uniform dilatation of the arterial coats is not so unfrequent as some modern writers have imagined; and although distinct in many respects from aneurism, is often conjoined, or exists simultaneously, with that disease. From aneurism, however, it differs chiefly in the circumstance of the vessel being enlarged throughout the circumference—whereas, in aneurism, the dilata- tion is commonly on one side. Besides this, a dilated artery seldom, if ever, contains a coagulum, which an aneurismatic artery always does. The larger arteries are most subject to di- latation; hence, the disease is very common in the aorta; also, where vessels divide, or where they form angles, dilatation is very apt to ensue. From this cause the arch of the aorta, the iliacs and carotids at their division are oftentimes greatly ex- panded beyond the natural size. Very urgent symptoms, and even fatal consequences, not unfrequently follow an enlargement of the great vessels in the vicinity of the heart. 340 Aneurism. Section 1. Aneurism. Aneurism has been defined " a pulsating tumour formed of arterial blood ;* and to this there can be no valid objection, pro- vided the explication be restricted to the form of the disease usually met with. Different appellations, also, have been given to certain varieties of the disease—such as true and false, cir- cumscribed and diffused. Again—we have varicose aneurism, and aneurism by anastomosis. By the term true aneurism, is commonly understood a simple dilatation of all the coats of an artery—by false aneurism, a rupture or wound of the three coats, so that the blood is extravasated among the surrounding parts. The terms circumscribed and diffused, relate merely to the form of the swelling or the extent of the extravasation. I shall de- viate so far from common authority, as to restrict the meaning of true aneurism to that condition of an artery in which all its coats are uniformly dilated, or else the internal and middle coats ruptured while the cellular coat remains entire. By false aneu- rism, I understand that arising from a wound or division of an artery. Varicose aneurism, and aneurism by anastomosis, will be noticed hereafter. In the incipient stage of aneurism, the tumour is small, free from pain, and easily made to disappear by pressure; but returns as soon as the pressure is discontinued. For a long time the skin preserves its natural colour; as the swelling augments, however, it becomes pale, and cedematous. The strength of the pulsation in the tumour, is greater during the early than the advanced stages of the disease; for in proportion as the swelling • C. Bell's Operative Surgery, vol. i. p. 70. Aneurism. 341 augments, the coagulated blood which fills the sac is interposed in such a way as to diminish the stroke of the artery in which the aneurism is seated. When the tumour attains a large bulk, the integuments covering it become painful and livid, and crack in different places; through the fissures a bloody serum is dis- tilled, ulceration follows, which, extending to the sac, opens a communication with its cavity, from which fluid blood issues in a stream, mixed with coagula; as the ulceration extends, the opening enlarges, the hemorrhage becomes more and more fre- quent, and, if not arrested, destroys the patient. Sometimes the tumour, by pressing upon a contiguous bone, causes its removal; this is effected through the medium of the absorbents: the bone, however, is not rendered carious, nor does the formation of pus accompany the process. Disputes have arisen, at different periods, respecting the for- mation of aneurism, or the mode by which the disease is in- duced—some contending that there is a uniform dilatation of the three coals—others, that the internal and middle coats are ruptured or ulcerated, and the tumour formed by a distention of the external or cellular coat. Both opinions seem to be well founded, and the error committed, as correctly remarked by Hodgson, appears to have been, that the advocates for each doc- trine took too limited a view of the subject. There can be no question, however, I think, that the theory broached by Sen- nertus, and supported with so much ingenuity by Scarpa, will be found to afford the true explanation of the phenomena usually met with in the generality of aneurismal tumours—that the in- ternal and middle coats are ruptured or destroyed, and that the sac is formed by a dilatation of the external coat. In proof of this being the true explanation, it will only be necessary to state, that in most aneurisms the tumour will be found upon dis- section to occupy one side of the artery, whereas, if all the coats were regularly dilated, it should embrace the whole circumfe- rence of the vessel. Again—if a careful separation of the dif- ferent coats be made, the external coat may be traced through- out, while the internal and middle coats, at the place where the entrance of the aneurismal sac communicates with the artery, will be perceived to terminate by an abrupt or fringed margin. On the other hand, there can be no doubt whatever, that a regular- ly dilated artery, and such as is commonly considered an aneu- Vol. II. 14 342 Aneurism. rismal artery, is sometimes met with, independently of a rupture of the internal coats, that, in other instances, these coats, after having expanded to a certain extent, ulcerate or are ruptured and give rise to the common form of the disease—the latter be- ing thus ingrafted, as it were, upon the former. It must not be supposed, however, from these observations, that every dilated artery can be considered an aneurismal artery, for there are many instances to the contrary. The arteries, for example, of the impregnated uterus, become greatly enlarged beyond their natural size; the collateral branches, also, after a main trunk is tied, are dilated in a similar manner. The distinction, then, should be drawn between the dilatation of a sound and a diseased artery; and, perhaps, it may with propriety be stated, that true aneurism is never produced without a previous morbid condition of the coats of the vessel in which it is seated. This morbid change of structure has been already noticed, as connected with calcare- ous deposition, or with the formation of atheromatous matter be- tween the internal or middle coats. Arteries thus situated are very liable to give way even under ordinary muscular exertion; hence, in nine cases out of ten, external aneurism is the result of sudden and violent extension or flexion of a limb, while the inter- nal is produced by lifting heavy weights, &c. False aneurism differs essentially from the true, inasmuch as the blood is not contained within the entire walls of the artery, or within its cellular coat, but poured into the cellular mem- brane adjoining the wounded vessels, where it is either confined within a narrow space, or else spread over an extensive surface —hence the origin of the terms circumscribed and diffused aneu- rism. When a considerable artery is cut across, or punctured, and the blood does not find a ready outlet by the external wound, it flows internally, and may inject the cellular membrane of a whole limb, and so separate the vessels from their surrounding connexions, as to cause them afterwards to ulcerate upon the application of a ligature, and the patient to perish from second- ary hemorrhage; or gangrene may ensue from the general pres- sure occasioned by the extravasation. If a moderate quantity of blood be effused, it seldom passes far beyond the boundaries of the wounded vessel, where it forms a coagulum which gives a temporary restraint to the hemorrhage; in the mean time, the external wound heals, and the loose cellular membrane around Aneurism. 343 the coagulum also closes up and forms a sac,, which invests the clotted mass. A tumour is thus formed on the sides of the wound- ed vessel, the cavity of which communicates with that of the ar- tery, constantly receives small portions of fresh blood, and at last comes to resemble the most common variety of the true aneu- rism, differing from it only in this—that the sac is formed not by the dilated external coat of the artery, but by the loose cellular membrane exterior to that coat. Treatment of Aneurism. Spontaneous cures of aneurism, although reported by writers, must be considered extremely rare. Such an event may be brought about by two or three different causes—by the forma- tion of a large and firm coagulum, which fills not only the en- tire sac, but, perhaps, a part of the artery above it—from the tumour, by change of position, pressing upon and obliterating the superior or inferior portion of the artery—by inflammation and sphacelation of the sac and whole tumour. The first is the most frequent, the second seldom met with, and the third, when it does occur, usually attended with distressing symptoms, and sometimes followed by fatal consequences. A fourth mode by which a spontaneous cure may be effected, has been noticed by some writers—the stoppage of the caliber of that part of the ar- tery, immediately below the tumour, by the accidental separa- tion of a fragment of coagulated mass lining the cavity of the sac. It appears to me, however, that this conclusion is gratuitous, or at least not altogether supported by well attested facts. Much may be done towards mitigating the symptoms of aneu- rism, and arresting the progress of the disease—by frequent and repeated blood-letting, by rigid abstinence, by confinement to bed or to the horizontal position, by the internal use of digita- lis, and the external application of various astringents and refri-, gerants. Such remedies cannot, however, be depended on in the 344 Aneurism. generality of cases; although examples have been cited by Val- salva, Morgagni, and other old writers, and more recently by Pelletan, of perfect cures having been effected under various cir- cumstances by the foregoing means. On this account, the prac- tice should always be pursued whenever the tumour is so large and so situated as to render the operation by the ligature im- practicable; but success cannot be calculated upon, unless the depleting system be carried to the utmost extremity. There are two modes, in the shape of an operation, practised for the cure of aneurism—compression and the ligature. Com- pression is now seldom resorted to—experience having proved its general inefficacy. The process has been found, moreover, even when successful, so extremely painful and tedious, that few patients can be induced to submit to it, or to persevere sufficient- ly long to accomplish a cure. That it operates, partly, upon the principle of the ligature, when it does succeed, there can be no doubt, by compressing the sides of the vessel, causing the ef- fusion of lymph, and finally, obliteration of the channel, so as to force the blood to abandon the sac, and pass off by the collateral branches. When applied to the sac itself, such an effect, owing to the interposition of the coagulated mass, can rarely, if ever, be produced. Different machines for compressing aneurismal arteries or tumours, may be found in most systems of surgery. The ligature, then, may be considered as the only mode ot operation upon which any great reliance can be placed in the treatment of aneurism, and this, too, frequently fails. From the numerous and diversified experiments of Dr. Jones and others, it appears that a ligature, when applied to an artery with sufficient force, divides the internal and middle coats, leaving the external coat entire. The blood, arrested in its passage by the approxi- mation of the sides of the vessel, soon coagulates and forms a plug extending as high as the first collateral branch. This serves as a temporary barrier, and takes off the force of the circulation from the ligature and the extremity of the artery. In the mean time, the divided edges of the artery pour out lymph, which is not only effused in the cavity of the vessel, but between its coats; the irritation, also, excited by the ligature, gives rise to an ac- cumulation of lymph on the outer surface of the artery. At last, the external coat, continually irritated by the ligature, sloughs, or ulcerates, and the ligature is detached, leaving the mouth and Aneurism. 345 edges of the vessel filled and surrounded by a bed of lymph, into which vessels shoot, and by uniting the sides of the artery forms a permanent closure. After a time, the coagulum is absorbed, and the channel of the artery as high as the first anastomosing branch, is obliterated and converted into a solid cord. Long before this- process is completed, however, the blood, forsaking the main route, passes through the collateral vessels, which vessels gradually en- large in proportion to the force of the column driven into them, until at last they equal or exceed in the aggregate the size of the original trunk, and the circulation becomes fully re-established. But, instead of a cure being always accomplished in this hap- py manner, it sometimes happens that secondary hemorrhage results, and the patient either dies or is with difficulty saved. Such an event may be referred to several different causes—to the improper form, mode of application, and premature removal of the ligature—to a morbid condition of the aneurismal artery —to a deficiency of coagulum within the caliber of the vessel— to an unnecessary denudation of the coats of the artery, and per- haps to some other causes. If a ligature, instead of being round and small, is flat and large,. and twisted or irregular in shape, it is not well calculated to di- vide the internal coats, or il does not divide them throughout their circle. Upon the same principle, if a large portion of the surrounding cellular membrane, or a contiguous nerve, be in- cluded in a ligature, the coats are partially divided or not divided at all. Again—even if the ligature be of a proper form and well applied, if, through the officiousness of the surgeon, it is pulled away before the adhesive process is perfectly accomplished,. and lastly, if from an ill-formed knot, the ligature be forced by the impetus of the circulation from the mouth of the artery, hemorrhage results. In most of these instances, the coats of the artery inflame from irritation, or the vasa vasorum being com- pressed or destroyed, the vessel is deprived of its nourishment, and ulcerates or sloughs, either at its mouth or above the liga- ture.—An artery is sometimes, in false aneurism, so separated from its surrounding connexions by extravasated blood, as to be completely insulated. Under such circumstances, it is soon, for want of support, reduced to a diseased state, and ulcerates if a ligature be applied to it. In cases of true aneurism, an artery is often ossified, or at least covered, at the place it is tied, with 346 Aneurism. calcareous depositions. Such an artery is extremely prone to ulceration, and there is nothing better calculated to excite it than the irritation of a ligature.—Although it has been stated that a coagulum is formed after the application of a ligature, it must be understood that under particular circumstances, this does not happen—as, for example,, in cases where a vessel is tied imme- diately below a large anastomosing branch. There is no oppor- tunity in such a case for coagulum to form; consequently, the ligature and the new-formed tender lymph along the extremity of the artery, sustain the whole force of the circulation; hence, it sometimes happens, after the ligature is detached, that the lymph, unable to resist the current of blood, gives way and he- morrhage ensues. With respect to the " unnecessary denuda- tion " of the vessel, it may be remarked, that the surgeon, from ignorance or want of dexterity, may mangle the parts adjoining -the artery, and cut off all communication between them, so as to render the vessel unfit afterwards to bear the ligature. It must not be supposed, however, that ulceration or slough- ing, and secondary hemorrhage, will necessarily result from these causes ; nor should it be inferred, that an artery cannot be permanently closed, unless the internal coats be divided by the ligature, nor that an ossified or denuded artery will never heal. Experience proves the contrary; but it also proves that the failure of the operation, in most cases, is owing to the circum- stances pointed out. Previous to the time of the celebrated Hunter, the practice of tying the vessel immediately above the tumour, and afterwards opening the sac and clearing it of the coagulated blood, was uni- versal ; but the operation so frequently failed, and the death of the patient so often followed, that this great pathologist was in- duced to investigate the subject in a particular manner. He found that the artery immediately adjoining the tumour was commonly in a diseased state, and therefore unable to bear the ligature; that the practice of opening the sac and removing its contents, excited a great deal of constitutional irritation, accom- panied by sloughing of the tumour and of the contiguous parts; and that from these causes many patients lost their lives. Mr. Hunter at once conceived the ingenious idea of tying the artery at a distance from the sac, and of leaving the latter untouched; the result was highly satisfactory, and proved most decidedly Aneurism. 347 the value of his theory—that the artery should be tied in a sound part, and the sac and its contents removed by the absorbents. During Mr. Hunter's time, the operation was confined, almost exclusively, to popliteal aneurism; it has been extended by many surgeons of the present day to every other aneurismal tumour upon which an operation is admissible. An objection, however, has been made to the Hunterian operation, which seems not al- together destitute of foundation—the occasional return of the blood into the sac through those anastomosing vessels, which happen to communicate with the main trunk somewhere inter- mediate to the sac, and the place where the ligature is applied. But this so seldom occurs, that it can scarcely be considered an objection. In performing the operation for aneurism, in general, it is only necessary for the surgeon to remember that he is to cut for a sound part of the artery, at a greater or less distance above the sac; that he is to penetrate cautiously with the knife, (not ex- tending the incision an immoderate length, and tearing the sur- rounding parts by his fingers or by instruments,) until he ob- serves the pulsation of the vessel, when he should endeavour to detach it only to such an extent from its connexions, as to ena- ble him to pass a common aneurismal or crooked needle, armed with a small round ligature, beneath it. The ligature should then be firmly tied, and one end being cut off near the knot, the other should be left hanging from the wound, the edges of which must be closed by adhesive straps. Many surgeons follow the practice of Mr. Abernethy, and apply two ligatures—afterwards dividing the artery between them. I am disposed to think, that few, if any, advantages are gained by this proceeding, and in certain cases that it will be attended with imminent peril. Brasdor, and afterwards Desault, conceived that under parti- cular circumstances—where the tumour, for instance, is so large or so situated that the artery cannot be tied above it—a ligature applied to the vessel beyond the tumour might effect a cure, by causing the blood to coagulate in the sac and upper part of the artery, as high as the first anastomosing branch. The experiment was tried by Deschamps and by Sir Astley Cooper —but without success, owing to one or more anastomosing ves- sels passing off between the sac and ligature, in such a way as 348 Aneurism. to keep up a constant stream of blood through the sac. At the Aims-House Infirmary, during the winter of 1827, in a case of femoral aneurism extending a considerable distance above Pou- part's ligament, in a patient nearly 70 years of age, in presence of Professor Mussey, of New Hampshire, and several other medical gentlemen, I cut down upon the femoral artery imme- diately below the tumour, and compressed the vessel for some time between two fingers, with a view of ascertaining whether the pulsation in the tumour could be diminished, intending in that event to apply a ligature. So far, however, from any favourable change being produced by the compression, the pul- sation continued without interruption, so as plainly to indicate that anastomosing vessels passed off between the ligature and sac. Under these circumstances, and particularly as the patient had iong laboured under an obstinate cough, and some apparent disease of the great vessels within the chest, I resolved not to apply the ligature, but bring the edges of the wound together, and suffer it to close, which it did, though not without difficulty, in two or three weeks. This patient died during the autumn of 1829, and, upon examination, it was found that four vessels, each nearly as large as the femoral artery, passed off from the lower part of the sac. The iliac and femoral arteries, as well as the sac and smaller vessels, were covered with calcareous incrus- tations. If the artery had been tied, it would, in all probabili- ty, have taken on ulceration, and, at any rate, the operation could not have been productive of any benefit. That the operation of Brasdor has, however, succeeded in a few instances, there is every reason to believe. Mr. Wardrop,* of London, who, within the last few years, has turned his atten- tion particularly to the subject, and who deserves great credit for the persevering efforts he has made to establish the operation, has published the result of four or five cases, in some of which the termination is said to have been successful. Mr. Wardrop has extended, likewise, the operation of Bras- dor, to aneurism of the arteria innominata—by tying the sub- clavian or carotid arteries. He has reported the successful ter- mination of a case of the kind, in which the subclavian was taken up by himself, and another by a Mr. Evans, who tied the carotid * Wardrop on Aneurism. London, 1828. Aneurism. 349 artery for aneurism of the innominata, and succeeded perfectly. Within the last few years Dr. Mott, of New York, performed a similar operation, but the patient did not recover. Other cases have been reported since, (making in all about sixteen or seventeen,) in which the operation has been per- formed, but without permanent benefit, except in a very few in- stances ; from all which it maybe inferred, that Brasdor'sopera- tion is, in every respect, a very dangerous and uncertain one— that it is liable to be followed by high inflammation, ulceration and sloughing, from the artery being tied (almost necessarilv,) in a diseased part, and by secondary hemorrhage—that it can seldom succeed when collateral vessels pass off from the sac—that it ought never to be performed, unless other operations are imprac- ticable, and the patient's life in immediate danger; and lhat, when performed, it should always be conjoined, if possible, with medical and other means. Whatever mode may be selected for the operation of aneurism, there is one point upon which most surgeons entertain the same opinion—that little danger is to be apprehended of gangrene, from want of collateral branches, or free distribution of blood, except amongst arteries of the largest class. Vol. II. 45 350 Aneurism of the Aorta- Section II. Aneurism of the Jlorta. There is no artery more subject to aneurism than the aorta; and, unfortunately, the disease, when thus situated, is seldom, if ever, cured. Owing to the rapidity with which the blood issues from the heart, and its forcible propulsion against the arch of the aorta, where it first meets with resistance, this portion of the vessel is particularly apt to suffer, and here the aneurism will be found, usually, to commence either in the form of a general dilatation of the coats, or, as is most frequent, by rupture of the internal and middle coat, with distention of the cellular; in which last case the tumour will be situated on one side of the artery— as explained in some of the preceding pages. The symptoms of aneurism of the thoracic aorta are more or less difficulty of breathing, a sense of uneasiness and constriction about the chest, palpitation of the heart, severe pain, shooting from the sternum towards the arms, (compared by some patients to that produced by a rope drawn tightly around the chest,) a troublesome hacking cough, difficulty of deglutition, feeble and intermitting pulse. In the advanced stages of the disease, or in proportion as the tumour acquires bulk, all these symptoms are aggravated, and others often superadded, such as tremendous pulsation in the tumour and large vessels adjacent to it, or about the heart. Frequently it happens, that a part of the swelling rises above the sternum, in which case the disease is liable to be mistaken for aneurism of the innominata, carotid, or subclavian arteries. When the tumour attains a great magnitude, its pres- sure upon the sternum, ribs, or clavicles, causes their absorption; every barrier is then removed except the integuments; and the tumour, whose dimensions are sometimes enormous, projects be- Aneurism of the Aorta. 351 yond the chest. At last, the integuments, the sac, and its im- mediate coverings inflame and ulcerate, and masses of coagulated blood are discharged. Pressure for a time, perhaps, arrests their progress, but the ulcerated opening continues to enlarge, and finally the patient, oftentimes without a moment's warning, is destroyed by hemorrhage. In many instances, however, and long before the aneurism acquires any considerable bulk, it bursts into the chest, into the cells of the lungs, or into the pericardium, and instantaneously proves fatal. In some rare instances, commu- nications have been established between the aneurismal sac and the pulmonary artery, or the oesophagus, or trachea, and, of course, with a fatal result. There are several diseases about the chest, whose symptoms bear a similitude to those of aneurism of the aorta; such as en- largement of the bronchial glands, collections of serum or pus, which by pressure on the heart force it towards the right side of the chest, where it may be felt pulsating strongly, morbid thick- ening of the parietes of the heart, &c. On the other hand, an- eurism of the thoracic aorta, from its pressure on the lungs, will sometimes give rise to symptoms resembling those of phthisis pul- monalis. For these reasons, the surgeon should be very cautious not to pronounce too hasty a prognosis. The abdominal aorta is often the seat of aneurism. Generally, the tumour is situated immediately below the diaphragm, and owing to the little resistance it meets with from the loose and yielding textures surrounding it, soon acquires considerable bulk, and pulsates most awfully, and so distinctly and forcibly, as in some instances to elevate the bed-clothes, of which the patient and by-standers are very sensible. When the tumour becomes very large, there is not only dropsy of the belly and limbs, from pressure on the thoracic duct, but, destruction of the lumbar ver- tebra?, followed by paralysis of the legs, and eventually by the death of the patient, which for the most part is occasioned by a rupture of the sac, the blood of which is poured into the duode- num, stomach, or cavity of the „elly. 352 Aneurism of the Aorta- Treatment of Aneurism of the Aorta. Although Sir Astley Cooper has been adventurous enough to tie the abdominal aorta, in a case of aneurism of that vessel, I trust that there are in this country but few surgeons, if any, disposed to follow his example; for, certainly, there is reason to believe, that independently of the great irritation which must necessarily follow such an operation, gangrene would, in every instance, be the result,—from the want of an adequate supply of blood. This observation is made with a perfect knowledge of the fact, as stated by Scarpa, Hodgson, and others, "that if the aorta be tied in the dead subject immediately below its arch, and a thin injection be thrown into the upper portion of the vessel, it will pass into the arteries of the lower extremities." All that we can hope to accomplish, then, in most cases, is to arrest the progress of the disease, or save the patient's life for a time. This may undoubtedly be done by strict abstinence, re- peated blood-letting, the internal use of digitalis,- the external ap- plication of astringents and cold, and in the advanced stages, by supporting the tumour with leaden compresses, adhesive straps, &c. Some instances, indeed, of perfect cures having been accom- plished by these means, are related, and upon most respectable authority. Few patients, however, can be brought to submit, for any length of time, to so rigid a system as the advocates of this practice have enjoined. Aneurism of the Carotid. 353 Section III. Aneurism of the Carotid. Carotid aneurism, whether from a wound or from disease in the coats of the vessel, may be considered comparatively rare. It is met with chiefly in hard-working people, especially those accustomed to carry heavy burdens upon their heads and should- ers. The tumour may occupy either the common trunk, or else, the internal or external carotid. Generally, it is situated near - the angle of the jaw, at the place where the artery divides. Like aneurism in most other situations, it may be known by its strong pulsatory motion, by its rapid enlargement, by the cough and difficulty of respiration, and of deglutition, occasioned by pressure of the tumour upon the larynx and oesophagus. It is sometimes, however, extremely difficult to distinguish between this disease and other tumours about the neck, and in the immediate vicinity of the artery. Common glandular or sarcomatous tu- mours, for example, if they happen to lie in contact with the carotid, have a pulsation communicated to them. In such cases, if the tumour can be elevated, or removed from the vessel by the fingers, the pulsation will cease, and the true nature of the dis- ease become manifest. Again—if pressure be made upon an or- dinary tumour, or upon the carotid running near it, the tumour is not diminished, whilst aneurism, treated in a similar manner, is sensibly decreased. Several cases are recorded of aneurisms of the aorta having ascended so high upon the neck, as to be mistaken for carotid aneurism. 354 Aneurism of the Carotid. Treatment of Carotid Aneurism. The fact that the carotid of one or both sides, might be obli- terated by disease, without curtailing the supply of blood des- tined for the brain, has been long known. Several instances, too, are mentioned by the older writers of wounds of the carotid terminating favourably, after the application of the ligature; but Sir Astley Cooper was the first, I believe, to tie this vessel in a case of aneurism; though the propriety of such a measure had been strenuously insisted upon by Mr. John Bell, as the following passage, (referring to the case of a woman who had been suffered to perish for want of an operation,) will evince. " Nothing could more tempt us to a daring experiment, than the desperate condition of such a patient, nor is there any thing in the relative situation of these parts to deter us; had this wo- man been under my care, or should ever such a case recur, I should never hesitate one moment, conscious that the most ab- solute bungler in surgery, might lay aside the muscle with a few strokes of his scalpel, open the common sheath of the ca- rotid and its accompanying nerve, and separate the vein, nerve and artery, so as to tie the latter without let or hinderance."* Since Sir Astley Cooper's operation, which was first per- formed in eighteen hundred and five, the experiment has been very frequently repeated, and has now become an established practice. To perform the operation to advantage, the patient should be placed in the recumbent position, with his head somewhat raised by a pillow, and slightly inclined towards the affected side. The surgeon then makes an incision two or three inches long on the inner edge of the mastoid muscle, com- mencing immediately below the tumour. An assistant pulls to one side the mastoid and sterno-hyoid muscles. This will bring into view the internal jugular vein, the omo-hyoideus muscle, and sometimes the decendens noni, all of which should be avoided. The next step of the operation is to expose and open * Principles of Surgery, vol. 3, p. 254. Aneurism of the Carotid. 355 the sheath of the artery, which is easily done by pinching up the sheath with a pair of dissecting forceps, and making a horizontal cut into it. The sheath being opened, an anuerismal needle or flexible silver probe, armed with a ligature, is passed around the artery; taking especial care before tying the ligature, to exclude the par vagum. Having tied the artery fairly, and secured the ligature by two or three knots, its ends are left hanging from the wound, the lips of which should be closed by adhesive straps. A single ligature, in case of carotid aneurism, should always be employed; for if two ligatures be applied, and the artery divided between them (as advised by Abernethy) the patient would inevitably perish by hemorrhage, if, from any cause, the ligature should be detached. 356 Axillary Aneurism. Section IV. Axillary Aneurism. Aneurism of the axillary artery is sometimes met with. It may arise either from a morbid condition of the coats of the vessel, or from a wound. In whatever manner produced, the tumour enlarges with great rapidity, soon fills the arm-pit, and, not unfrequently, extends above the clavicle. The characters of the disease are so well marked, as to be seldom mistaken; yet instances are related of such tumours being opened by igno- rant surgeons, under the impression that they were abscesses. Treatment of Axillary Aneurism. If the aneurism be small, and seated low in the axilla, which seldom happens, the surgeon may possibly find sufficient space between the sac and the clavicle, to enable him to include the axillary artery in a ligature; on the contrary, should the tumour be large, and occupy the commencement of the vessel, it will be necessary to tie the subclavian artery. The two operations differ materially from each other, on which account it will be necessary to describe them separately. To tie the axillary artery, the surgeon should make an in- cision, (the patient being seated in a chair with his shoulders thrown a little backwards, and supported by an assistant,) two or three inches in length, commencing near the sternal extre- Axillary Aneurism. 357 mity of the clavicle—running downwards in a semilunar direc- tion and terminating near the edge of the deltoid muscle. Fol- lowing the course of the external incision, the fibres of the pec- toralis major should be next divided, until the pectoralis minor is exposed. Between the clavicle and the superior edge of this last muscle, the axillary artery will be found. Here the vessel is encompassed by the axillary vein, and by a plexus of nerves. The surgeon must, therefore, proceed very cautiously, lest he divide some of these parts with the knife, or include them in the ligature. The vessel being fairly exposed, and separated to such an extent as barely to permit the aneurismal needle, with its ligature, to pass beneath it, should be tied, when the pulsation in the tumour and at the wrist will immediately cease. When it is necessary to take up the subclavian artery, (the operation commonly practised for axillary aneurism) the position of the patient will be found a matter of immense importance. He is seated on a low stool or bed, with his head thrown back- wards, and inclined towards the sound side, and the posture steadily maintained by an assistant. Another assistant keeps the arm close to the chest, and at the same time pushes the shoulder downwards and forwards as low as possible. The surgeon makes an incision through the skin above the clavicle, commencing near the sternal extremity of that bone, and terminating at the an- terior edge of the trapezius muscle. The fibres of the platysma myoides, and cervical fascia, are next carefully divided, until the external jugular vein is exposed. An assistant holds aside this vessel with a curved spatula or blunt hook, while the operator separates, with the handle of the knife, the loose cellular mem- brane, until he reaches the acromial edge of the anterior sca- lenus muscle. Near the origin of this muscle, from the first rib, the artery will be found. Owing, however, to the great depth of the vessel, it cannot be easily reached, (if the tumour is large) by the common aneurismal needle; on this account, particular instruments have been invented by Deschamps, Bellocque, De- sault, Ramsden, Watt, and others. I prefer that of Bellocque, and the common artery forceps of Dr. Physick,* to most of them. Bel- locque's instrument consists of a silver cannula, six inches long, straight at the upper extremity, and slightly curved at the lower, • See vol. i. p. 55. Vol. II. 46 358 Axillary Aneurism. containing within its cavity a watch-spring, which, by means of a silver stilet attached to it, may be pushed forward or retracted at pleasure. The lower extremity of the spring is covered by a small silver bulb, which not only serves to render the end of the cannula obtuse, but, from being perforated, to convey the ligature. A ring at the superior portion of the cannula, enables the sur- geon to hold the instrument steadily. Two different vietvs of this instrument may be seen in Plate VIII. figs. 1 and 2. Having laid bare the subclavian, the surgeon will experience no difficulty in passing beneath it this instrument, with the spring retracted, which being done, it only remains to push forward the stilet, when the spring ascends from the bottom of the wound, and a ligature being passed through the eye of the silver bulb, the whole instrument is withdrawn, carrying along with it the ligature and depositing it beneath the vessel. An instrument, however, differing in principle from every other, which I have used upon several occasions, and which I published the following account of in 1828, is calculated, 1 think, to do away all the difficulties that surgeons have so long complained of. " Having experienced much greater difficulties than I expected in passing the ligature beneath the subclavian, I called soon af- ter the operation, upon Mr. Schively, one of the most ingenious and eminent cutlers in the United States, and requested him to make for me an instrument of the shape and size of the common aneurismal needle, calculated to hold a steel stilet capable of being passed, without difficulty, beneath deep-seated vessels. His in- genuity soon removed the defects usually complained of, and pro- duced an instrument, which I do not hesitate to say, in point of simplicity and usefulness, is as yet unrivalled. It consists of a silver cannula, fixed in a wooden handle surrounded (near the part where the cannula joins the handle,) with a silver collar, through which a steel stilet, made of a narrow watch-spring, the length of the instrument, passes and immediately after enters an opening just below the collar, in order to traverse the whole ca- vity of the cannula and emerge at its point. This extremity of the stilet is covered with a flattened silver cap moderately blunt, whilst its other or upper extremity passing upwards from the collar above mentioned, lays parallel with the handle, and has an eye near its end for holding a ligature. A small screw, for the purpose of fixing the stilet while the surgeon is in the act of /•/.,.• ■-.' V.l Plate. 9 Fo 1.2. \ Axillary Aneurism. 359 passing the instrument beneath the artery, works through the silver collar, and may be used or not as the surgeon pleases. It will be seen at once, that the great advantage which this in- strument possesses over those in common use, is that the ligature being held by the upper instead of the lower end of the stilet, the surgeon can draw the stilet along with the ligature, at once, through the cannula and under the vessel—whereas, in other instruments, the ligature being passed through the lower end of the stilet, must, after having been carried beneath the artery, be in part retracted again before the surgeon can tie it."* An additional stilet, if necessary, with a sharp point, may accom- pany the instrument. The use of the instrument, however, as well as its form and size, will be better understood by the draw- ing in Plate IX. figs. 1 and 2. It may sometimes be found, owing to the great depth of the wound, very difficult to close completely the knot of the ligature. In that case I would em- ploy the ingenious contrivance of Dr. Alexander Hosack of New York, which, by holding the first knot firm, enables the surgeon to tie a second or third with the utmost facility. This instrument is so simple and so easily understood, as to render a description of it superfluous. See Plate VIII. fig. 3. Although both the axillary and subclavian arteries have been repeatedly tied in cases of axillary aneurism, yet it is to be la- mented that the operation has very seldom succeeded. This may, perhaps, be ascribed to the operation being generally delayed too long, or to the same disposition to disease in the vessel, which gave rise to the aneurism itself. The operation, however, has proved satisfactorily, that there is no want of collateral branches and consequently seldom danger of gangrene from want of a sup- ply of blood. The honour of having first successfully tied the sub- clavian artery is due to the late Professor Post of New York. • The project of tying the arteria innominata, in certain cases of axillary and subclavian aneurism, has been suggested by different surgeons; and our friend Dr. Mott, of New York, was bold enough, a few years back, to try the experiment—but without success. A similar operation has since been performed by Grasffof Berlin, and with a similar result. I have no disposition to condemn these • See Gibson's Case of Axillary Aneurism, in Philadelphia Journal of Medical Sciences for 1828; and vol. 1st of this work, p. 337. 360 Axillary Jlneurism. attempts, because every effort towards saving the life of a fellow creature, when he must necessarily perish, without relief, should be deemed praise-worthy; but I cannot help thinking that the chance of success must necessarily (owing to the great size of the innominata, its contiguity to the heart, and the probably diseased condition of its coats) be so very limited, in most cases, as not to justify the practice. Another objection, and a very strong one, that might be urged against tying the innominata, is this—that subclavian and axillary aneurisms have sometimes been cured spontaneously. A ligature upon the carotid or subclavian, I should conceive the proper plan in all cases of the kind. Brachial Aneurism. 361 Section V. Brachial Aneurism. It is remarked by Hodgson, that he has « never seen an aneu- rSm Ilthlarm WhiGh WaS n0t Produced by accidental vio- lence. The experience of other surgeons confirms the state- ment, and proves a diseased condition of the coats of this vessel to be a very rare occurrence. The most frequent cause of the aneurism is a wound of the artery at the bend of the arm from the common operation of blood-letting. The external wound having healed, the blood is gradually diffused in the cellular membrane around the artery, and beneath the fascia; a tumour is thus formed, which, in proportion as it augments, causes the fingers and fore-arm to contract, (owing to the unyielding nature of the fascia, or the firm aponeurotic expansion of the biceps) the hmb to diminish, and the patient to experience very con- siderable numbness and pain. Treatment of Brachial Aneurism. Surgeons are unaccustomed, now, except under particular circumstances, to lay open the aneurismal sac at the bend of the arm, and evacuate the clotted blood; experience having proved that the Hunterian operation is as well calculated to succeed here, as in other parts of the body. The aim, therefore, of the • Diseases of the Arteries and Veins, p. 389. 362 Brachial Aneurism. operator, in brachial aneurism, is to cut for the trunk of the ar- tery at some distance above the sac* The tourniquet being loosely applied, chiefly with a view to render the subcutaneous veins conspicuous, and to prevent the surgeon from wounding them, an incision should be made through the integuments, about two inches and a half in length, along the inner edge of the biceps muscle, and about the middle of the arm. The fascia be- ing next divided, the cellular sheath, containing the artery, veins, and radial nerve, will be brought into view; and upon opening this, the artery may be readily found and tied; without risk, if the surgeon is at all careful, of including nerves or other contigu- ous parts. A common aneurismal or curved needle will be suf- ficient to convey the ligature: and this being tied, the wound is dressed in the ordinary way. • A larger share of experience has taught me, that the Hunterian operation is not to be relied upon to the extent I have stated; for I have found that when the artery is simply tied in one place above the tumour, that the pulsation will be apt to continue or return in the sac, through the medium of collateral branches. Dr. Physick has made the same observation; and Dr. Hartshorne informs me that he was obliged, in one case, to cut down and tie the artery below the sac, before he could effect a cure. Upon the whole, then, I am inclined to believe that the safest, and least troublesome practice, will be to tie the vessel above and below the sac, in the generality of cases. Inguinal Aneurism. 363 Section VI. Inguinal Aneurism. When a true aneurism forms, at or near the bend of the groin, a small circumscribed pulsating tumour is perceived, which, from the femoral artery being closely surrounded by dense cellular membrane, and covered by the unyielding fascia of the thigh, increases very slowly, and sometimes so insensibly that neither the patient nor surgeon are aware of its nature, or, per- haps, mistake it for an enlarged inguinal gland, or a hernia. In time, however, these doubts are dispelled by the increase of the tumour, by the general swelling, numbness, coldness, and insensi- bility of the limb, and, finally, if the disease is permitted to run its course, by the inflammation, and, perhaps, sphacelation of the sac, when the patient will either perish from hemorrhage or from irritation, or else obtain, as has sometimes happened, a spontane- ous cure. Treatment of Inguinal Aneurism. Although Guattani and Mr. John Bell, had amply demon- strated the existence of very large and numerous inosculations, calculated, as they believed, to afford a full supply of blood to the thigh, in case the femoral artery should be obliterated, or 364 Inguinal Aneurism. tied, above the origin of the profunda, it remained for Mr. Abernethy to prove by an operation on the living subject, the correctness of their views. This distinguished surgeon, in a hopeless case of femoral aneurism, was induced, in seventeen hundred and ninety-six, to tie the external iliac artery, and though the patient did not recover, he lived long enough to evince the propriety of repeating the operation in subsequent cases. Mr. Abernethy's second attempt was alike unfortunate; but his third and fourth were crowned with complete success, and served to establish the operation, which has since been re- peatedly executed by different surgeons, and often with the hap- piest effect. In America, the operation was performed, for the first time, by the late Dr. Dorsey, in eighteen hundred and eleven, and with a result that usually followed the efforts of that accom- plished surgeon. Mr. Abernethy's operation for inguinal aneurism, which I pre- fer to that of Sir Astley Cooper, or any other I am acquainted with, is executed in the following way. The patient being laid upon a table, an incision should be made in the course of the ex- ternal iliac, commencing about an inch and a half from the an- terior superior spinous process of the ilium, and extending within half an inch of Poupart's ligament. The tendons of the external oblique muscle being cut through to an extent corresponding to the wound in the integuments, a finger should be carried be- neath the margins of the internal oblique, and transversalis, to prevent the peritoneum from being injured while the surgeon is dividing these last mentioned muscles. As soon as this stage of the dissection is completed, the finger can be readily passed be- hind the peritoneum as far as the inner edge of the psoas muscle, where the external iliac artery, and its corresponding vein will be found. The vein, running along the inner side of the artery, should be gently separated from that vessel by the finger nail, or handle of the knife; a ligature may then be passed around the artery, by means of the aneurismal needle, and tied; and the wound being dressed, the patient must be put to bed, and the muscles of the limb kept in a relaxed position. Gluteal aneurism is occasionally met with; and it was for- merly the practice, in such cases, to lay open the sac, and secure the artery where it emerges from the pelvis. The late Mr. Gluteal Aneurism. 365 John Bell performed a terrific operation of the kind, upon a tu- mour of immense size, and succeeded, though with great diffi- culty, in curing his patient. His example was followed in a few other cases; but the high inflammation, suppuration, and caries of the innominatum and ischium that sometimes ensued, induced surgeons to seek for less formidable measures. To Dr. Stevens, of Santa Cruz, the profession is greatly indebted for a more simple and effectual operation—namely, the application of a ligature to the internal iliac artery. From experiments made upon the dead body, Dr. Stevens was induced to believe that the internal iliac might be taken up in the living subject, and a case of glu- teal aneurism, nearly as large as a child's head, having present- ed itself to him in 1812, he determined to try the experiment. " An incision, above five inches in length, was made," says he, " on the left side, in the lower and lateral part of the abdomen, parallel with the epigastric artery, and nearly half an inch on the outer side of it. The skin, the superficial fascia, and the three thin abdominal muscles, were successively divided; the peritoneum was separated from its loose connexion with the iliacus internus and psoas magnus; it was then turned almost directly inwards, in a direction from the anterior superior spi- nous process of the ilium to the division of the common iliac ar- tery. In the cavity which I had now made, I felt for the inter- nal iliac, insinuated the point of my fore-finger behind it, and then pressed the artery between my finger and thumb. Dr. Lang now felt the aneurism behind; the pulsation had entirely ceased, and the tumour was disappearing. I examined the ves- sel in the pelvis; it was healthy, and free from its neighbouring connexions. I then passed a ligature behind the artery, and tied it about half an inch from its origin. The tumour disappeared almost immediately after the operation, and the wound healed Ilindly. About the end of the third week the ligature came away, and in six weeks the woman was perfectly well." Dr. Stevens informed me during the winter of 1831, that he found no difficulty in avoiding the ureter, which retired along with the peritoneum when that membrane was raised from the tu- mour. Mr. Atkinson, of York, in England, next tied the internal iliac artery for gluteal aneurism, in 1817, but the patient died Vol. II. 17 366 Iliac Aneurism. on the nineteenth day after the operation. A Russian surgeon is said to have been the third person who tied this vessel, and the fourth operation of the kind was performed by Dr. S. P. White, of Hudson, New York state, in 1827. With the excep- tion of Mr. Atkinson's, these patients all recovered ; and this fact is sufficient, consequently, to establish the operation. The common iliac artery was first tied by myself so far back as the year 1812—in a case of gun-shot wound. The patient lived thirteen days after the operation, notwithstanding the un- favourable circumstances of the case, and died, finally, from pe- ritoneal inflammation and secondary hemorrhage. He lived sufficiently long, however, to prove satisfactorily to me, that the largest artery in the body, (except the aorta,) might be tied without cutting off permanently the supply of blood to the lower extremity—for the circulation of the limb was re-established on the seventh day—and to enable me to lay down the principle, which I then did, that aneurisms of the external and internal iliac arteries should be treated by tying the iliaca communis. This I consider the more important, inasmuch as surgeons were accustomed at that time to view such aneurisms as necessarily fatal. It affords me great pleasure to add, that my friend Dr. Mott of New York, acting upon the principle I had established, has been able to demonstrate the practicability of my proposal, by lying successfully the iliaca communis in a case of aneurism of the internal iliac artery, an operation which in every point of view does him great credit, and the following account of which, cannot fail to be read with peculiar interest. " The tumour was of large size, protruding the belly considerably at the iliac region; the patient suffered most excruciating pain, which appeared to increase as the tumour enlarged. Dr. Mott's incision extended from the external abdominal ring, to one or two inches above the crest of the ilium, dividing the tendon of the external oblique, and cutting through part of the origins of the internal oblique and transversalis. He then cautiously raised the peritoneum with his fingers, and succeeded in detaching it entirely from the tumour and vessels, without doing it the slightest injury. The artery was then examined, and the aneurismal dilatation was found to cease at about half the distance between the bifurcation of ihe aorta and the origin of the internal iliac branch. The ligature was passed from the outside of the vessel, by the aid of Iliac Aneurism. 367 the instrument devised by Drs. Parrish and Hewson* carefully avoiding the iliac vein. The protrusion of the intestines ren- dered this part of the operation the most difficult. After the ligature was passed around the vessel, the wound was held open in such a manner as to allow the medical gentlemen present to see, and satisfy themselves of the exact situation of the ligature, which was just below the bifurcation of the aorta into the pri- mitive iliacs, and on the side of the sacro-vertebral promontory. The ligature was then drawn tight and secured; the pulsation of the tumour ceased; its size was much diminished, and the pa- tient was relieved from the agonizing pain, previously unre- mitting. The wound was lightly dressed, and the patient put to bed; the limb of the side operated on was cold, as might be an- ticipated ; it was wrapped in cotton, and covered up to pre- serve the temperature until the circulation should be restored. To the great surprise and satisfaction of the surgeon, in a little more than half an hour after the operation, the circulation and temperature were entirely restored, and all fear respecting the supply of blood to the limb effectually dissipated. No untoward circumstance occurred after the performance of the operation. The patient complains of no inconvenience, except a peculiar sensation of fulness or tension in the limb, as if the small vessels had not yet become accustomed to their new office in sustain- ing the great mass of the circulation for the support of the mem- ber."! * An imitation of Dr. Physick's instrument for taking up deep-seated arteries. f Philad. Jour, of the Med. and Phys. Sci. for May. 4j£ 368 Popliteal Aneurism. Section VII. Popliteal Aneurism. The popliteal artery is peculiarly subject to aneurism ; so much so, that many surgeons consider the disease nearly as frequent as that of aneurism of the aorta. It may arise either from a wound, or from a diseased condition of the coats of the vessel; but the latter is by far the most common. It is difficult to assign very satisfactory reasons for the extraordinary frequency of this complaint; for although there can be no doubt that the almost incessant motion of the knee joint, the great weight it is ac- customed to bear, the shocks it is liable to, and the resistance which the blood must often encounter from the acute angle formed by the artery when the leg is bent upon the thigh, will contribute more or less to the rupture of the coats of the artery; yet the same causes should operate, to a certain extent, upon arteries of the axilla and elbow; true aneurism, however, of the axillary artery, is rather uncommon, and that at the bend of the arm almost unknown. However induced, popliteal aneurism may be known by the situation which the tumour occupies between the ham-strings, by its distinct pulsation in the early stages of the disease, by its gra- dual increase, by the great pain and numbness in the ham and calf of the leg, occasioned by pressure on the branches of the sciatic nerve, by the general swelling and cedema of the limb,—from the veins and lymphatics being obstructed,—by coldness of the whole limb, from diminished supply of arterial blood, by want of pulsat£ in the tumour, after it has attained a large size, and by the contraction and injury of the knee joint —which is almost sure to follow the disease when of long standing. Popliteal Aneurism. 369 Treatment of Popliteal Aneurism. So few patients recovered, after the old operation of opening the sac of the popliteal aneurism and tying the artery immediate- ly above it, that many intelligent surgeons abandoned the prac- tice altogether, and in place of it amputated the thigh. How much we owe to the illustrious Hunter for his discovery of the true mode of managing the disease, may easily be estimated when I state that any surgeon who should now venture to am- putate, Except under very particular circumstances, in any case of aneurism, must encounter the severest censure and disgrace. The operation, upon the Hunterian principle, as now usually performed, is as follows. An incision is made, while the pa- tient is in the recumbent position, along the inner margin of the sartorius muscle, commencing about two inches and a half be- low Poupart's ligament, and extending downwards between three and four inches, through the integuments of the thigh. Having reached the sartorius, its inner edge may be gently se- parated from the surrounding cellular membrane, and being held to one side by an assistant, the surgeon next proceeds to divide to the extent of an inch, the fascia lata of the thigh, beneath which he will find the femoral artery and vein and the saphena nerve enclosed in their sheath. The sheath being opened, and care taken to exclude the nerve and vein, the ligature is passed by* the aneurismal needle, around the artery and tied. The wound is afterwards dressed in the usual way. 370 Aneurism by Anastomosis. ' Section VIII. Aneurism by Anastomosis. This variety of aneurism was first particularly noticed by Mr. John Bell,* and denominated by him aneurism by anasto- mosis, on account of the tumour being formed of an assemblage of small arteries and veins, with an intermediate cellular struc- ture. " The tumour/' says he, " is a congeries of active vessels, and the cellular substances through which these vessels are ex- panded, resembles the cellular part of the penis, the gills of a turkey cock, or the substances of the placenta, spleen, or womb." Aneurism by anastomosis often arises from some slight injury; the tumour at first is scarcely perceptible; gradually, however, it enlarges, and acquires a thrilling, pulsatory, or jarring motion, which, together with its evident vascularity, forms its chief characteristic. In the early stages, the skin is seldom disco- loured, but in the latter it has a mottled or purple hue, arising apparently from numerous small sacs of blood distributed throughout the tumour. These sacs, towards the surface, are apt to fret and take on ulceration: when this occurs, troublesome and very profuse hemorrhagies ensue. Frequently the disease seems closely allied to those vascular specks or growths, so com mon on the head and other parts of new-born children, known by the name of ncevi materni. Treatment of Aneurism by Anastomosis. I have never known more than one instance of spontaneous cure of aneurism by anastomosis: this happened several years * See Principles of Surgery, vol. i. p. 456. Aneurism by Anastomosis. 371 ago in a child of the present Chief Justice of the U. States. The patient was under the care of an able and accomplished physi- cian—Dr. William Bradley Tyler, of Fredericktown—who con- sulted me respecting the case. The tumour filled up the hollow behind the angle of the jaw, involved a part of the ear, was very large and vascular, and pulsated with such violence as to appear, when the child cried, ready to burst. 1 advised the speedy removal of it, by the knife, as the only mode of saving the child's life, and it was resolved, for this purpose, to bring it to Philadelphia. The journey, however, was delayed, in con- sequence of a fever with which the patient was attacked, and which continued for a considerable time. From that period the tumour diminished, and shortly afterwards disappeared—leaving in its place only a loose bag or fold of skin. The records of surgery do not furnish, I believe, a similar termination. Two operations have been proposed for the cure of aneurism by anastomosis—Compression and excision of the tumour. The first seldom answers, but, on the contrary, generally aggravates the disease; the second is always hazardous, and never succeeds unless every vestige of the tumour be completely eradicated. Mr. John Bell laid it down as a rule never to be deviated from —" not to cut into the tumour, but cut it out." This, however, if it be a large aneurism, cannot always be done at once, or so readily as might be imagined. At all events, it is easier said than done. Very small tumours of this description, especially if seated over a bone, may, no doubt, be removed by one or two sweeps of the knife ; but to point out what I conceive to be the true mode of managing this disease after it has attained an in- ordinate bulk, I relate the following case. Elizabeth Loush, a married woman, twenty-five years of age, residing in the neighbourhood of Reading, came to Philadelphia in the month of April, 1823, anxious to obtain relief for a very large pulsating tumour, which nearly covered the right side of her head, and sometimes bled so profusely from numerous ulcerated spots on its surface, as frequentlyto endanger her life. This tu- mour had existed from infancy, but its increase was so gradual, and the pain attending it so inconsiderable, that it gave her little uneasiness. After her marriage, however, and especially during her second pregancy, (in which she was advanced four months at the time I saw her,) the growth of the swelling was so rapid, 372 Aneurism by Anastomosis. its pulsation so alarming, and the hemorrhagies from it so fre- quent and debilitating, that she was prepared to submit to any operation I might propose for her relief. I was aware at once of the nature of the disease, and saw plainly the necessity of acting promptly and decidedly. To have dissected off* a tumour of such magnitude, and so extremely vascular, at a single ope- ration, would have been little better than madness. I re- solved to proceed in a very different manner, and having placed my patient in a private department of the Aims-House Infirma- ry, I commenced without delay a series of operations. My first object was to cut off temporarily the chief supply of blood to the tumour. With this view, I made several incisions, each about an inch long, through the scalp and at some distance from the margin of the tumour, and tied the chief branches of the occipital and temporal arteries, many of which were en- larged to the size of the common carotid. Having in this way encircled the diseased mass, I had the satisfaction to observe the pulsation diminish, and the tumour partially to shrink; the hemorrhage, also, from the surface had ceased. A slight ery- sipelas of the scalp followed the operation. This occasioned a week's delay; in the mean time, the blood was evidently finding its way again through the anastomosing vessels to the tumour. An incision was made about two inches long, by a single stroke of the knife, through the integuments to the bone, commencing near the back part of the ear, and midway be- tween the edge of the tumour and the line at which the arte- ries were taken up in the first operation. An incredible quan- tity of blood issued in a moment from every part of the wound; in a few moments, however, every vessel was secured. The cut was then repeated to the extent of three, inches more, and the vessels in like manner secured. By this time the patient was so extremely faint, as to render it impossible to proceed further; indeed, many of the spectators supposed her to be dying. Without delay, therefore, she was conveyed to bed, and the wound dressed, by interposing lint between its edges to prevent their reunion. In ten or twelve days the patient had so far recovered her strength, as to enable her to submit to a further incision of the scalp, commencing at the place where the last operation had terminated. This operation was also con- tinued as long as the patient could bear it, or as was deemed ,*.'., v 10 V .i 'Sf^'-^x^ :'>■■'i.-.t\i,^/- Varicose Aneurism. 377 Treatment of Varicose Aneurism- The most common form of varicose aneurism—that in which the artery and vein communicate directly with each other— very seldom requires any other treatment than moderate com- pression. Indeed, even this is not always necessary, and may, sometimes, prove injurious, by obstructing the passage of the blood into the vein and forcing it into the cellular membrane, thereby causing the second variety of the disease. In most cases, it will be sufficient for the patient to abstain from violent or laborious exertions of the limb in which the aneurism is seated. But even this does not always cause the tumours in the vein and artery to enlarge, for, in the case I have detailed, the patient had been accustomed to laborious employments for twenty or thirty years without any material alteration in his disease. If an operation is performed for this disease, it should be done in the early stage of it. When an aneurismal sac is formed out of the cellular mem- brane, between the artery and vein, it frequently attains so large a size, as by pressure to injure the surrounding parts, or by bursting or taking on ulceration, to endanger the patient's life. To guard against, or obviate such consequences, an ope- ration may possibly become necessary. This was first per- formed by Mr. Park,* of Liverpool, and next by Dr. Physick.t In both instances, the brachial artery was tied above and below the sac, and the patients recovered. Of late years, the opera- tion has been performed repeatedly, and generally with success. * Medical Facts and Observations, vol. 4. f Coxe's Philadelphia Medical Museum, vol. 1. On Aneurism, consult J. Bell's Principles of Surgery, vol. 1—Abernethy's Sur- gical Works, vol. 1, p. 272, edit. 1819—Scarpa on Aneurism, by Wishart, 1819 —C. Bell's Operative Surgery, vol 1, p. 70—Pelletan CUnique Chirurgicale, tom. 1 and 2—Richerand's Nosographie Chirurgicale, tom. 4, edit. 4—Burns' Observations on some of the most important Diseases of the Heart, on Aneurism of the Thoracic Aorta, &c. p. 203—Burns' Observations on the Surgical Anatomy of the Head and Neck, edit. 1824—Hodgson's Treatise on the Diseases of Arteries and Veins, containing tlie Pathology and Treatment of Aneurism and Wounded Arteries, Svo. 1815, decidedly the most valuable work extant. 378 Diseases of the Veins. CHAPTER XIII. DISEASES OF THE VEINS. Previous to the discovery of the circulation of the blood, the structure and functions of the venous system were very much studied; since that period, the attention of surgeons has been directed almost exclusively to the arteries, and the veins have been neglected. Like the arteries, however, they are subject to important changes, or to disease in their coats, which frequently give rise to serious, and even fatal consequences. A common disease of the veins is inflammation. This may arise from wounds, as in venesection, or from the application of the ligature. In either case the lining membrane of the vessel is the chief seat of the disease, and along this membrane the inflammation, sometimes, travels until it reaches the heart __producing great irritation and symptoms resembling those of typhus fever. In other instances an effusion of coagulable lymph takes place, and the sides of the vessel being thus glued together, frequently in different places, the extent of the in- flammation is limited, or pus, if it should form, prevented from passing through the circulation, and the patient's life, probably, thereby saved. This obliteration of a vein from the effusion of lymph, is sometimes produced slowly by pressure from an ad- joining aneurismal sac, or some other species of tumour. In all such cases the circulation is carried on by the collateral veins, which anastomose so freely throughout the body with the main trunks, that little inconvenience is experienced from the obstruc- tion, even although veins of the largest class be obliterated. Varicose Veins. 379 Inflammation of the veins sometimes terminates in ulceration, and gives rise to hemorrhage. This, however, is a rare occur- rence ; the formation of calcareous concretions in the venous coats is equally rare. Veins are occasionally ruptured from muscular exertion, from engorgement or over-distention of their coats by blood, produced by sudden immersion in a cold bath, or by other causes. But the most common venous affection, per- haps, is varicose enlargement, of which it will be proper to treat in a separate section. Section I. Varicose Veins. The deep-seated as well as the superficial veins, are frequent- ly rendered varicose by undue muscular exertion, by interrup- tion of the circulation from ligatures, by the pressure of tumours, by collections of hardened fasces in the intestines, by the en- largement of the gravid uterus, &c. If from any of these causes the disease is once induced, it continues gradually to increase and to extend from one vein to another, until numerous ramifi- cations are affected. The veins of the upper extremities rarely become varicose, but those of the leg and thigh, especially the saphenas and their branches, are very prone to the disease. In the commencement, numerous small circumscribed swellings may be observed. After a time, the venous trunks and branches appear enlarged throughout their whole extent, and run in a ser- pentine or tortuous direction. Sometimes they are knotted or dou- bled upon each other, and these gyrations are particularly conspi- cuous in the neighbourhood of the valves. In proportion as the veins enlarge, the support afforded by the valves to the column of blood is diminished, until it is entirely lost. Not only are the veins expanded greatly beyond their natural size, but their 380 Varicose Veins. coats also, in many instances, are very much thickened. This, together with the coagulated blood which not unfrequently fills their cavities, renders them solid and incompressible. Under particular circumstances, these coagula are absorbed, and the diseased veins are converted into cords. In by far the greater number of cases, however, the vessels remain pervious, and the fluid blood still circulating through them sluggishly, keeps up incessant irritation, and gives rise to inflammation in the sur- rounding cellular membrane, that often terminates in extensive and very painful ulcerations.* Profuse hemorrhage, from sud- den rupture or ulceration of a varicose vein, followed by extreme debility, and even death, has repeatedly happened. Treatment of Varicose Veins. In addition to compression with the roller and laced stocking, which, in slight cases, are well calculated to effect a cure, the older surgeons frequently extirpated large portions of the trunks or branches of varicose veins, sometimes with success, but of- tener with an unfavourable issue. On this account the opera- tion has long been abandoned, and that of simply including in a ligature the largest varicose trunk substituted in its stead. This mode of practice, although familiar to Celsus and other an- cient writers, was introduced to the notice of the profession many years ago by Sir Everard Home, and has since been ex- ecuted repeatedly by different surgeons, generally without any serious consequences, but sometimes with a fatal result. Many surgeons of the present day, therefore, never resort to the ope- ration, especially as there is no certainty of a radical cure. Sir Astley Cooper, a surgeon of great experience, pointedly con- demns the practice, and states that he has known it to prove fatal in eight instances. " Another overwhelming objection to * See an account of the varicose ulcer, in vol. i. p. 154. Varicose Veitis. 381 the operation," says he, " is, that when it does not prove fatal, its ultimate effects are useless. If I were asked which of the following operations I would rather have performed upon my- self, viz. the saphena major vein or the femoral artery tied, 1 certainly should choose the latter."* In opposition to Sir Astley's statement, that the operation is never permanently use- ful, I may remark, that I have practised Sir Everard Home's plan of taking up the vena saphena above the knee, for more than twenty-five years; in numerous instances, without an un- pleasant symptom, and generally with great relief to the patient and a speedy cure of the accompanying ulcer. It is an ope- ration, however, that I have never undertaken lightly or upon every common occasion, being fully aware of the danger of in- flammation extending along the inner surface of an injured vein to the heart. Of late years, Mr. Brodie, in order to avoid the occasional ill effects of the ligature, has proposed, as a substi- tute, the simple division of the vein by the knife ;t but this ope- ration, also, it is stated, has sometimes been followed by fatal consequences. Petit was in the habit of opening varicose veins with a lancet, and withdrawing the coagulated blood; after which, in many instances, he found that the vessels became obliterated, and the patient experienced no further inconvenience from the disease. Even drawing off, occasionally, small quantities of fluid blood by puncture, produces great relief. This mode of treatment, indeed, conjoined with the use of the roller, astrin- gent washes, and an elevated position of the limb, will often ef- fect a cure, and should always be tried before an operation is re- sorted to. * The Lectures of Sir Astley Cooper, by Tyrrel, vol. i. p. 205. ■{•"For this operation," says Air. Brodie, "I have generally employed a nar- row sharp-pointed bistoury slightly curved, with its cutting edge on the convex side. Having ascertained the precise situation of the vein, or cluster of veins,' from which the distress of the patient appears principally to arise, I introduce the point of the bistoury through the skin on one side of the varix, and pass it on between the skin and the vein, With one of the flat surfaces turned forwards and the other backwards, until it reaches the opposite side. I then turn the cutting edge of the bistoury backwards,'and in withdrawing the instrument the division of the varix is effected. The patient experiences pain, which is occasionally se- vere, but subsides in the course of a short time. There is always hemorrhage, which would be often profuse if neglected, but which is readily stopped hy a moderate pressure, made by means of a compress and bandage carefully ap. plied." Vol. H. W 382 Cirsocele. Section II. Cirsocele. The veins of the spermatic cord, and those of the scrotum, often become varicose. To the former the term cirsocele, has been applied—to the latter varicocele. The two diseases some- times exist simultaneously. Cirsocele is chiefly met with amongst young, vigorous, unmarried men, those especially who have led very chaste and exemplary lives. In several instances I have known it connected with despondency or hypochondria- sis. When examined, the whole of the cord appears to consist of a congeries or bundle of knotted and tortuous veins, which feel like a bunch of worms wrapped around and twisted upon each other. Generally, the disease first shows itself at the bot- tom of the testicle or scrotum, and thence gradually travels up the cord, producing more or less weight, uneasiness, or pain. When the patient is laid in the recumbent position, the tumour subsides, and the diseased veins feel soft and flaccid. The mo- ment, however, he stands erect, especially if, at the same time, the upper part of the cord be compressed with the finger, the tu- mour reappears. This will serve to distinguish cirsocele from hernia hydrocele, and other complaints. Treatment of Cirsocele. It is seldom that the testicle, or cord, sustains any injury from varicose enlargement of its veins. Sometimes, however, Cirsocele. 383 it happens that the testicle, from long continuance of the disease, or from neglect, wastes away. To guard against this, and to relieve the unpleasant weight and uneasiness, of which most patients complain, there is nothing so effectual as a bag truss, so contrived as to suspend the testes and give them a firm and equable support.* Conjoined with this, cold astringent washes, applied by means of linen rags to the affected parts, will be found highly serviceable. Robust and plethoric patients will also derive benefit from general and local blood-letting, from purging, low diet, &c. Extirpation of the diseased veins has been practised by some modern surgeons, in cases of cirsocele at- tended with severe pain and extraordinary enlargement of the cord and testicle. I have seldom met with cases requiring an operation of the kind. • The bag, or hunting truss, is variously formed, and of different materials. The best I have seen was invented lately by Dr. Maxwell of the U. S. Navy. On Diseases of the Veins, consult—Hunter's Observations on the Inflammation of the Internal Coats of Veins, in Transactions for the Improvement of Medical and Chirurgical Knowledge, vol. 1, p. 18—Hodgson on the Diseases of Arteries and Veins, p. 511—Observations on Varix and Venous Inflammation, &c, by Richard Carmichael, in Transactions of the Association of Fellows and Licen- tiates of the King's and Queen's College of Physicians in Ireland, vol. 2, p. 345— Home's Practical Observations on the Treatment of Ulcers of the Legs, to which are added some Observations on Varicose Veins, &c. p. 274—On Wounds and Ligatures of Veins, by B. Travers, in Surgical Essays by A. Cooper, &c. part 1, p. 227—Brodie's Observations on the Treatment of Varicose Veins of the Leg, in Medico-Chirurgical Transactions, vol. 7, p. 195—Oldknow's Case, in which the Operation of Tying the Vena Saphena, for the Cure of an old Ulcer of the Leg, ter- minated fatally, in Edinburgh Medical and Surgical Journal, vol. 5, p. 175—C. BelFs Operative Surgery, vol. \,p. 89 and 94—Delpech's Precis Elementaire des Maladies Reputtes Chirurgicales, tom. 3, p. 251, Article Varices. 384 Injuries of the Head. CHAPTER XIV. INJURIES OF THE HEAD. Iy a pathological, as well as practical point of view, there are no diseases more deserving of the surgeon's attention, than those usually comprehended under the name of injuries of the head. These embrace several affections very distinct from each other in character, and requiring the most opposite modes of treatment. On this account, it will be proper to consider them in separate sections. It must not be supposed, however, that these diseases are always so well marked and insulated in their symptoms, and altogether so independent of each other as never to exist simul- taneously. This is so far from being the case, that we often find them blended or intermixed in a manner so extraordinary, as to puzzle or confound the most intelligent practitioner. Indeed, as has been well remarked by the experienced Hennen, " the young surgeon, who, for the first time, witnesses a series of injuries of this description, will at every step have something to unlearn; he will find symptoms so complicated, contradictory, and insufficient to give any rational clew to their causes; diagnostics, of the truth of which he had read himself into a conviction, so totally unsup- ported by the results of practice ; and the sympathies he was led to look for as infallible accompaniments of certain states of dis- ease, so often wanting altogether, that he will probably be in- clined to relinquish the hope of ever arriving at a correct theory, or at least he will enter the clinical ward with the pride of science considerably subdued." Fracture of the Skull. 385 Section I. Fracture of the Skull. Fractures of the skull differ widely from each other in ap- pearance and extent; hence their division by writers into several varieties, such as fissure, counter-fissure, depressed fracture, double depressed or camerated fracture, stellated fracture, punc- tured fracture, &c. These distinctions are of some importance, since the mode of treatment must in many instances depend upon the particular variety of fracture that may happen to exist. By the term fissure, is understood a simple crack or division of one or more bones of the skull; by counter-fissure, a separation pro- duced at a point opposite to that upon which the force was ap- plied. A depressed fracture is that in which the bones are forced beneath their natural level. The fracture is said to be came- rated when " the centre is depressed in a direct line, and the sides decline towards that centre, like the form which the two hands make when laid together edgeways."* A stellated frac- ture takes ils name from the resemblance it bears to a star. Punctured fracture is the result of a pointed instrument driven through the bone. These varieties of fracture, are owing in part to the shape of the instrument by which they are produced, to the force with which it is impelled, and to the inequality of thickness and strength of the different bones composing the skulk Were it not for this inequality, counter-fissure would very fre- quently take place; for the skull being formed upon the prin- ciple of a hollow sphere, any force applied to it must extend its influence throughout the circle, and produce fracture at a point * See J. Bell's Principles of Surgery, vol. 2, part 2, p. 795. 386 Fracture of the Skull. opposite to that upon which the force was exerted. But this is prevented by the circumstance of some of the bones being thin- ner and weaker than others. If, for example, a man in falling back- wards receives a violent blow upon the occiput, this bone being un- usually thick and strong, does not give way, but the percussion is propagated towards the temples where the bones are weak, and here the fracture occurs. The same thing may arise from a blow upon the top of the head. In like manner, a force applied to the frontal bone, will often, instead of fracturing that bone, fracture the orbitar plate. My preceptor, Sir Charles Bell, has satisfac- torily illustrated these and several other interesting points re- lating to fractures of the skull in a most ingenious paper, con- tained in the first volume of his " Surgical Observations." In the paper referred to, Sir Charles not unaptly compares the skull to the roof of a house, in which the sphenoid bone serves as the tie beam to prevent the rafters, or parietal bones, from giving way. Again; the broad and expanded surface of the petrous part of the temporal bone is supposed to bear a resemblance to the groining of an arch in masonry, and, as such, to afford a foundation for the parietal bones to rest upon, while the mastoid, zygomatic, and petrous processes are likened to arches built under a wall to in- crease the security of the foundation. Treatment of Fracture of the Skull. Simple fissures or fractures of the rcranium, unaccompanied by injuries of the brain or its membranes, seldom demand par- ticular treatment. Indeed, there is reason to believe that such accidents often escape the notice of the surgeon, and are cured without his assistance. But even when the fracture is known to exist, the patient's safety may be endangered by officiousness in tracing it, or attempting its elevation. The rule, in all cases of the kind, should be to refrain from an operation so long as the contents of the skull remain unaffected, and of this the sur- Fracture of the Skull. 387 geon is to judge by the symptoms. It will always be proper, however, to remove sharp points or ragged edges of bone, by the cutting forceps, trephine or saw, to prevent them from ir- ritating the dura mater, brain, or the soft parts exterior to the skull. In certain cases, also, the bone becomes carious some weeks after the fracture, and, if suffered to remain, may destroy the patient, by exciting inflammation upon the surface of the brain. The treatment necessary for fractures, conjoined with injury of the brain, will be pointed out under the head of com- pression of the brain. 388 Concussion of the Brain. Section II. Concussion of the Brain. ' It often happens, that a man receives a smart blow upon the head, which does not fracture the skull, or materially injure the brain, but disorders the intellectual functions, and produces ver- tigo, sickness of stomach, trembling of the limbs, dimness of vision, &c. This may be considered a case of slight concussion. In more severe injuries of the kind, the symptoms are different. The accident is immediately succeeded by insensibility, cold- ness of the skin, relaxation of the extremities,? feebleness and irregularity of pulse, difficulty of breathing, and dilatation of the pupil. The breathing, however, though weak and labour- ing, is commonly free from stertor. After a time the sensibility is partially restored, so that the patient may be roused from the apparent sleep or lethargy in which he is usually found, and made to answer questions, especially those relating to the seat of his injury. Gradually the pulse rises, and the natural breathing is restored, the pupil contracts and the body recovers its warmth. There is now danger of inflammation of the brain, since the pulse, in proportion as the immediate symptoms wear away, continues to augment in volume and strength, and the blood is determined forcibly to the head. Independently of this, in most cases of severe concussion, there is reason to be- lieve that blood is poured out upon the brain or its membranes, in greater or less quantity, and afterwards becomes a source of irritation. Concussion of the Brain. 389 Treatment of Concussion of the Brain. If called immediately after an accident, and symptoms of concussion are found to exist, the surgeon should be very care- ful not to adopt the practice, but too common among the igno- rant and vulgar, of bleeding the patient instantaneously. But he must wait until the pulse rises, or until reaction is established, and this usually takes place in an hour or two; he will then bleed to diminish vascular action, and to prevent inflammation of the brain, which, in severe cases of concussion, is extremely apt to ensue. If blood-letting, however, is pernicious in the first stage of concussion, the administration of stimulants will, generally, prove equally so; for although the patient may seem to be benefited for the time by a mouthful of wine or brandy, yet the effect of such practice will be, in the end, to hurry on the cerebral excitement. A few tea-spoonsful of cool water, immediately after the injury, will often be found singularly useful in reviving the patient, and cannot interfere with the after treatment. With regard to the cohtinuance of blood-let- ting, much will depend upon the extent of the injury, and the age and constitution of the patient. Many instances are re- corded of death from profuse evacuations of blood, designed to obviate inflammation of the brain. A medium must, therefore, be observed. In addition to blood-letting, low diet and purga- tives should be resorted to. Applications to the head, which ought, previously, to be shaved, will also be found highly ser- viceable, such as cloths dipped in cold water, &c.; and after full benefit has been derived from these, blisters may be used with decided advantage: keeping the head in an elevated position, also, during the whole treatment, will greatly contribute to- wards the prevention and removal of inflammatory action. Vol. II. 50 390 Compression of the Brain^ Section III. Compression of the Brain. Compression of the brain may arise from three different causes—from a depressed fracture, from effused or extravasated blood, and from suppuration within the brain, or its membranes. It seldom happens, however, that a mere depression of the bone, unattended by other injury, will give rise to severe symptoms, or to such as characterize a compression of the brain. Indeed, the records of surgery furnish numerous examples of perfect recoveries after the most extensive depressions, from which the patients sustained very little inconvenience, and for the relief of which no operations were performed. On the other hand, cases are now and then met with, where, from depression of both tables of the skull, or from extensive fracture of the inner table, the most urgent symptoms have followed, but have been speedily relieved upon elevating the bones to their natural level. Compression arising from extravasation of blood is very com- mon, and may accompany fracture of the bone, or be indepen- dent of it. Sometimes the blood is poured out between the dura mater and the skull, in which case the membrane is actu- ally shaken from the bone, and the blood issues from numerous small vessels. Sometimes the middle artery of the dura mater is torn by the rough edge of the fractured bone, or by the force which produced the fracture, and then the hemorrhage is very sudden and profuse. At other times, the vessels of the brain are torn, and the blood is spread over its surface, forced into its substance, or poured into the ventricles. In most cases of ex- travasation, there is commonly an interval between the injury and the appearance of the symptoms of compression, and this- Compression of the Brain. 391 when it does occur, may be considered as a sufficient characte- ristic of its nature; for immediately after the vessels are torn, there is no compression, but as the blood accumulates and ex- tends itself widely, the symptoms denoting that condition, are gradually developed and finally confirmed. Matter, like the coagulum formed by extravasated blood, may give rise to compression; it is always, however, the result of inflammation, and, on this account, does not immediately follow an injury of the skull. Often it proceeds from the irritation produced by fragments of the shattered internal table, or from sharp or ragged spicula wounding the dura mater or brain. A depressed fracture, too, although it may not have produced, at first, symptoms of compression, will sometimes eventually cause suppuration on the surface of the dura mater. Even when the skull has not been fractured, but severely bruised, suppuration may follow with caries of the bone. Extravasated blood, also, may give rise to suppuration between the bone and dura mater or within the brain. If from either of the foregoing causes compression should arise, it will be denoted by the following symptoms. The pulse will be found slow and regular, the pupils of the eyes greatly dilated and insensible to the strongest light, the breathing stertor- ous, slow and difficult, the limbs loose or yielding, and sometimes paralytic, the insensibility complete, so much so that the patient cannot be roused by the most powerful stimuli. There is no sickness or vomiting. These symptoms will distinguish it from concussion, in which the pupils are either contracted or moderately dilated, the pulse weak and tremulous, the breathing without stertor, the insensibility partial, the affection of the stomach almost universal. It must be confessed, however, that we seldom meet, in these two states of disease, with the symp- toms so insulated and distinct, as to enable us accurately to se- parate them; that, on the contrary, they are commonly com- bined, and so intermixed as often to create great confusion and doubt in the mind of the surgeon. 392 Compression of the Brain. Treatment of Compression of the Brain. When called to a patient labouring under all the symptoms of compressed brain, the surgeon can scarcely do wrong in draw- ing blood from the arm, and in repeating the operation as often as the pulse may seem to require it. In addition to this treat- ment, purgatives should be administered; and by pursuing this plan, he will often have the satisfaction to find that the symp- toms abate, or are so entirely removed as to render an operation unnecessary; should he be disappointed, however, in this expec- tation, and an operation be afterwards demanded, the patient, from the previous depletion, will have a better chance of re- covery. If, notwithstanding this treatment, the comatose symp- toms continue, and there is reason to believe that the brain is op- pressed by a coagulum, the trephine must be resorted to, whe- ther the skull be fractured or not, and the coagulum removed. The same observation will apply to fracture with depression, al- ways recollecting, however, that the symptoms call for the opera- tion, and not the mere fracture; and that the skull, if the brain be uninjured, will often unite like any other fractured bone, even although the depression be left. On the other hand, it should be stated, that a depressed fracture, which at first did not in- terfere with the functions of the brain, will sometimes give rise to inflammation of the dura mater or brain, and subsequently to compression from the formation of matter; and that these con- sequences might have been prevented, perhaps, by a timely ope- ration. But a great deal of judgment will be required to enable the surgeon to anticipate such consequences. The instruments that may be required for an operation on the skull, are two or three trephines, the largest about an inch in diameter, the second three-quarters, and the third half an inch; all of them provided with sharp teeth widely set, and with centre pins; Hey's saw, a lenticular, raspatory, trepan forceps, two elevators, a brush for cleaning the trephine and saw, a tooth- pick or probe, tenacula, sponges, crooked needles, ligatures, a scal- pel, Sf-c Tl^tr u r. A' Fia.l. Drawn j£ Eng'd by J.Draytm. Compression of tlie Brain. 393 The object the surgeon has in view in applying the trephine, is either to make an opening for the removal of coagulated blood, or for the introduction of the elevator beneath a depressed bone. In the former case a large trephine should be employed, in the latter a small one. Very frequently, however, it happens, that there is a sufficient space between the edges of the frag- ments of bone to insinuate the elevator, and with it restore the depressed portion to its natural level. Under such circumstances, the trephine need not always be employed. It is commonly recommended to plant the crown of the trephine partly upon the sound, and partly upon the depressed bone. Whenever the latter is sufficiently firm to bear the pressure of the instrument, I prefer resting it entirely upon it, in order to save the sound bone. If there is a wound of the scalp along with the fracture, it may be enlarged, if necessary, or so changed in shape, as to en- able the surgeon to get at the bone, and effect his purpose in the easiest way possible. If the integuments remain entire, I would recommend an incision, in the shape of the letter D,—the rounded portion of the letter to be raised from the bone. The flap of the integuments being turned back, the centre pin of the trephine, without the preliminary measure formerly prac- tised, of scraping away the pericranium,* is fixed upon the bone, and serves the purpose of guiding the saw, which being worked steadily backwards and forwards for a few seconds, forms a track or gutter for itself, in which it will afterwards run without the assistance of the pin. The pin being withdrawn, or made to retire within the axle of the trephine, the operator continues to divide the bone (occasionally removing the saw and brushing away the sawings, or dust, to prevent them from clogging the • Having seen much mischief result from the common practice of rasping the pericraneum, and from the teeth of the saw when applied in the way above di- rected, I have used, for some time past, a trephine with a small moveable lancet attached to its outer surface, the extremity of which can be made to project about the sixteenth part of an inch beyond the teeth of the instrument. The ob- ject of this is to cut the pericraneum smoothly, instead of tearing it. As soon as this is accomplished, theoperator may retract the lancet and proceed to saw the bone. The advantages gained by this simple proceeding must appear too obvious to re- quire illustration; and yet I am not aware that either the principle upon which the operation is founded, or the instrument itself, have ever before been suggested or applied. (See Plate XII. figs. 1 and 2.) 394 Compression of the Brain. teeth) until he has reason to believe that he is nearly through. He should then examine carefully and very repeatedly with the probe or tooth-pick, lest he cut into the dura mater or brain, be- fore he is aware. Frequently it occurs, that one part of the bone is divided, whilst another remains entire. The surgeon in this case should discontinue the saw, and attempt the removal of the circular piece of bone, by breaking up its attachment with the forceps. Any irregularity or projecting edge of bone that may remain may be smoothed off by the lenticular. If blood be extravasated between the dura mater and skull, and the per- foration has been made in the proper place, the coagulum will be presented as soon as the circle of bone is removed, and evacuated through the whole by the pulsation of the brain. If the blood be effused between the brain and dura mater, this membrane will sometimes be forced into the opening, and the dark blood will appear beneath it. The surgeon should then cautiously open the membrane, and evacuate the blood; though the ope- ration does not commonly succeed when this is necessary. Still it is the only chance the patient has. In many instances, the moment the brain is relieved from the pressure of a depressed bone, or from the load of extravasated blood, the symptoms of compression instantaneously disappear, and the patient recovers his reason. In other cases the comatose state continues, and no benefit is derived from the operation. If any large arteries are divided during the operation, they may be taken up by the tenaculum or needle. In a very ex- tensive fracture of the skull, which I attended many years ago with Dr. Gustavus Warfield, an eminent practitioner of Mary- land, I had occasion to tie up the middle artery of the dura mater: this was easily accomplished by the needle. Sometimes this artery runs in a groove in the bone: in that case, it may be compressed by a plug of soft wood. After the common opera- tion of the trephine, the edges of the wound should be drawn together by adhesive straps, and secured by a pledget and light dressing. For extensive extravasations, one or more openings with the trephine may become necessary. As it cannot always be de- termined readily whether there is extravasation or not, Mr. Abernethy has suggested the ingenious expedient of cutting down upon the bone, and scraping the pericraneum before per- Compression of the Brain. 395 forating the skull. This operation is founded upon the fact of the free interchange of vessels between the dura mater, bone, and pericranium, or rather upon the circumstance of the latter membrane being in a great measure dependent for its supply of blood upon the dura mater. Hence it was inferred, that if by a shock communicated to the skull the dura mater was torn up from the inner surface of the skull, the vessels passing through the bone to the pericranium must also be torn, and consequent- ly that that membrane, if scraped, would not bleed, and vice versa. Mr. Abernethy has found this to hold true in practice, but his statements have not been confirmed in toto by other sur- geons. With the exception of the occipital bone, the trephine may be applied with equal effect, and comparatively with little dan- ger to any part of the skull. When the frontal sinus is frac- tured, and it is necessary to trephine its inner table, two tre- phines should be employed—a large one for the outer portion of bone, and a smaller one for the inner portion. This mode of performing the operation was first pointed out by Sir Charles Bell. It is founded upon the unequal form of the sinus, in con- sequence of which a single trephine could not be made to work perpendicularly against its inner table. If a patient recovers after the application of the trephine, the external wound gradu- ally heals up, and the opening in the bone is covered by a mem- brane, formed partly from the pericranium, and partly from the dura mater, which serves afterwards to protect the brain, but the bone is seldom, if ever, regenerated. If the patient dies af- ter the operation, it is commonly from inflammation of the brain, or from suppuration within its substance. This will show the propriety of endeavouring to combat the inflammatory action, both before and after the operation. The trephine, when em- ployed to evacuate matter from the brain, is seldom found to succeed. The trephine is sometimes employed for the relief of epilepsy. By Sir A. Cooper and Dr. Dudley, of Kentucky, se- veral successful cases of the kind have been reported. When performed with this view, however, the operation has often failed—as was the case in a patient upon whom I operated, three winters ago, in the Blockley Hospital. 396 Inflammation of the Brain. Section IV. Inflammation of the Brain. If, from any of the causes pointed out in the preceding sec- tions, inflammation of the brain should arise, it will be charac- terized by the following symptoms. The face becomes flushed, the eyes are red and impatient of light, the pupils are contracted, the skin hot, the pulse hard and quick, and the tongue dry. The pain in the head is intensely severe, the scalp is puffy and cedematous, retains the impression of the finger, has a peculiar glossy aspect, and the wound, if there be one, discharges a sa- nious matter. Soon after the appearance of these symptoms, the patient is seized with rigors or shiverings, which occur at irregular intervals, and are always indicative of great danger. During the early stages of the inflammation, the patient often continues sensible for days together, and answers questions very distinctly: when the disease is further advanced, however, he becomes irrational, moans or sighs heavily, tosses from one side of the bed to the other, mutters constantly, withdraws his hand from the surgeon, and seems unconscious of all that is passing around him. These symptoms are sometimes followed or accom- panied by hemiplegia, and violent convulsions. If the patient survive until the suppurative stage is established, the matter will be found either between the dura mater and bone, between the pia mater and brain, in the substance of the brain itself, or in the longitudinal sinus. Inflammation of the Brain. 397 Treatment of Inflammation of the Brain. To counteract inflammation of the brain, or its membranes, the most active antiphlogistic measures must be pursued. Blood- letting is more to be relied on than any other remedy; but the surgeon should not be satisfied with merely drawing blood from the arm; he should take it freely from the scalp by leeches, or open the temporal artery, or the jugular vein. Purgatives, also, will be found essentially necessary, and after full effect has been produced by these and by blood-letting, the scalp may be covered with a large blister, which should be repeated as often as the symptoms require it. If, in spite of these remedies, the inflam- mation terminate in suppuration, and give rise to the symptoms of compressed brain, the trephine should be resorted to, though it must be confessed that the patient's chance of recovery is very limited, when such a measure seems to be called for. In some instances, months or years elapse before inflammation or suppu- ration of the brain takes place from injuries of the head. A carious bone, in such cases, will commonly be found to be the cause of the mischief; but, unfortunately, the removal of it by the trephine, will seldom prevent the patient's death. Vol. II. 51 398 Fungus Cerebri. Sec rion V. Fungus Cerebri, or Encephalocele After extensive fractures, and the removal of large pieces of the skull, or after the operation of the trephine, a tumour having all the appearances of a vascular organized growth, sometimes sprouts from the brain, fills up the openings in the bone, pro- jects beyond the scalp, and often acquires considerable mag- nitude. Commonly this morbid enlargement is first seen making its way through a laceration in the dura mater; but in other instances the dura mater ulcerates, from being forced repeatedly by the pulsations of the brain against the sharp edges of the bone, and the tumour appears immediately beneath, and after- wards increases with wonderful rapidity. Mr. Abernethy is in- clined to believe that " this disease frequently consists of a tu- mour formed by coagulated blood, and that an organized fungus could hardly be produced in so short a time as that in which these tumours are usually formed." Sir Charles Bell, on the contrary, maintains that the tumour is vascular, and formed of the substance of the brain itself; that it bleeds when torn or cut, which would not be the case if formed of mere coagulum; that it is affected, like spongy granulation, by caustic, and collapses after death; all which, in my opinion, furnish decided evi- dence of its vascular nature. Indeed, Sir Charles' views have been amply confirmed by the observations and dissections of sub- sequent writers. In particular, Mr. Stanley having had occa- sion to cut off a tumour of this description, found, upon dissection, " the exterior of the tumour to consist merely of a layer of coa- gulated tblood, and the rest of the mass of brain, possessing a natural appearance, the distinction between the cortical and me- Fungus Cerebri. 399 dullary matter being readily seen with the convolutions and pia mater dipping down between them." Tumours, very different in structure from the foregoing, sometimes sprout from the external surface of the dura mater. They are apt to follow blows and other injuries of the head, in which the bone has been bruised, but not fractured. The pa- tient, in such cases, usually complains of deep-seated severe headach, which may continue for weeks or months together. At last, the swelling is observed beneath the scalp, communicating a pulsatory motion to the finger, and rapidly enlarging, without the integuments taking on ulceration—though this sometimes' happens in the advanced stages of the disease. If the integu- ments are divided, and the tumour examined, it will be found to consist of a vascular growth from the surface of the dura ma- ter ; a further examination will also show that the bone has been absorbed by the pressure of the tumour. Treatment of Fungus Cerebri. The termination of this disease is almost always unfavoura- ble, especially when it is followed by symptoms of compression of the brain. Spontaneous cures sometimes, though rarely, take place—from the fungus being strangulated by the rapid increase of the surrounding granulations, or by pressure from the edges of the bone. From what I have seen of the disease, I am disposed to believe that light dressings, conjoined with occasional moderate pressure upon the tumour, will prove of more service than any other remedies. Caustics and excision have been highly extolled by some writers, and as pointedly con- demned by others. " In the treatment of this disease," says Sir A. Cooper, you are to apply to the fungus a piece of lint, wet- ted with liquor calcis; and over this a strap of adhesive plaster: when you examine the parts, on the following day, you will find the fungus considerably diminished ; you are then to use a thicker 400 Fungus Cerebri. piece of lint, and the strapping as before. Pursuing this plan, you at length bring the fungus to a level with the scalp; but this is not sufficiently low for your purpose; therefore, you must pro- ceed until you have succeeded in getting it on a level with the bone; in which position it must be cautiously preserved, when at last the scalp heals over it, and your object is accomplished." When a fungus protrudes from the external surface of the dura mater, and increases to such an extent as immediately to endanger the patient's life, its removal by the knife should be attempted. The operation, however, seldom succeeds. Consult —Pott's Chirurgical Works, by Earle, vol. 1—Abernethy's Surgical Works, vol. 2—Desault's Surgical Works, by Smith, vol. 1—John Bell's Princi- ples of Surgery, vol. 2, part 2—Hennen's Principles of Military Surgery, p. 277 —Thomson's Report of Observations made in the Military Hospitals in Belgium, p. 49—C. BelVs Operative Surgery, vol.1, p. 403—C. Bell's Surgical Obser- vations, p. 461—Dorsey's Surgery, vol. 1, p. 291—Richerand's Nosographie Chi- rurgicale, tom. 2, p. 230—Lassus' Pathologie Chirurgicale, tom. 2, p. 252—Cal- lisen's Systema Chirurgise Hodiernae, tom. 1, p. 728, et sequent.—Stanley's Cases of Hernia Cerebri, with Observations in Medico-Chirurgical Transactions, vol. 8, part I,p. 12—Sir Astley Cooper's Lectures on the Principles and Practice of Surgery, with Additional Notes and Cases, by Frederick Tyrrel, Esq., vol. 1, p. 252. Local Diseases of the JVerves. 401 CHAPTER XV. LOCAL DISEASES OF THE NERVES. The diseases to which the nervous tissue is subject, have re- ceived, with few exceptions, but little attention from surgical or medical writers. This has been owing, no doubt, in great mea- sure, to the complicated structure of the nerves, their minute division, and intricate and endless distribution, the study of which alone would be sufficient to embrace no inconsiderable portion of time. There is great reason to hope, however, that the splen- did discoveries of Sir Charles Bell, discoveries which have not only immortalized their author, but have shed a halo of glory around his country, have so unravelled the mysteries of the ner- vous system, as to open a rich mine for the observations and ex- periments of future inquirers, and that at no distant day, the dis- eases of the nerves will be as susceptible of demonstration as those of the arteries and some other textures. Under the heads of neuritis, neuralgia, neuroma, and tetanus, I shall endeavour to include the chief surgical diseases of the nerves. 402 "1 JVeuritis. Section I. Neuritis. Inflammation of the neurilema, or of the substance of a nerve, whether acute or chronic, and to designate which wri- ters have employed the term neuritis, appears to be by no means jjunfrequent. Cases of the kind, strongly marked, and minutely detailed, have been furnished by Sir Everard Home, Martinet, Weinhold, Brandreth, Swan, Descot, Langstaff, Lob- stein and others. The symptoms are deep-seated pain, some- times constant, sometimes periodical, swelling and redness of the part affected, spreading in the course of the nerve or its branches, and followed by induration of the surrounding parts, and, eventually, by thickening of the nerve, from deposition of coagulable lymph in the interstices of its fibres. In some in- stances the pain is intensely severe, accompanied by spasms of the muscles, and inordinate constitutional disturbance, hysteria, &c. Paralysis, or loss of sense of feeling in the affected part, is a frequent attendant, and in chronic cases of neuritis, is asso- ciated with extraordinary coldness and insensibility of the skin. The causes of the disease are either constitutional or local. Incised, contused, lacerated, and gun-shot wounds, pressure upon nerves by ligatures, or by tumours, and various other in- juries, may be considered as the most common of the local agents. Ulceration of the nervous tissue, as appears from the observations of Swan, Craigie, and others, sometimes follows an inflamed nerve. Swan, in particular, has related cases of ulcers of the leg in which the nerves were found, upon dissec- tion, in an ulcerated state in some parts, thickened in others, or else surrounded or complicated with fungus. JYcuritis. 403 Treatment of Neuritis. In acute neuritis, constitutional, as well as local remedies in the shape of depletion, are chiefly to be relied on. Low diet, general blood-letting, leeches, purgatives, blisters, position and absolute rest, are essential in most aggravated cases of the dis- ease. Sometimes it resists the combined operation of them all. In such cases, the preparations of opium and colchicum may be tried. Stramonium and hyoscyamus, in chronic cases, may be also resorted to. When there is reason to believe that the disease has been the result of local irritation, and is kept up by the pressure of a tumour, or by consolidation of the parts in im- mediate contact with the inflamed nerve, from ligatures or the cicatrices of wounds, a division of the parts by the knife, or am- putation of the limb may become necessary. Langstaff has re- lated the case of a female, whose fore-arm was amputated on account of an injury which had been followed by violent symp- toms. The operation was productive of no benefit. Some months afterwards, a second amputation was performed above the elbow, the nerves were drawn out to the extent of half an inch, by the tenaculum, and cut off. From that moment the pa- tient was relieved of pain, and never had the slightest return of the severe symptoms she had so long suffered from. "When very painful ulcers exist," says Swan, "ointment made with powdered opium, or lotions made by mixing pow- dered opium with water, or lime water, should be applied on lint to the sore, and then a folded cloth moistened with water, or laudanum and water, over the surrounding skin, and attention should be paid to the digestive organs." The same surgeon has recommended, in case of ulcerated nerves, the di- vision of them, taking care to make the separation as far as pos- sible from the ulcer, in order to prevent the divided extremities of the nerve from afterwards taking on ulceration. 404 Neuralgia. Section II. Neuralgia. This, as the term implies, is a painful affection of one or more nerves, exceedingly common, which may occupy any organ or texture of the body; though it attacks the face oftener than any other part. By most writers it has been described under the title of tic douloureux. Whether seated in the head, face, cheek, spine, abdomen, Or extremities, the symptoms are nearly the same. These are, a peculiar, thrilling, darting, vibratory pain, commencing at a single point, and shooting along the course of one or more nerves, their filaments or branches: the pain is paroxysmal and periodical, and along with it there is generally muscular twitching. The degree of suffering varies in different patients, according to the parts attacked and the duration of the complaint. Some patients suffer immensely, and are so agonized as to be driven almost to desperation. But, generally, the pain, although extremely severe and frequent, is not intolerable, and is the more readily borne, as the paroxysms are succeeded by remissions, although there is seldom perfect immunity from suffering. For weeks, or months, the disease may endure, and at last wear away, and the patient console himself with the hope that it has been conquered. With all the irregularity of an in- termittent, however, it comes back, and sometimes renews the attack with more than usual ferocity. In other instances, the periodical visitation is not manifested, and for months and even years, the patient may be entirely free from the disease. The local symptoms enumerated, are in some cases preceded by ge- neral indisposition, such as chilliness, creeping sensations, gas- tric, uterine, and arthritic derangements. In other cases, the part is assaulted, without previous notice, and with a suddenness Neuralgia. 405 and impetuosity, that surprises and alarms the patient. Marks of inflammatory action are seldom visible in the part affected, nor is the circulation so far disturbed, in the generality of cases, as to amount to fever, even when the pain is at the height of paroxysmal intensity. Every age and sex are amenable to neuralgic invasion; but middle-aged females, of various tempera- ments, and whose systems have been impaired by dyspeptic agencies, are most exposed to its assaults: on the other hand, very vigorous and athletic young men, and even children, some- times become a prey to its ravages. Besides the parts already mentioned as most frequently implicated in neuralgia, we find the uterus, testicles, urinary bladder, kidneys, liver, spleen, rec- tum, stomach, heart, lungs, and brain, under the occasional in- fluence of ils operation. The causes of neuralgia, are local and constitutional. Among the former may be enumerated, mechanical lesions of every description, such as incised, lacerated, punctured, penetrating, contused, gun-shot, and poisoned wounds. Pressure, of various kinds, whether acting directly on individual nervous trunks, or branches, through the medium of cicatrices, spicula of bone, ligatures, corsets, bandages, or indirectly, will often give rise to the disease. Abscesses, ulcers, caries, particularly when seated in or near, the roots of the teeth, or about the face, or scalp, are equally powerful in inducing neuralgic aggression. The most prominent of the constitutional causes are, palludal exhalations, dyspeptic depravities, uterine irregularities, arthritic diatheses, hemorrhages, exposure to cold, mental emotions, masturbation, excessive venereal excitement and indulgence, immoderate use of tobacco, &c. With rheumatism, and other complaints, neuralgia is often confounded. But rheumatic pain is pulsatile, dull, has no dis- tinct remission, and is widely spread, while that attendant upon neuralgia is penetrating, vibratory, paroxysmal, and often pe- riodical, and unaccompanied by inflammation. Tic doloureux of the face may be distinguished from the toothach, by the pain at- tendant on the latter being deeply seated and continued, and by the swelling of the face and gums which accompanies toothach, and often ends in suppuration, and is unattended by that excru- ciating torture peculiar to neuralgic diseases. Vol. II. 52 40G Neuralgia. Treatment of Neuralgia. The local, and constitutional, causes of neuralgia being very numerous, and diversified, it is natural to infer that the cura- tive indications, and modes of treatment, should hold a propor- tionate correspondence. We find, accordingly, that countless remedial contributions have been furnished towards the removal of the complaint, and that as soon as one specific has acquired a reputation and lost it, its place has been filled by another. " Sic unda supervenit undam." The remedies, then, for neuralgia, must be looked upon, in most cases, as palliative merely. Under this head, may be enu- merated general and local blood-letting, blisters, stimulating plas- ters, caustics, opiate and saturnine lotions, fomentations, poultices, acupuncturation, compression by the roller or tourniquet, opiate and mercurial frictions, electricity, galvanism, magnetism, the in- ternal use of opium, belladonna, stramonium, hyoscyamus, quinine, sulphuric ether, arsenical solution, valerian, peroxide of zinc, sub-carbonate of iron, emetics, colchicum, subnitrate of bismuth, warm-baths. Of all these, most benefit appears to have been derived from quinine, sub-carbonate of iron, and emetics. So far back as the time of Vesalius, the celebrated anato- mist and surgeon, the division of the nerve, in tic doloureux of the scalp, was practised successfully. In the case of Prince Charles, (son of Philip the Second King of Spain,) who suffered immensely from a neuralgic affection of the scalp, succeeding a wound, Vesalius, by dividing that integument to the bone, effected a perfect cure in a very short time. Pouteau, one of the best of the older French surgeons, details two very in- teresting cases of the same kind; and, by pursuing a simi- lar practice, was equally successful. From the result of these operations, there is reason to believe the modern practice of dividing the branches of the fifth pair of nerves in tic doloureux of the face originated—a practice now seldom resorted to, ex- perience having proved its general inefficacy. It is not easy to imagine, indeed, how such a measure should prove permanently Neuralgia. 407 useful, if the view taken by Sir Charles Bell, that " tic doloureux has its source in visceral irritation, communicated through the sympathetic nerve," be correct. Why, it may be asked, then, has the operation ever succeeded? Ultimately, I believe, it very seldom has; for, out of numerous cases reported, immediate- ly after the operation, as successful, a very small proportion only have received permanent benefit—owing, perhaps, to the diffi- culty of selecting the precise nerve, or of cutting off its communi- cation with adjoining branches; but, above all, of preventing its reunion, even when portions of it have been cut out. 408 Neuroma. Section III. Neuroma. Br the term neuroma, is to be understood an enlargement or tumour of a nerve. There are three or four varieties of the dis- ease—one which is solid, or sarcomatous, situated as an interstitial deposite between the fibrils of the nerve, and which, by involving a number of these fibrils, may attain considerable magnitude— another, in form of a tubercle, about the size of a pea, and which occupies, there is reason to believe, one or more of the subcu- taneous nerves—a third, which is seated upon the extremity of a divided nerve, in shape of a button-like excrescence, and is produced by the application of a ligature—a fourth, which seems to consist of gelatinous matter enclosed in a cyst, and appears to be a secretion from the substance of the nerve. The first variety of neuroma was particularly noticed by Sir Everard Home, who, in 1796, detailed two cases of it, the first of which occupied the outside of the biceps muscle of the right arm, just below the middle, was the size of a pullet's egg, ex- tremely painful when handled, and, when exposed by the knife, was found connected above and below to a strong white cord, which turned out to be the musculocutaneous nerve. In the second case, the tumour occupied one of the large nerves which form the axillary plexus; and, when dissected out, was found of a yellowish white colour, three inches and a half long, two inches thick, and of an oval form. Sir Charles Bell, in 1809, published a very interesting case of tumour of the tibial nerve, produced by a fall over the side of a ship, the ham of the pa- tient being caught by a projecting bolt. For a long time the patient suffered extremely, not so much from the tumour as from pain in the foot, and finally died, worn out by long con- Neuroma. 409 tinued suffering and hectic. In 1812, I was consulted by a wo- man in the service of John Barney, Esqr., of Baltimore, on ac- count of a tumour the size and shape of a goose-egg, seated on the inner edge of the biceps muscle, near the middle of the right arm, very firm and solid to the touch, moveable, but not par- ticularly painful. Upon cutting down to the tumour, and lay- ing it bare, 1 found its upper and lower ends connected with a large white cord, which proved to be the median nerve. I hesi- tated, at first, about dividing the nerve, but concluded that it would be better so to do. Numbness of the arm, fore-arm, and fingers, particularly of the fore, middle and ring fingers, amount- ing almost to paralysis, followed the removal of the tumour. The wound healed kindly, however, and in a short time the general numbness disappeared, though it remained in the fingers, which were cold and almost useless for nearly three years; but, at the end of that time, was entirely removed, and the use of the fin- gers restored. The second variety of neuroma has been described by Mr. Wood of Edinburgh, and by Marshall Hall, under the title of "subcutaneous tubercle:' In all the cases detailed by Mr. Wood, the tumours were so excessively painful as to amount to agony. They were met with in different parts of the body, but generally in the extremities, and invariably occurred in females. Marshall Hall's patient, however, was a male. The button-like excrescence, so often produced, by awkward and ignorant operators, in tying the extremities of nerves, along with the arteries, in wounds, and on the face of amputated stumps, has been long familiar to surgeons; but has been more pointedly noticed by the late Mr. John Bell, Hennen, and Lar- rey than any other writers. The pain following the applica- tion of the ligature, under such circumstances, is intensely se- vere, and, in the course of time, becomes agonizing beyond en- durance, and sometimes gives rise to paralysis or tetanus. The ligature, too, instead of producing the effect it does when ap- plied to an artery, remains on the nerve, which is comparatively indestructible, for months together; and is with great difficulty pulled away, on account of the bulbous excrescence which is reared upon the end of the nerve, and is sometimes so large, as, in a case reported by Larrey, to resemble a mushroom. By some modern writers, it is said, that in proportion as the liga- 410 Neuroma. ture compresses the nerve, lymph will be thrown out around the ligature, and that the substance of the nerve will be destroyed, and the separation of the ligature soon follow. Experience has taught me the reverse. Encysted neuroma has been noticed by Sir Everard Home, and by Swan. Epilepsy, and other diseases, have been known to follow neuroma. Treatment of Neuroma. Large tumours, situated among the fibrils or involving the substance of a nerve, may give rise, as already remarked, to very urgent symptoms, or may destroy the patient. On the other hand, death has followed the extirpation of such tumours, or the functions of a part have been interfered with, or mate- rially deranged, by the division of a large and important nerve, like the ischiatic or median. There seems, however, in most cases, to be no other resource than an operation; and this we are justified in performing, upon the ground that reunion of the nerve will take place, in the course of time, (even when the in- termediate portion has equalled in length two or three inches, as proved by the result of the case in which I divided the me- dian nerve,) and that death will be almost sure to follow, if the sufferings of the patient are not speedily mitigated. The cases of subcutaneous tubercle, reported by Wood and Hall, were all cured, effectually, by extirpation. Dupuytren, who has also given a minute account, so far as his description can be depended upon, of the subcutaneous tubercle, (but under the title of encysted tumour,) concurs with Wood, in the state- ment that females are most subject to the disease, and that ex- tirpation is the only remedy. By Dupuytren, moreover, the disease is considered as not seated in the nervous tissue, and as liable to terminate in cancer. An interesting case, correspond- ing with the description of that eminent surgeon, occurred last summer in the practice of my friend Dr. Caspar Morris of this Neuroma. 411 city. A tumour about the size of a pullet's egg, soft, woolly, slightly elastic, acutely sensible, feeling, when lightly touched, as if it contained rice, occupied the left shoulder of a gentleman about twenty-seven years of age, and was situated just where the suspender crosses the most prominent part of the root of the neck —being caused, indeed, as the patient supposed, by the pressure of that article of dress. I advised, in consultation, extirpation, and performed the operation, by laying open the integuments, and dissecting out the whole of the sac and rice-like substance which it contained. The wound, however, did not heal, but became puffy and painful. Shortly, afterwards, I performed a second operation, removing integuments, as well as the substance of the tumour, and, by making a very extensive dissection, succeeded in effecting a cure. Nothing less than removal of the ligature will put a stop to the extreme suffering which follows the inclusion of nerves in wounds, aneurisms, and amputations. For months I have known the ligature to hold its place with the utmost tenacity, and the patient to be thrown into spasms upon touching the string in the gentlest manner. Even after it has been separated from the nerve the effect will remain, in some cases, for a long time. This was strikingly evinced in the case of Captain M----, who was blown up, during the late war with Great Britain, at Fort George, and had one of the nerves of an amputated leg included in a ligature. Symptoms of tetanus came on almost immedi- ately, and the ligature was cut away; but for months afterwards his agony was extreme, especially upon sudden atmospheric changes. On account of his sufferings, having become my pa- tient, I tried, ineffectually, various remedies; and only suc- ceeded eventually in arresting the spasms and pain, by laying open the stump and applying the actual cautery to the injured nerve. Hennen has furnished interesting cases of great dis- tress following the tying of a nerve, and Larrey reports two fa- tal cases of tetanus from the same cause. 412 Tetanus. Section IV. Tetanus. A violent and extremely painful contraction of the volun- tary muscles, without complete intervening relaxation, has been considered by most writers as constituting tetanus. Several varieties of the disease, differing from each other, chiefly, in situation, and proceeding from different causes, have also been pointed out. These are Opisthotonos, or a violent contraction and rigidity of the muscles of the back and posterior part of the neck, by which the body is bent backwards, or recurvated__ Emprosthotonos, or that variety in which the body is bent for- wards—Pleuroslhotonos, or lateral inclination of the body—Tris- mus, or locked jaw, in which the muscles of the lower jaw and throat are affected. Again; we have traumatic and idiopathic tetanus, and also the acute and chronic,—the former proceed- ing from wounds, the idiopathic from various causes, while the terms acute and chronic are intended to denote the period and duration of the attack. Of these varieties, however, the opisthotonos is, by far, the most common, and whether the result of a wound, or of cold, or any other cause, is characterized by the following symp- toms—painful rigidity of the neck, resembling rheumatism, difficulty of deglutition, followed by inability to swallow li- quids, and in attempting so to do, by spasms in the throat. To these succeed, sooner or later, violent spasmodic, lancinating pain, which shoots, with the rapidity of lightning, through the chest, from the sternum to the spine, recurs at shorter and shorter intervals, and is augmented, at last, to an intolerable degree of intensity. With this peculiar symptom, which is strikingly characteristic of the disease, the contraction of the Tetanus. 413 rcruscles of the neck, back, and jaw, keep pace; the head, in par- ticular, is thrown painfully backwards, and cannot be restored to its natural position, the breathing is interrupted by the action of the muscles of the neck on the windpipe, the pulse is fluttering, small and quick, the face flushed, the forehead wrinkled, the eyes turned upwards or distorted, the nostrils dilated, and the whole countenance greatly distressed. At last every voluntary muscle of the body appears more or less implicated; those of the abdomen are drawn up into knots, and the whole belly feels as hard as a board. In proportion as the spasmodic contractions increase, the head and lower extremities approach each other in a backward direption, so that the body forms an arch towards the bed, whilst its anterior part assumes the convexity of the segment of a hoop—the weight of the body being sustained upon the head and heels. By this time the jaws become immoveably fixed; but sometimes are occasionally relaxed in a slight degree, and then suddenly snap together with a convulsive jerk, which has been known in some instances nearly to sever the tongue, which is very apt to be protruded, at every stage of the disease, beyond the lips. The patient is scarcely a moment free from the most agonizing spasms; but, notwithstanding his extreme suffering, the intellect remains unclouded to the last, and the pulse scarcely ever amounts to the height of fever. In general, sudden and violent convulsions terminate the scene. Traumatic tetanus may follow the most insignificant scratch, in some instances, and in others, cannot be produced by the most extensive laceration. Occasionally it shows itself almost immediately, and, in other cases, does not come on until the wound is entirely healed. In general, however, it makes its appearance before the tenth day, and, where there is a tendency towards the disease, may be induced in a very short time by exposure to cold, or to a stream of cold air, even in the hottest weather. It is most common in warm climates, and in the sum- mer months. Wounds in the palms of the hands or fingers, and especially in the soles of the feet and toes, are most apt to give rise to it. That it derives its origin from wounded filaments, or trunks of nerves, rather than from wounds of tendons, (as formerly imagined,) there is every reason to believe; for seve- ral cases have been reported where foreign bodies have been Vol. II. ®* 414 Tetanus. found lodged in the substance of nerves, and where wounds have been traced to one or more branches. On the other hand, it must be confessed, that dissection has been frequently unable to reveal to us the source of this inexplicable, and most formi- dable malady, Treatment of Tetanus. In the treatment of tetanus, the prospect of success will de- pend much upon the cause of the disease. When it arises pure- ly from cold, from vegetable and other poisons, and is chronic, instead of acute, recovery often follows, even under the most opposite modes of treatment. But traumatic tetanus, gene- ' rally, defies the most vigorous and skilful efforts of the surgeon. So far as my own experience goes, I am inclined to rely, main- ly, and from the first, upon very large doses of opium. Twenty years ago I attended, along with Professor Baker, of Baltimore, a boy, seventeen years of age, who, from being precipitated from a scaffold, amidst a pile of bricks, had the bones of the forearm fractured about the middle, dislocated at the wrist, and protruded some inches. Tetanus followed in four or five days, and, as soon as its approach was announced, we commenced with opium in very large doses. Perceiving at once an ameliora- tion of symptoms, the remedy was persevered in, and directions left with the mother of the boy to pour down laudanum, during our absence, whenever she perceived the spasms to come on. Our instructions having been rigidly adhered to, and the opiate exhibited almost without reference to quantity, the system of the patient became so saturated with the medicine that a per- fect cure was effected, although the spasms continued, with more or less severity, for six or eight weeks. At one period of the disease, the boy took four, and sometimes five, hundred drops of laudanum in twenty-four hours. In a few other cases J have since succeeded in effecting cures by similar means; but, i Tetanus. 415 in the majority, have totally failed, in spite of opium in im- mense doses, and every other remedy that could be thought of. In one case of traumatic tetanus, under care of my friend, Dr. Antrim Foulke, a most respectable practitioner of Montgomery county, with whom I saw the patient about six years since, a cure was effected through the medium of large quantities of opium and asafcetida. But the same treatment, although rigor- ously pursued, during the last summer, in a case which I at- tended with Dr. I. G. Nancrede of this city, was productive of no benefit whatever. As a general rule, poultices should be ap- plied to the wound, in order to excite the suppurative action, both in cases where we have reason to apprehend tetanus, and after that disease has come on. The other remedies employed in tetanus, general as well as local, and still relied upon by some practitioners^ may be barely enumerated. These are, the warm and cold bath, ardent spirits and wine, mercury, sudorifics, musk, volatile alkali, purgatives* elatereum, prussic acid, colchicum, electricity, tobacco enemata, turpentine, blood-letting, sub-carbonate of iron, digitalis, Camphorj amputation, caustics and the actual cautery to the wounded partj or along the spine. Consult The Nervous System of the Human Body, by Sir Charles Bell, 4to. London, 1830—Swan on Diseases and Injuries of the Nerves. London, 8otf. 1834—Dissertation sur les Affections Locales des Nerves, par P. J. Descot. 8t».— On Painful Subcutaneous Tubercle, by William Wood, in Edinburgh Medical and Surgical Journal, vol.8, p. 238—Case of Painful Subcutaneous Tubercle, by Marshall Hall, ibid, vol. 11th, p. 466—An account of an uncommon Tumour formed in one of the Axillary Nerves, by E. Home, in Transactions of Medical and Chirurgical Society, vol. 2d, p. 152—C. Bells Operative Surgery, vol. 2, p. 331— Of Nervous Ganglions, or Tubercles, by Baron Dupuytren, in Clinical Lectures on Surgery, translated by Doane, 8vo. Philad. 1833—Remarks on Tic Dolou- ' reux, with Cases, by N Chapman, in Amer. Jour, of Med. Sciences, No. . XXVIII. 1834. On Tetanus, Consult Larrey's Memoires—Hennen's Military Surgery—Sir James M'Grigor, in Medico-Chirurgical Transactions, vol. 6—Cooper's Surgical Essays, &c 416 Amputation: CHAPTER XV. AMPUTATION. From the earliest periods the question of the propriety or im- propriety of amputation, in certain diseases and injuries, has been agitated with warmth, and even with acrimony—some contend- ing that the operation was scarcely ever necessary, under any circumstances—others, that patients were often suffered to.die for want of it. Unfortunately, these points are almost as un- settled at the present day as at any former period; and so long as the constitutions of patients continue to differ, and the circum- stances favourable, or unfavourable, to their recovery vary, it will, perhaps,'be impossible to lay down definite rules adapted to every case. Still, however, much may be pointed out as ap- proaching to certainty, and the rest must be left to the discretion and experience of the surgeon. The injuries and diseases for which amputation may be re- quired, may be arranged under the following heads:—1st, Gun- shot wounds and fractures. 2d, Mortification. 3d, Tumours. 4th, Diseased joints. 5th, Ulcers. Military surgeons have been often accused of amputating limbs unnecessarily; but it should be remembered, that after a battle the wounded are liable to be hurried from post to post, and in carts or wagons, for days together. Under these circumstances, the patient would not only suffer immense pain, but his life, in many instances, be sacrificed. The military surgeon, aware of this, amputates the limb on the field of battle, or as soon as possible Amputation. 417 afterwards, and dresses the stump. Thus situated, the patient may be moved about, with comparative ease, and with consider- able prospect of eventual recovery. In civil life, on the contrary, with every convenience and comfort at hand, the removal of the limb, except in extreme cases, would be considered improper and unjustifiable. The distinction, therefore, should always be drawn between the two cases. In all gun-shot and other wounds, whether accompanied with fractures or not, the first object of the surgeon should be to de- cide at once upon the treatment. As a general rule it may be observed, that if the chief arteries of a limb are divided, the muscles lacerated, and the bones broken, there can be no ques- tion concerning the propriety of amputation. On this point all surgeons of the present day entertain but one opinion. When the injury is less extensive, a question will necessarily arise how far the surgeon may be authorized in risking the patient's life, in order to save his limb. This can, of course, only be determined by the peculiarity of the case; but experience, or the termina- tion of former cases, will be the best guide. If a musket ball, for example, pass through the fore-arm, and the radial and ulnar arteries escape, amputation will seldom be required. On the contrary, if the ball should penetrate the wrist and fracture the bones, the operation will, in most cases, prove necessary. Wounds and fractures of the carpus, metacarpus, and metatarsus, rarely require amputation ; but similar injuries of the tarsus, or of the ankle joint, almost invariably terminate unfavourably, unless am- putation be performed. The same may be said of gun-shot in- juries of the fingers and toes, from which tetanus is extremely apt to ensue. When balls lodge deeply in the tibia, when both bones of the leg are fractured, and their arteries at the same time are wounded, and when the injury has been inflicted upon the extremities of the bones, near the knee or ankle joints, nothing less, in most instances, than amputation will save the patient. Gun-shot wounds of the knee, elbow, and shoulder joints, almost without exception, prove fatal, unless a timely re- moval of the limb be resorted to. Gun-shot fractures of the thi'crh bone are so extremely hazardous, that very few patients recover from them. Much will depend, however, upon the situation of the fracture. If the bone is broken below its middle, the ne- cessity for amputation will not be so urgent, and perhaps a cure 418 Amputation. may take place without this operation. When the upper por- tion of the bone, however, is fractured, recoveries very rarely follow, owing to the shock communicated to the system, and to the high fever, and extensive abscesses which form among the mus- cles of the hip and thigh. Admitting the above statements, however, to be correct, (and they correspond with the views of the best modern writers,) another question will naturally present itself:—At what period should the operation be performed 1 On this subject, a great di- versity of opinion has prevailed; some contending, that im- mediate amputation, in the severer injuries, is indispensable; others, that a secondary operation is more likely to be attended by a favourable result. If the weight of authority, may be deemed sufficient to settle the question, the number of advo- cates for immediate amputation, will be found greatly to exceed that of its opponents. Among the former may be enumerated the names of Ledran, Boucher, Ranby, Pott, Schmucker, Mur- sinna, Boy, Percy, J. Bell, Larrey, Graefe, Guthrie, Thomson, and Hennen—among the latter, Faure, Martiniere, Hunter, and Lombard. When immediate amputation, however, is spoken of, it must not be understood that the operation is to be per- formed instantaneously, or as soon as possible after the injury* On the contrary, it is agreed, upon all hands, that the surgeon should wait until reaction takes place, and that, after this, the sooner the operation is performed the better; inasmuch as symp- toms of inflammation may afterwards be expected to supervene} and if the operation be performed during this stage, the patient's chance of recovery will be very much diminished. As regards the period at which reaction occurs, after injuries, this will de- pend altogether upon the extent of the injury, and the pecu- liarity of the patient's constitution. Some will recover from the shock communicated to the system in an hour or two; others will remain twelve or fifteen hours with a cold skin and feeble pulse. So long, therefore, as these symptoms continue* it may be repeated, the operation must not be undertaken; otherwise, the patient will be apt to die on the table, or a few hours after he is removed from it. Whenever the patient has so far recovered from the injury that his pulse becomes regular, his countenance lively, and he begins to complain of pain and stiffness in the part, this will be the most favourable period for imputation. 419 the operation. Provided the operation be performed within forty-eight hours after the injury, it has been customary for military surgeons to denominate it primary amputation. On the contrary, when it is delayed until the symptomatic fever has lessened, and the suppuration is copious, it is called secon- dary amputation. From what has been stated, it will appear that amputation should be performed, in all those cases where the operation seems to be inevitable, before the accession of inflammation, and as soon as possible after reaction is completely established; but in slighter injuries, such as would seem not imperatively to demand the operation, and under circumstances calculated to favour the patient's recovery, it will become the duty of the surgeon to attempt to save the limb—calculating, if he should be disappointed in his expectation, upon secondary amputation as a resource. It should never be forgotten, however, that an operation, performed after the limb has passed through the stages of inflammation, cannot, in general, prove so successful as the primary one, because the muscles, cellular membrane, blood vessels, and bone, have all taken on more or less disease. Independently of this, secondary amputation, performed upon soldiers who are crowded together in ill-ventilated hospitals, is apt to terminate unfavourably, either from the stump being at- tacked by hospital gangrene, or from the prevalence of some epidemic disease. But one of the strongest objections that I know of to delay, and which has been particularly pointed out by Mr. Guthrie, is this: " When an amputation," says he, " is delayed from any cause, to the secondary period, a joint is most frequently lost; for instance, if a leg be shattered four inches below the knee, it can frequently be taken off on the field of battle, and the joint saved. Three or four weeks afterwards, the joint will, in all probability, be so much concerned in the disease, that the operation must be performed in the thigh; the same in regard to the fore-arm and hand, and the upper part of the arm with the shoulder joint. This is a very important point for the consideration of military surgeons, in recommend- ing delay in doubtful cases, as well as the knowledge that am- putations in unsound parts are frequently fatal, and are always attended with danger." I might detail numerous cases that have fallen under my own care or notice, in proof of all the 420 imputation. foregoing positions relating to amputation as a resource in gun- shot injuries; but so many of the kind are detailed in the works of military surgeons, as to render the relation unnecessary. Mortification, when it attacks the extremities, may require amputation. But it has long been an established maxim among surgeons, not to operate for this disease during its progress, or until a line of demarcation has been formed, and the dead parts are about to separate from the living—when an amputation will become necessary to form a proper stump, and to remove the bone. If, as experience has proved, in innumerable cases, the surgeon were to apply the knife while the disease was advancing, no benefit would result, as the mortification would attack the stump, and continue to increase until it spontaneously ceased, or destroyed the patient. There are certain cases, however, in which it would be proper to deviate from this course, and perform the operation, notwithstanding the progression of the disease. If, for example, gangrene, from a gun-shot injury, has seized upon the leg, and is rapidly extending along the thigh towards the body, the patient's chance of recovery will at any rate be small, and under these circumstances, it is possible, though not very pro- bable, that the removal of the thigh may save his life. At all events, the operation should be tried, because it has sometimes proved successful, where death, without it, would speedily have happened. There is another case, also, in which it will be pro- per not to wait for the line of separation. It is this. A man is shot through the thigh, the femoral artery and vein torn across, and being yet able to walk about, his wound is considered a slight one. About the third or fourth day, however, the. toes and foot are found discoloured, and the limb cold and painful. The nature of the disease is then rendered evident, and if not speedily arrested by amputation above the wound, will soon have a fatal termination. For a knowledge of this fact, the profession is particularly indebted to Mr. Guthrie. Notwithstanding the axiom that amputation should not be performed during the pro- gress of mortification in ordinary cases, it is proper to state that Larrey, Hennen, Hutchinson, Lawrence, and some other dis- tinguished surgeons, have long been in the habit of deviating from the rule, and, according to their accounts, with considera- ble success. There are many tumours, most of which have been noticed Amputation. 421 in the preceding pages, that may require, (if they attain a large size, and seriously affect the patient's constitution,) amputation. These are, osteo-sarcoma, spina ventosa, exostosis, fungus haema- todes, &c. The latter disease, as formerly stated, invariably proves fatal, unless arrested by a timely amputation, and, in- deed, in many instances, this will not ensure the patient's life, even when resorted to in the very commencement. Formerly, many limbs were sacrificed on account of aneurismal tumours, but the improved methods of treating that disease, may be said to have exploded the practice of amputation in such cases. White szoellings, as they are called, when neglected, or im- properly treated, by exhausting the patient's constitution through the medium of hectic and diarrhoea, often prove fatal. To re- move this constitutional disturbance, and to save the patient's life, amputation, in many instances, will, unfortunately, become necessary; and its benefit is surprisingly evinced upon many occasions, by the rapid amendment of the patient's general health, and early cicatrization of the wound. But there is rea- son to believe that the operation too often becomes a dernier resource, rather from the mismanagement of the surgeon, than the intractable nature of the complaint. In civil life, old and inveterate ulcers of the leg very fre- quently call for the removal of the limb; and upon such occa- sions, the practice of amputation is, perhaps, as justifiable as in most other surgical diseases; for after having, for years, exhaust- ed the resources of his art, the surgeon will find that the con- stitutional irritation and disturbance will carry off his patient, unless he can eradicate them by laying the axe at the root of the evil. There is one error, however, that an inexperienced surgeon may commit upon these occasions, and which it will be proper to point out. It may happen that an incurable ulcer, accompanied by diseased bone, has existed for years, and has served in bad constitutions, especially the old and debilitated, as an issue or drain, which so long as it is kept open, tends to appease a cough or some other troublesome symptom. If, under these circumstances, amputation be performed, and the stump heal up, the patient, perhaps, in a short time, recovers his plumpness, and gets apparently well; but in the course of a few months, evident disorder of some of the internal organs, and of the lungs especially, shows itself, and death, in a short Vol. II. 54 422 Amputation. time, follows. I have witnessed too many examples of this sort, not to be fully aware of the danger of an amputation, when thus improperly performed. Mr. Guthrie, Dr. Hennen, and some other writers, notice such consequences, sometimes following secondary amputations, after gun-shot wounds. The instruments and dressings required, for most amputations, are two amputating knives, one rather larger than the other, a catling, two or three scalpels, the same number of tenacula, ar- tery forceps, needles, ligatures, sponges, a large and small saw, bone nippers, two tourniquets, compresses, rollers, linen retrac- tors, a Malta cross, lint, tow, adhesive straps, lint spread with cerate, two or three basins of warm water, wine and water in a tea-pot. Formerly, amputating knives, extremely concave on the cut- ting edge, were employed. The modern knife is nearly straight, rather short, but substantial in the blade, and rough on the handle, to enable the operator to take a firm hold. The catling is a narrow, two-edged knife, tapering away to a point, and bears a strong resemblance to a dirk. It is intended to pass be- tween bones, and separate the soft parts adhering to them. The amputating saw is about the size of a carpenter's dove-tailed saw, and its handle should also resemble, in some respects, that of the latter. The blade should be thinner as it approaches the back of the instrument, the teeth widely set, and so constructed as to cut vrith both edges as they are passed backwards and for- wards. In using the saw, the surgeon will discover, after a little practice, that the instrument works to the best advantage when moved steadily by long strokes, always taking care to commence by applying the heel of the instrument first to the bone, and drawing thence to the point. When the bone is nearly cut through, the operator should move the saw cautiously and gently, lest the bone suddenly break and leave a projecting point or snag. When this happens, however, it is commonly owing to the assistant not supporting the limb with steadiness. The bone nippers are designed to remove the projecting portion of bone, should it break, and are well calculated for the purpose. The handles of this instrument should be longer than they are usually made, and its cutting part placed obliquely upon the shafts. Retractors are made of linen, cotton, leather, and some- times of metal in the form of plates; but the linen are the best. Amputation of the Thigh. 423 They are formed, by taking a piece of linen, eighteen inches or two feet in length, and a little broader thjan the stump, and di- viding it along the middle ten or twelve inches. The use of the retractor is to draw up the muscles after they are divided, and prevent them from being torn by the teeth of the saw. The Malta cross is formed by sewing two pieces of linen or cotton roller, each about two feet long, across each other at the centre. It serves the purpose of confining the lint or tow upon the front of the stump, and, in this way, assists the roller. A piece of lint, spread with cerate, and large enough to cover the whole stump, will always be found extremely useful in prevent- ing the ends of the ligatures from being glued to the surround- ing dressings, by the matter that escapes from the wound. As the patient will have frequent occasion for drink during the operation, and cannot conveniently take it from a tumbler, whilst lying on his back, the spout of a teapot, or some similar vessel, applied to his lips, will be found to answer a better purpose than any thing else. Sectk)i* I. imputation of the Thigh. The patient being seated on the edge of a strong table, with his back supported by pillows, and assistants on each side to take charge of his hands and arms, the tourniquet is applied by an assistant, about three inches below the groin—a small com- press of muslin being previously placed under the frame of the tourniquet, while the pad of the instrument is fixed above the femoral artery. Having ascertained that the circulation of the blood in the limb is interrupted by the pressure of the tourni- quet, the surgeon directs an assistant to elevate the leg, and support it nearly in the horizontal position, and then carrying 424 Amputation of the Thigh. the amputating knife under the limb, until it nearly reaches the side on which he stands, applies it to the thigh as low down as the disease will admit, and with one continued sweep divides by a circular cut, the integuments, fat and fascia. The large knife is then exchanged for a scalpel, with which the operator separates the loose cellular membrane connecting the integu- ments to the muscles, and turns back the skin to the extent of two inches, in the same way that one would turn back the cuff of a coat. Having resumed the amputating knife, and keeping it close to the rounded margin of the reverted integuments, the surgeon next cuts through the muscles down to the bone. In making this incision, the edge of the knife should be inclined upwards, in order, as it were, to hollow out the front of the mus- cles in the form of a cone. With the scalpel, the surgeon se- parates the muscles from the bone for two or three inches, after which an assistant applies the slit of the retractor around the bone, twists its ends together, and forcibly pulls the muscles upwards. The bone is next divided by the saw, and the limb removed. A soft sponge is applied to the surface of the stump, and the blood being cleared away, the femoral artery, enclosed by its sheath, and lying near the bone, may be distinctly seen. With a tenaculum, it is drawn out, separated from its accom- panying nerve, and tied with a strong round ligature. After this the assistant slackens the tourniquet slightly, when a jet of blood will generally be perceived from some of the branches of the profunda and other arteries. These vessels must likewise be taken up successively, until the whole are secured. But often it happens that the vessels, from an approach to syncope, retract, and for a time do not bleed. The surgeon, aware of this, must not be too hasty in closing the stump, but should rouse the ar- terial action by wine and water, the admission of fresh air into the room, and solicit, gently, the extremities of the vessels on the stump, by warm water and the sponge. As soon as all danger of secondary hemorrhage is over, the stump may be dressed. The ligatures being brought out of the upper and lower corners of the wound, its edges are pressed together by an assistant, in such a way as to cover completely the extremity of the bone, and form a cushion for it out of the cut muscles and integuments. While thus held, the surgeon carefully wipes the surface of the skin, for several inches around, so as to render Amputation of the Thigh. 425 it perfectly dry and fit to receive the adhesive straps, which are next warmed and applied—with interspaces of half an inch be- tween them.* Over the straps is laid the cerate plaster, and above the plaster a thick pledget of tow. This last, in its turn, is secured by the Malta cross, and the ends of the latter fastened down by a roller, made to cover by circular turns the whole thigh, and kept from slipping downwards, by being carried once or twice around the patient's pelvis. The tourniquet being ap- plied loosely about the limb, (that it may be suddenly screwed in case of secondary hemorrhage,) the patient is put to bed, laid on his back or side, and the stump supported by a pillow, and, se- cured to it by pins and short strips of muslin. Over the stump is placed a frame to take off the weight of the bed clothes. If the patient is to lie on his back during the cure, the edges of the wound should be put together so as to form a perpendicular cicatrix, to allow the matter greater facility of draining off. On the contrary, should he be confined to his side, the edges must be approximated in a horizontal direction. During winter, the dressings may remain on seven or eight days, but in summer only two or three. They should be poulticed three or four hours previously to attempting their removal. The after dress- ings may be repeated once in forty-eight hours. About the tenth day, the ligatures usually come away, and under favourable cir- cumstances, the wound is healed in three or four weeks. To prevent corners from being left, at the upper and lower angles of the wound, in consequence of the integuments being puckered in these situations, an inevitable consequence of the circular incision, as practised in the operation I have just de- scribed, Professor Davidge, of Baltimore, has long been in the habit of making his incision through the skin with a common scalpel, deviating above and below from the circular direction, and forming an angle which serves the purpose of rounding off the corners. The operation is not only neater than the ordina- ry one, but possesses an advantage over it as regards the facili- • To prevent the edges of the skin from uniting by the first intention, and be- fore the wound closes from the bottom, and thereby to guard against the accu- mulation of pus beneath the integuments, the late Dr. Physick was in the habit of sometimes interposing a bit of lint between the lips of the wound, and keep- ing it there for a few days. 426 Amputation of the Thigh. ty of escape of the matter, which, instead of collecting in a pocket, formed by the pouting integuments, drains off as soon as secreted. It may be proper to observe, however, that after the stump has healed, the corners, (which always exist imme- diately after the common operation,) disappear, and do not sub- ject the patient to any inconvenience. Amputation of the Leg. 427 Section II. Amputation of the Leg. As much as possible of the thigh, should, in all cases, be saved, but the rule does not always hold good in amputation of the leg. If, for example, the leg be amputated just above the ankle, the bone, from the deficiency of surrounding muscle, can- not be well covered, and is, therefore, not calculated to bear the pressure of an artificial leg. On this account, the patient is obliged to have an instrument of the kind adapted to the knee, and the leg, therefore, is carried out behind at right angles with the thigh, and by its weight greatly incommodes the patient— so much so, indeed, that I have known several submit to a second operation, for no other reason than to get rid of the incum- brance. It is usual with surgeons, in amputating the leg, to perform - the common circular operation, when it is desirable to take oft' the limb a few inches below the knee, and the flap operation when the leg is removed just above the ankle. I prefer the lat- ter, however, in all cases. It is done as follows:—The tourni- quet being placed about the middle of the thigh, the leg is sup- ported by an assistant holding at the foot, the surgeon calcu- lates beforehand the quantity of soft parts that may be required to cover the bone, and passes the common amputating knife ob- liquely upwards on the back part of the leg through the skin, which being drawn up by an assistant, the knife is next carried alon0- the margin of the divided skin, through the muscles to the bone, then perpendicularly over the tibia, until it meets the oblique cut on the other side of the leg. The catling is next thrust between the bones, and the musclos and interosseous 428 imputation of the Leg. membrane divided, a retractor with three tails introduced, the integuments and muscles drawn up, and the bones sawed off The arteries being carefully tied, and the nerves excluded from the ligature, the flap formed out of the muscles and skin is turned up in front of the bones, and forms over them a thick cushion, calculated afterwards to bear the pressure of a wooden leg. In dressing the stump, however, (in the way recommended for the thigh,) care should be taken not to press the flap too forcibly against the sharp edges of the tibia—lest ulceration be excited. Amputation of the Arm and Fore-arm. 429 Section III. Amputation of the Arm and Fore-arm. When it becomes necessary to amputate the arm, the patient should sit on a chair, or lie over the edge of a bed, and while the limb is carried out at right angles from the body, and sup- ported by an assistant, a circular incision is made through the skin and muscles, (according to the directions already given when treating of amputation of the thigh,) the bone sawed off, the vessels secured, and the dressings applied. If the operation is performed about the middle of the lower part of the arm, the tourniquet may be applied above; but when it becomes neces- sary to amputate very high up, there will be no space left for this instrument, and the surgeon must then trust to compression of the subclavian artery, where it passes over the first rib. Un- der these circumstances, Larrey and some other surgeons ad- vise the amputation of the arm at the shoulder joint; but I should prefer making a flap out of the deltoid muscle, and with this covering the extremity of the bone. Amputation of the fore-arm may be performed either by the common circular incision, or by the flap. The former, in most cases, will answer extremely well, and, as being more simple than the flap operation, should be preferred. As much of the fore-arm as possible ought to be preserved. Vol. II. 55 430 Amputation at the Shoulder Joint. Section IV. Amputation at the Shoulder Joint. By a cannon-shot, the head of the os humeri is sometimes carried away, or the bone so shattered, as to render amputation at the shoulder joint necessary. The same may be said of frac- ture from a bullet or grape-shot. Various tumours, also, such as fungus haematodes, exostosis, &c, may give rise to this ope- ration, which was formerly looked upon, under any circum- stances, as hazardous in the extreme. The experience, how- ever, of modern military surgeons, tends to prove its perfect safety as well as simplicity. There are various modes of per- forming the operation; but the old plan of La Faye, as modified by later operators, should, I think, in most cases, be preferred. It is executed in the following way:— The patient is seated on a chair, whilst an assistant, standing behind him, presses on the subclavian artery, where it passes over the first rib, by a boot hook, or large key, covered with a firm linen compress. A semicircular incision, with its convex- ity downwards, is then made, transversely with a large scalpel, through the integuments and deltoid muscle to the bone, three or four inches below the acromion process. This flap being turned upwards, the tendon of the long head of the biceps is ex- posed and divided, the capsule of the joint opened, and the head of the bone turned out of its glenoid cavity. As soon as this is accomplished, the soft parts beneath the arm are cut through, at a single stroke of the knife, the arm separated from the body, and the axillary artery instantly picked out by the tenaculum and tied. Any other vessels that may bleed.being secured, in like manner, the edges of the wound are brought together, and dressed in the ordinary way. But it sometimes happens that Amputation at the Shoulder Joint. 431 the deltoid is shot away, and of course the surgeon cannot de- pend upon it for a flap. • In that case the glenoid cavity may be covered by the muscles on the sides or under part of the arm. I have twice, only, found it necessary to amputate at the shoul- der joint. In certain cases it may be possible to save the patient's arm, notwithstanding a gun-shot wound and fracture of the head of the humerus—by laying open the joint immediately after the in- jury, and removing the fragments of bone, or by waiting until suppuration is established, and the shattered pieces become loose. An operation of the kind, however, can only be depended upon when the fracture is comparatively limited, and the shaft of the bone not splintered. Baron Larrey, Mr. Guthrie, and other surgeons, have repeatedly succeeded, under these circumstances, in preserving the limb, and saving the patient's life. 432 Amputation at the Hip Joint. Section V. Amputation at the Hip Joint. This is, perhaps, the most formidable and terrific operation in surgery; yet there are examples on record of its successful termination; though it must be confessed that it has failed in an immense number of cases. Having never performed the ope- ration, I cannot from experience speak of the best mode of exe- cuting it, and shall therefore give it in the words of Mr. Guthrie, whose method, it seems to me, has at least simplicity to recom- mend it. " The patient should be laid on a low table, or two field pan- niers placed together, covered with a folded blanket, to prevent the edges giving pain, and properly supported in a horizontal position. An assistant leaning over, and standing on the outside, should compress the artery against the brim of the pelvis, with a firm, hard compress of linen—such as is usually used before the tourniquet; he should also be able to do it with his thumb, be- hind the compress, if it be found insufficient. The surgeon stand- ing on the inside, with a strong pointed amputating knife of a middle size, with the back curved, makes his first incision through the skin, cellular membrane, and fascia, so as to mark out the flaps on each side, commencing about four fingers' breadth, and in a direct line below the anterior superior spinous process of the ilium, in a well-sized man, and continuing it round in a slanting direction, at an almost equal distance from the tuberosity of the ischium, nearly opposite to the place where the incision com- menced. Bringing the knife to the outside of the thigh, he con- nects the point of the incision where he left off with the place of commencement, by a gentle curved line, by which means the outer incision is not in extent more than one-third of the size of the internal one. The integuments having retracted, the glu- taeus maximus is to be cut from its insertion in the linea aspera, and the tendons of the glutaaus medius and minimus from the top Amputation at the Hip Joint. 433 of the trochanter major. The surgeon now placing the flat edge of the knife on the line of the retracted muscles of the first in- cision, cuts steadily through the whole of the muscles, blood ves- sels, &c, on the inside of the thigh. The artery and vein, or two arteries and vein, if the profunda is given off high up, are to be^ken between the fingers and thumb of the left hand, un- til the surgeon can draw each vessel out with the tenaculum, and place a ligature upon it. Whilst this is doing, the assistants should press with their fingers on any small vessels that bleed. The surgeon then cuts through the small muscles running to be inserted between the trochanters, and those on the under part of the thigh, not yet divided; and with a large scalpel opens into the capsular ligament, the bone being strongly moved outwards, by which its round head puts the ligament on the stretch. Having extensively divided it on the fore and inside, the ligamentum teres comes into view, and may readily be cut through. The head of the bone is now easily dislocated, and two or three strokes of the knife separates any attachment the thigh may still have to the pelvis. The vessels are now carefully to be secured. The capsular ligament and as much of the ligamentous edge of the acetabulum may be removed as can readily be taken away. The nerves, if long, are to be cut short, the wound well sponged with cold water, and the integuments brought together in a line from the spinous process of the ilium to the tuberosity of the ischium. Three sutures will in general be required, in addition to the straps of adhesive plaster, to keep the parts together: the ligatures are to be brought out in a direct line between the su- tures, a little lint and compresses are to be placed over the wound, and on the under flap, to keep it in contact with the cotyloid cavity, and assist the union of the parts. A piece of fine linen is to be laid over them, and the whole retained by a calico ban- dage put around the waist and brought over the stump."* Amputation at the hip joint can never be required, perhaps, except for a gun-shot wound, or some similar extensive injury, in which the muscles, large vessels, and nerves, are lacerated, and the head, neck, or superior part of the thigh bone, or part of the pelvis are crushed. Such effects generally arise from cannon, or grape-shot, or from the bursting of shells, and from machinery in motion. * Guthrie on Gun-shot Wounds of the Extremities, p. 178. 434 Amputation of the Fingers and Toes. Section VI. Amputation of the Fingers and Toes. When the hand and fingers are shattered by the bursting of a gun, by grape-shot, bullets, by machinery, or any other cause, amputation will often become necessary, in order to guard against tetanus, and the effects of inflammation. Where it can be done, however, without risking too much the patient's life, an attempt should always be made to save, at any rate, one or more fingers, as the patient will find them, even when mutilated, extremely useful. In such cases, the mode of operating, must depend very much upon the extent and shape of the wound and fractures. Instead of using the spring saw contained in most amputating cases, when the metacarpal bones are injured or diseased, and require extirpation, the semicircular trephine, of Sir Charles Bell, will be found the most convenient instru- ment for removing the bone. Fingers and toes are, generally, amputated at the joints, and the following is the mode of per- forming the operation, as usually practised. Whilst an assistant draws up the skin, the surgeon makes a circular incision three or four lines below the joint. The skin is next separated and turned back, the tendons surrounding the joint divided, the finger or toe bent so as to render the joint more conspicuous, the capsular and lateral ligaments cut through, and the extremity removed. It is seldom necessary to take up any vessels, but the oozing of blood should be allowed to stop, after which the surgeon may draw together the edges of the skin, so as to cover the end of the bone, and retain them by strips of adhesive plaster, and a narrow roller. Amputation of the Fingers and Toes. 435 Many attempts have been made, of late years, by Lisfranc, in particular, and other French surgeons, to modify and improve the operation of amputation. With very few exceptions, their methods have not been found to answer on the living subject, however neat and advantageous they may have appeared ou the dead. On Amputation, consult Pott's Works, vol. 3—Hey's Practical Observations, edit. o—Desault's Works, by Smith, vol. 1—7. BeWs Principles of Surgery, vol. 1—Larrey's Military Surgery, by Hall, vol. 1 and 2—C. Bell's Operative Sur- gery, vol. 2—Guthrie on Gun-shot Wounds of the Extremities—Thomson's Re- port of Observations made in the Military Hospitals in Belgium; after the Battle of Waterloo; with some Remarks upon Amputation—Pelletan Clinique Chirurgi- cale, tome 3-r-Hennen's Principles of Military Surgery, edit. 2—C. Bell's Surgi- cal Observations—Dorsey's Surgery, vol. 2, edit. 3—Coster's Manual of Surgical Operations, by Godman, Philad. 1825—Liston's Elements of Surgery, Ed. 1832 —Article Amputation, in Dictionnaire des Sciences Medicates, tom. 1— Velpeau, Noveaux Elements de Medicine Operatoire, Paris, 1832—Geddings, in Cycbpse- dia of Practical Medicine and Surgery, and a Digest of Medical Literature by Isaac Hays, M. D., article Amputation. 436 Hysterotomy or Ccesarian Section. CHAPTER XVII. * HYSTEROTOMY OR CiESARIAN SECTION. In cases of extraordinary diminution, or deformity, of the pelvis—of exostosis, and other tumours within its cavity—of fractures of the innominata and sacrum, followed by irregularity of reunion or profusion of callus—of dislocations of one or both thigh bones—of wounds of the uterus—of extraordinary size of the foetal cranium—of foetal monstrosity—of hernia of the ute- rus—of preternatural presentation of the foetus—of rupture of the uterus—of obliquity of the uterus—of large stones in the blad- der—of strictures and adhesions in the vagina—of enlargement of ovaries—of extra-uterine conceptions, and others diseases, ac- cidents, malformations, or death of the mother, it may become necessary to lay open the parietes of the abdomen, divide the peritoneum, cut into the womb, and remove the child. From the earliest periods the operation has been, resorted to, with more or less success, in some countries, and in others with total fail- ure. Thus, in Great Britain, although performed between thirty and forty times, there is but a single instance* in which both mother and child have been saved, and very few, where the life of the infant alone has been preserved. In France, Germany, and some other parts of the continent, however, the operation has frequently proved successful, and has been re- peated on the same patient with similar result. Indeed, out of two hundred and thirty-one operations reported, one hundred and thirty-nine are said to have been followed by partial, or complete, success. That the operation has been attempted, by * Lately by Mr. Knowles of Birmingham. Hysterotomy or Casarian Section. 437 surgeons, two or three times in the United States, there is rea- son to believe; but in no instance has the life of mother and child, so far as my information extends, been saved except in the cases, I shall now relate. Mary R----d, wife of Joshua M. R----d, Esq., of this city, 26 years of age, was married, the 16th of May, 1830, and on the fourteenth of June, 1831, was in labour with her first child. Dr. George Fox, being called to her assistance, found the os uteri sufficiently dilated to admit a finger, and feel the protruding membrane. Discovering, a few hours afterwards, great deformity of the pelvis, he was led to believe that Mrs. R. could not be delivered per vias naturales, and, therefore, requested thp as- sistance of Professor James, and subsequently, that of Drs. Meigs, Lukens, Hewson and J. R. Barton. After repeated, and most accurate examination, it was concluded that the antero-posterior diameter of the pelvis did not exceed two inches; and it then be- came a question, whether the division of the symphysis pubis, the Caesarian operation, or embryotomy, should be performed. " The Caesarian operation was thought to be attended with so much risk to the mother as almost to be necessarily fatal, some of the most distinguished surgeons being decidedly opposed to its performance; and Dr. Physick, who was called upon for his opi- nion, on the propriety of this operation, was decided, and positive in his opposition to it. Under the weight of such authority, the idea of the Caesarian operation was abandoned.'"* It was then determined to perform cephalotomy, and Dr. Meigs agreed to undertake it. Before he commenced that operation, however, Dr. M., conceiving, after further examination, that "cephaloto- my would be attended with as much risk to the life of the mo- ther as the Caesarian operation, thought it better to call another consultation, to reconsider the propriety of performing the Caesa- rian operation."!" During this consultation it was decided that the child was dead; there being, therefore, " no further hesitation as to the propriety of cephalotomy," that operation was com- menced immediately by Dr. Meigs, and performed in the most • Relation of a case of labour, in a female with deformed pelvis, by George Fox, M. D., in North American Medical and Surgical Journal, No. xxiv. October, 1831, p. 485. f Ibid. Vol. II. 56 438 Hysterotomy or Casarian Section. skilful manner, and the patient, (notwithstanding the great dif- ficulties the operator had to encounter,) recovered in three weeks after delivery, though she had almost fallen a victim to exhaus- tion."* On the 22d of June, 1833, Mrs. R's. labour with her second child commenced. Dr. Meigs was again called to her assist- ance, and performed a second time the operation of cephalotomy —having previously ascertained that Caesarian section would not be submitted to. The patient again recovered, and with less difficulty than after the first operation. In June, 1834, Mrs. R----d became pregnant with her third child, and my friend Dr. Jos. G. Nancrede, now one of the oldest and most respectable accoucheurs of this city, was consulted, and after mature deliberation decided, that Caesarian section was the only appropriate operation in her case, inasmuch as it had been performed on the continent of Europe, in several instances, with success, and was considered by the most eminent accoucheurs not more hazardous, under certain circumstances, than embryotomy. Upon these and other grounds, Dr. Nancrede determined to use his influence with the patient, and her friends, to induce them to consent to the operation, and requested me to make every preparation for its performance—in case I approved of and was willing to undertake it. Coinciding with him in sentiment, and having considerable time for reflection, and opportunity for ex- amining authorities as to the best mode of performing the ope- ration, I made all the necessary arrangements/ On Wednesday, the 25th of March, 1835,1 received notice that Mrs. R----was in labour; and at 3 o'clock, P. M., saw her, for the first time, with Drs. Nancrede and F. S. Beattie. Labour had commenced the night before, though the pains during that night, and the whole of Wednesday, were slight. The os uteri, however, had dilated sufficiently to admit two or three fingers, but the membranes remained entire. In this state of affairs it was explained to Mrs. R——-, by Dr. Nancrede, and the Rev. Mr. Hughes her pastor, that it was deemed improper, in every point of view, to destroy her child, and that it was her duty to risk her own life in the hope of saving that of her offspring. * Meigs on Deformed Pelvis, &c, in Baltimore Medical and Surgical Journal and Review, vol. 2nd, p. 30. Hysterotomy or Ccesarian Section. 431) After consulting for some time with her husband, and other friends, she consented to have the operation of Caesarian sec- tion performed.* A firm table was selected, and covered with a mattress and sheets, the patient placed upon it, on her back, and her pelvis and shoulders supported by pillows. In presence of Dr. Nancrede, Professor Dewees, Dr. Dove of Richmond, Professor Horner, Dr. Beattie, Dr. Wm. Coxe, Dr. Theodore Dewees, and my son, Dr. Charles Bell Gibson, I made an incision, at the centre of the linea alba, commencing about an inch be- low the umbilicus, through the integuments, and extending nearly to the pubes. To save the patient pain and to prevent this first, or perpendicular, cut from penetrating too deeply, I requested Dr. Horner to fold up the skin with his fingers, and while thus held 1 passed the knife through it with its back to- wards the abdomen. The superficial fascia being exposed was divided, then the tendons of the abdominal muscles, next the peritoneum, and lastly the body of the uterus, all to the extent of six inches. The uterus, however, at this stage of the opera- tion, was not cut entirely through, but a line or two in thick- ness, of the interior of its walls, left—with the view of draw- ing off the waters before I opened the womb, penetrated the membranes and exposed the child. At my request Dr. Nan- crede introduced a finger into the os uteri and endeavoured to rupture the membranes, but could not succeed. A similar at- tempt was made by Dr. Beattie, which also failed. Having re- sumed the knife, the remaining fibres of the uterus were divided, the membranes exposed, and cautiously, opened by running Cooper's bistoury for strangulated hernia, upwards and downt wards, to the oxtent of six inches, while Dr. Horner held closely together the sides of the wound, to prevent protrusion of the intestines and the escape of any portion of the waters into the bag of the peritoneum. There was a right lateral obliquity of the uterus, and the po- sition of the child found to correspond with the third breech presentation of Baudelocque. Dr. Beattie then introduced his hand, and drew out the feet, while Dr. Nancrede supported the hips and back, and removed the body, and lastly, the head • There are several modes of performing Caesarian section, but I prefer the one I have here described. 440 Hysterotomy or Casarian Section. of the child, from the womb. It proved a girl of large size, and apparently healthy. For some seconds, however, it did not breathe, and, indeed, not until friction on the chest, blowing into the mouth, and the introduction of a few drops of brandy were resorted to. The cord being cut, the child (Maria Caesariana) was removed, and in a short time cried lustily. Whilst Dr. Horner still kept the sides of the wound together, Dr. Beattie extracted, with- out difficulty, the placenta and membranes, and, at the same time, pushed a finger from the interior of the uterus through the os tincae, to make a free communication with the vagina. During these manipulations, two portions of intestine, each the size of a pigeon's egg, protruded on the right side of the uterus, and near the upper corner of the wound. They were readily kept back, however, and did not again protrude; nor did any fluid, so far as could be observed, find its way into the peritoneal bag. No hemorrhage took place from the removal of the placenta, nor was it necessary to secure a single vessel with the ligature. There was a visible contraction of the womb, after the removal of its contents, and the incision in it had sensibly shortened in the course of a few seconds. My attention was next drawn towards closure of the wound. With great care, and the utmost nicety, the edges of the peri- toneum, muscles, and integuments were held together by assis- tants, while I passed, successively, three stout silk ligatures, in form of interrupted suture, through the integuments—avoiding the peritoneum and muscles—an inch and a half from each other, and supported the whole by adhesive straps, lint, a com- press and roller around the abdomen. To give vent to any se- cretion of serum, or pus, the lower angle of the wound was left open for the space of half an inch. The patient was then raised very carefully, by several assistants, and laid in bed upon her back and great pains taken to render her position as comfortable as possible, and to prevent the slightest movement. There was less difficulty in this respect than could have been anticipated, arising partly from the little pain, comparatively, during the operation, the natural firmness and equanimity of the patient, and her faithful reliance upon Providence for a happy issue out of her affliction* Under the cheering influence of such feelings, she slept soundly for several hours, and did not change her po- sition in the slightest degree. Hysterotomy or Ccesarian Section. 441 By Drs. Nancrede, Beattie and myself,* she was visited, for a week or ten days, three times a day; was kept entirely on barley water, during that time, under the influence of an occa- sional opiate at niurht, took, now and then, small doses of mag- nesia, or used encmata, had her diet gradually increased; on the twenty-fifth day after the operation, was enabled to sit up,— the wound, with exception of a single spot, the size of a pea, being entirely cicatrized—and, finally recovered, and now en- joys, together with her child, perfect health. A second time has it fallen to my lot to perform Cassarian sec- tion upon the individual whose case has just been detailed, and with the same fortunate result, as the following particulars will show. Sunday, Nov. 5th, 1837, eight o'clock A. M., Dr. George Fox called upon me, and requested a consultation with himself and Dr. Meigs in case of Mrs. R. Dr. Fox also stated that Mrs. R. had only been seized with labour pains about six o'clock of the same morning, although the membranes had been ruptured two days before. At nine o'clock A. M., I met in consultation, Drs. Meigs, Hodge, and Fox, and it having been decided that the child was alive, and that, under all circumstances, it would be better to perform Caesarian section, than Embryotomy, the consent of the patient being also obtained, Dr. Fox requested me to undertake the ope- ration. Every arrangement having been made, with as little delay as possible, the patient was placed on her back upon a table covered with a mattress, when, asssisted by the above gen- tlemen, and by Drs. George W. Norris and Charles Bell Gibson, I made an incision through the integuments, about an inch and a half below the umbilicus, and extended it five inches and a half towards the pubes, through the original cicatrix. The tendons of the external oblique appeared to have been converted into con- densed cellular tissue, and the adhesions of the superjacent integu- ments to them were very perfect. Penetrating, cautiously, through the cicatrix, the peritoneum, which seemed to adhere. to the surface of the uterus for four inches, was divided, and the uterus itself, opened to the extent of five or six inches, its walls towards the fundus, for an inch and a half, being half an * After the operation the patient was kindly visited, repeatedly, by Drs. De- wees, William Coxe, Horner, Spackman, and others. 442 Hysterotomy or Cmsarian Section. inch thick, but towards the neck not more than the eighth of an inch. These walls were divided chiefly by the bistoury, guided by the directory. At the upper and lower corners of the in- cision the peritoneum was necessarily cut through, about three- quarters of an inch at each place, and through each of these openings an intestine protruded slightly, but was easily kept back by the fingers of Dr. Fox. Only a single artery appeared that seemed to require the ligature; and this in oneof the thick edges of the uterus. It soon shrunk, however, and could not afterwards be found. As soon as the uterus was fairly divided, I requested Dr. Meigs to rupture the membranes, and take out the chikh This was accordingly done, with the utmost dexterity, by first removing the left arm and leg and afterwards the body and head; after which, the placenta was taken away. The edges of the uterus were then pressed together, with the fingers, and the whole of the organ was distinctly seen to contract in a few se- conds. The hemorrhage, at first considerable, soon ceased. The integuments being drawn together by six tacks of the interrupted suture, were supported by adhesive straps, compresses and ban- dages, and afterwards by general compression over the abdomen. The patient was permitted to remain on the table in the posi- tion she was in during the operation. She expressed herself comfortable, and only complained about fifteen minutes after the operation, of slight nausea and flatulency, to relieve which, she took an anodyne and a little lime water. Three and a half, P. M. met Drs. Meigs and Fox and found the patient very easy and quiet, had slept comfortably, and pulse nearly natural. , Nov. (>th, half past ten o\clock A. M., met Drs. Meigs and Fox, patient passed a restless night—but does not complain this morn- ing of any thing. Pulse eighty-five. Loosened the bandage, and found the parts had undergone no change. Belly distend- ed with flatus, but no pain or uneasiness upon pressure—or- dered bi-carbonate of potash and morphia. Nov. the 1th, half past ten o'clock, A. M., met Drs. Meigs and Fdx. Patient passed a good night, pulse seventy-eight, no thirst, no uneasiness of any kind—abdomen soft, although last night tumid with flatus, which was instantly discharged in large quan- tity by the stomach tube per rectum. Slept well without opium. Hysterotomy or Ccesarian Section. 443 Nov. the 8th, half past ten o'clock A. M, Drs. Meigs, Fox, and Hodge present. Breasts of patient gradually swelling and some increase of pulse, probably from this cause—pulse one hundred,— abdomen still soft, and not the slightest pain from pressure; pa- tient removed from table this morning, and placed in bed; wound beginning to suppurate, and more or less smell from it and from lochia—bowels have not been opened., Has taken freely of the carbonate mixture, and still kept on barley water, slept soundly without an opiate. Child not so well to-day, and some- what reduced, owing to want, perhaps, of a proper nurse. Nov. 9th, patient quite as well to-day, as yesterday; pulse nine- ty-seven, mixture of carbonate of potash omitted. Nov. 10th, pulse one hundred to-day, but skin soft, almost too much so. Removed adhesive straps, and found wound, for most part, closed except at centre, where an opening ofan inch in ex- tent exists, and from this a slight discharge, rather sanious. Wound, however, probably not closed by perfect adhesion. Ordered gentle enema. Belly stjll soft, and every symptom, so far, as favourable as possible. Nov. lllh, pulse ninety-eight; symptoms very favourable. Nov. 12th, dressed the wound, and removed some of the straps; every thing going on well. Nov. 13th, patient still improving. Dec. 26th, patient perfectly well, and the wound healed, with the exception of a very small fistulous opening. Feb. 10th, 1838, fistulous opening completely closed, and the wound, throughout, firmly cicatrized. The boy—Cassar Augustus,—in perfect health. On Caesarian Section, consult Sabatier's Medecine Operatoire—Simon in Mem. de VAcad. de Chirurg. tom. 3d, and5th edit. 12mo.—Baudelocque Traits des Ac- couchements—Hull's Defence of Caesarian Section, 8vo.—C. Bell in Med. Chir. Transact, vol. 4th—/. H. Green, ibid, vol. 12—Dictionnaire des Sciences Medi- cates, tom. 17—Plancton Traiti complet de V Operation Cesarienne. Paris, 1801 —Arisiaux's Dissertation sur FOperation Cesarienne, &c. Paris, 1803—Dewees' Midwifery—Essays, Cases, &c. by ihe following writers, may be consulted with advantage:—Kaiserschnitt, Weinhart, Nettman, Rhode, Wigand, Flammant, Kulenthal, Meyer, Ploderl, Huter, Kittel, Friedemann, Graefe, Bobertag, Wan- ner, Papius, Davids'jfm, Michaelis, Siebold; an account of which may be found 444 Hysterotomy or Ccesarian Section^ in Dictionnaire de Medicine, ou repertoire Generate des Sciences Medicales, tom. Septieme, p. 156. Paris, 1834—The 7th vol. of Sprengel, Histoire de la Medecine, and Cooper's Surgical Dictionary, may also be referred to. But the most elabo- rate work ever published on the Caesarian section is said to have betn written lately by Mansfeldt, a German surgeon,- for an account of which, see Ryan's Manual of Midwifery.—Observations on the. Caesarian Operation, accompanied by ihe Re- lation of a Case, in which both Mother and Child were preserved, (by Professor Gibson.) By Joseph G. Nancrede, M. D., in American Journal of Medical Sciences, No. xxxii. Aug. 1835—Account of a Case of Caesarian Section, performed by Dr. Gibson, successful in saving, a second time, both Mother and Child by George Fox, M. D., in American Journal of Medical Sciences, No. xliii. May, 1838. THE END. BOOKS PUBLISHED BY CAREY, LEA & BLANCHARD, AND TO BE HAD OF ALL BOOKSELLERS. MEDICINE, &c. DR. ARNOTT. 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By John Syme, Professor of Surgery in the Univer- sity of Edinburg. In 1 vol. 8vo. DR. TWEEDIE. CLINICAL ILLUSTRATION OF FEVER, comprising a Report of Cases treated at the London Fever Hospital in 1828-29. By Alexander Tweedie, M. D., Physi- cian in the Fever Hospital, &c. 1 vol. 8vo. JOHN THOMPSON, M. D. LECTURES ON INFLAMMATION, ex- hibiting a view of the General Doctrines, Pathological and Practical, of Medical Sur- gery. By John Thompson, M. D., F. R. S. E. Second American edition. 1 vol. 8vo. PROFESSOR WHEWELL. ASTRONOMY AND GENERAL PHY- SICS, considered with reference to Natu- ral Theology. By the Rev. William Whewell, M. A., Fellow and Tutor of Trinity College, Cambridge; being a part of the Bridgewater Treatises on the Power, Wisdom, and Goodness of God, as mani- fested in the Creation. In 1 vol. 12mo. C. J. WILLIAMS, M. D. A RATIONAL EXPOSITION OF THE PHYSICAL SIGNS OF DISEASES OF THE LU NGS AND PLEURA; illustrating their Pathology and facilitating their Di- agnosis. By Charles J. Williams, M. D. In 8vo. with plates. Books published by Carey, Lea Sr Blanchard. THE MEDICAL STUDENT. THE MEDICAL STUDENT, OR AID TO THE STUDY OF MEDICINE, including a Glossary of the terms of the Science, and of the mode of prescribing; Bibliographical Notices of Medical Works; the regulations of the different Medical Colleges of the Union, &c. By Robley Dunglison, M. D., Professor of the Institutes of Medicine and Medical Jurisprudence in Jefferson Medical College, late Professor in the University o Maryland, and University of Virginia, &c. In 1 vol. 8vo. "This is another of those valuable compilations for which the profession in America is so much indebted to Professor Dunglison. "Although chiefly intended for students in the American States, it will be useful for stu- dents in all countries, as it contains a vast deal of that kind of miscellaneous and varied information which is so constantly needed, yet so difficultly found by them. Besides the mere technical matters, this volume touches on many subjects of yet higher importance, and, among others, on the moral duties and professional conductof the medical practitioner, which are laid down clearly and forcibly, and with a just appreciation of the dignity of the office. The following titles of the five chapters of which the work consists, will give a general but not very exact notion of its contents, as it comprehends many things very in- teresting to the student, yet hardly suggested by ils title: Preliminary education, Medical education prior to attendance on Lectures, Medical education during the period of atten- dance on Lectures, Medical education after Graduation, a Medical Bibliography for the Student and Young Practitioner. "We recommend 'The Medical Student' in the strongest terms to his brethren in all countries, and in an especial manner to his compatriots."—British and Foreign Medical Review. GENERAL THERAPEUTICS. GENERAL THERAPEUTICS, OR PRINCIPLES OF MEDICAL PRACTICE, with tables of the chief remedial agents and their preparations, and of the different poisons and their antidotes. By Robley Dunglison, M. D., &c. &c. 1 vol. large 8vo. "There being at present before the public several American works on Therapeutics, written by physicians and teachers of distinction, it might be deemed unjust in us, and would certainly be invidious, to pronounce any one of them superior to the others. Wo shall not, therefore, do so. If there be, however, in the English language, any work of the kind more valuable than that we have been examining, its title is unknown to us. "We hope to be able to give such an account of the work as will strengthen the desire and determination of our readers to seek for a farther acquaintance with it, by a candid perusal of the volume itself. And, in so doing, we offer them an assurance that they will be amply rewarded for their time and labour."—Transylvania Journal, Vol. IX. No. 3. Dec. 1836. "Few writers in our profession have been more industrious than Professor Dunglison, and ' fewer still have sustained themselves equally well in the course of so many practical pub- lications. From the hasty perusal which we have given it, we are inclined to think that it possesses equal if not superior merit to any which have preceded it from the prolific pen of its author. It shows the learning and research of its author on every page, and as an eclectic production it will bear comparison with similar works in any country. We would advise our readers to purchase and peruse it for themselves."—Western Journal of the Medical Sciences, No. XXXVIII. p. 252, for September, 1836. The work ought not to be thus hastily dismissed. From an attentive examination less cannot injustice be said, than that while we find nothing to excite a single captious feeling, we find every thing to instruct and entertain. Although Dr. Dunglison may be regarded a prolific writer, if he produces always such volumes as this, we shall certainly not think him in danger of the charge of overworking his genius. We must leave it with the candid advice to every medical man to be soon in possession of this volume of sound and rich ob- servations in the art, he would advance with pleasure, as well as practice as a duty.— Boston Medical and Surgical Journal. Books published by Carey, Lea fy Blanchard. YOUNG'S MATHEMATICAL WORKS. AN ELEMENTARY TREATISE ON ALGEBRA, Theoretical and Practical; with attempts to simplify some of the more difficult parts of the science, particularly the de- monstration of the Binomial Theorem, in its most general form; the Solution of Equations of the higher orders; the Summation of Infinite Series, &c. By J. R. Young. A new edition, corrected and improved. "A new and ingenious general method of solving Equations has been recently discovered by Messrs. H. Atkinson, Holdred, and Horner, independently of each other. For the best practical view of this new method and its applications, consult the Elementary Treatise on Algebra, by Mr. J. R. Young, a work which deserves our cordial recommendation."—Dr. Gregory's edition of Hutton s Mathematics. "For the summation of Infinite Series the author gives a new and ingenious method, which is very easy and extensive in its application."—Newcastle Mag. ELEMENTS OF THE INTEGRAL CALCULUS; with its Applications to Geometry and to the Summation of Infinite Series, &c. Revised and corrected by Michael O'Shannessy, A. M. 1 vol. 8vo. "The volume before us forms the third of an analytical course, which commences with the 'Elements of Analytical Geometry.' More elegant text books do not exist in the English language, and we trust they will speedily be adopted in our Mathematical Seminaries. The existence of such auxiliaries will, of itself, we hope, prove an inducement to the culti- vation of Analytical Science; for, to the want of such elementary works, the indifference hitherto manifested in this country on the subject is, we apprehend, chiefly to be ascribed. Mr. Young has brought the science within the reach of every intelligent student, and, in so doing, has contributed to the advancement of mathematical learning in Great Britain."— Presbyterian Review, January, 1832. ELEMENTS OF THE DIFFERENTIAL CALCULUS; comprehending the General Theory of Curve Surfaces, and of Curves of Double Curvature. Revised and corrected by Michael O'Shannessy, A. M. 1 vol. 8vo. "The whole Elements of the Differential Calculus, comprehending all that is most valu- able in the large works of the most celebrated Analysis, are contained in one volume beautifully printed on a fine paper, and neatly bound in cloth. It appears to be in every respect well fitted for a Class-Book, and can scarcely fail to be very generally adopted."— Presbyterian Review, September, 1831. ELEMENTS OF GEOMETRY; containing a new and universal Treatise on the Doc- trine of Proportions, together with Notes, in which are pointed out and corrected several important errors that have hitherto remained unnoticed in the writings of Geometers. Also, an Examination of the various Theories of Parallel Lines that have been proposed by Legendre, Bertrand, Ivory, Leslie, and others. 1 vol. 8vo. "His observations on the theory of parallel lines, the labour he has bestowed on the doc- trines of proportion, as well as his corrections of many errors of preceding Geometers, and supplying their defects, together with his minute attention to accuracy throughout, may be justly considered as rendering his performance valuable, especially to the learner."—Phi- losophical Magazine. "We have never seen a work so free from pretension and of such great merit. Various fallacies latent in the reasoning of some celebrated mathematicians, both of ancient and modern date, are pointed out and discussed in a tone of calm moderation, which we regret to say is not always employed in the scientific world."—Monthly Magazine. "This is a work of valuable information, the conception of a most enlightened mind and executed with a simplicity which cannot but carry the important truth it speaks of, home to the conviction of every understanding."—Weekly Times. THE ELEMENTS OF ANALYTICAL GEOMETRY; comprehending the Doctrine of the Conic Sections, and the General Theory of Curves and Surfaces of the second order with a variety of local Problems on Lines and Surfaces. Intended for the use of Mathe- matical Students in Schools and Universities. "If works like the present be introduced generally into our schools and colleges, the con- tinent will not long boast of its immense superiority over the country of Newton in everv branch of modern analytical science."—Atlas. THE ELEMENTS OF MECHANICS; comprehending Statics and Dynamics, with a copious Collection of Mechanical Problems, intended for the use of Mathematical Stu- dents, in Schools and Universities; with numerous Plates. Revised and corrected bv John D. Williams. 1 vol. 8vo. y ELEMENTS OF PLANE AND SPHERICAL TRIGONOMETRY; with its applications to the Principles of Navigation and Nautical Astronomy, with the necessary Logarithmic and Trigonometrical Tables. By J. R. Young. To which is added, some Original Re- searches in Spherical Geometry. By T. S. Davies, Esq. Revised and corrected by John D. Williams. 1 vol.8vo. * ■- M1 . T.'.'W"